1 2 3

4 5 6 7 8 9 10 Military Health System Coding Guidance: 11 12 Professional Services and Specialty Coding Guidelines 13 14 Version 2.0 15 16 Unified Biostatistical Utility 17 18 19 2008 20 21 Effective date for this guide version: 1 March 2008 22 Effective date for audit use: 1 May 2008 1 2 TABLE OF CONTENTS 3 4

23Chapter 1 OVERVIEW...... 1-1 24 1.1. Purpose...... 1-1 25 1.2. Diagnostic Coding...... 1-2 26 1.3. Procedural Coding...... 1-2 27 1.4. Evaluation and Management (E&M) Coding...... 1-3 28 1.5. Coding Table Updates...... 1-3 29 1.6. Legal Reference...... 1-3 30 1.7. Getting Help...... 1-3 31 1.8. Coding Reviews/Audits of Professional Services...... 1-4 32 1.9. Health Insurance Portability and Accountability Act (HIPAA)...... 1-7 33 1.10. Use of the term SADR...... 1-8

34Chapter 2 DIAGNOSTIC CODING...... 2-1 35 2.1. Code Taxonomy (Structure)...... 2-1 36 2.2. Guidelines...... 2-2

37Chapter 3 EVALUATION AND MANAGEMENT (E&M) CODING...... 3-1 38 3.1. E&M Coding: 99201–99499...... 3-1 39 3.2. Office Outpatient Services, 99201–99215...... 3-5 40 3.3. Hospital Observation Services 99217-99220 and 99234–99236...... 3-5 41 3.4. Hospital Inpatient Services...... 3-7 42 3.5. Emergency Department ………...………………………………………………...…3-8 43 3.6. Telephone Services ...... 3-8 44 3.7. Provider (privileged and non privileged)Initiated Telephone Calls...... 3-9

45Chapter 4 CONSULTATION...... 4-1 46 4.1. Consultation Guidelines...... 4-1 47 4.2. Consult versus Referral...... 4-1 48 4.3. Documentation for Consultation...... 4-1 49 4.4. Consultations that require more than one encounter...... 4-2 50 4.5. Clearing Patients for Specialty Care ...... 4-22 51 4.6. Preoperative Consultation ...... 4-2 52 4.7. Preoperative Emergency Department Referrals vs Consultations...... …………4- 53 33 54 4.8. Coding Consults in AHLTA...... 4-4

55Chapter 5 PROCEDURAL CODING...... 5-1 56 5.1. Procedures...... 5-1 57 5.2. Modifiers...... 5-1 58 5.3. Bundled Procedures and Global Procedures...... 5-2 59 5.4. Clinical Pharmacists...... 5-3 60 5.5. Chaplains and Pastoral Counselor...... 5-3 61 5.6. Electrocardiogram (ECG or EKG) Services 93000-93042...... 5-4

5 i 6 7 TABLE OF CONTENTS 8 9 62 5.7. Laser Tattoo and Hair Removal...... 5-4 63 5.8. On Call...... 5-4 64 5.9. Medical Evaluation Boards (MEB)...... 5-4 65 5.10. Records Review...... 5-5 66 5.11. Injections and Infusions...... 5-5 67 5.12. Cast/Splint Application………...…………………………………………………...5-6 68 5.13. Tobacco Use Cessation………...…………………………………………………...5-6 69 5.14. Physician’s Voluntary Reporting Program Codes…...……………………………..5-6

70Chapter 6 SPECIALTY CODING...... 6-1 71 6.1. Anesthesia…..………………………………………………...…………………….6-1 72 6.2. Audiology...... 6-8 73 6.3. Chiropractic Services...... ………6-13 74 6.4. Dialysis …………………………………………………………………………...6-15 75 6.5. End Stage Renal Disease (ESRD).………………………………………………..6-17 76 6.6. Flight Medicine Services...... 6-21 77 6.7. Gynecology...... 6-25 78 6.8. Mental Health...... 6-28 79 6.9. Nutritional Medicine Encounters...... 6-31 80 6.10. Obstetrics Services...... 6-37 81 6.11. Occupational Therapy...... 6-49 82 6.12. Ophthalmology/Optometry...... 6-53 83 6.13. Physical Therapy – Coding for Physical Therapist/Technician...... 6-62 84 6.14. Preventive Medicine Services...... 6-666 85 6.15. Radiation Oncology Services...... 6-722 86 6.16. Radiology, Interventional………....……………………………………………....6-76 87 6.17. Readiness Assessment...... 6-768 88 6.18. Reconstructive/Cosmetic Surgery...... 6-82 89 6.19. Social Work and Family Advocacy Services...... 6-84 90 6.20. Substance Abuse Program Services...... 6-888

91Chapter 7 CODING AMBULATORY PROCEDURE VISIT (APV) ENCOUNTERS...... 7-1 92 7.1. Definitions...... 7-1 93 7.2. Coding Pre- and Post Procedure APV Encounters...... 7-2 94 7.3. Patient Admitted from APV...... 7-3 95 7.4. Consultation for APV...... 7-3 96 7.5. Assistant at Surgery...... 7-3 97 7.6. 99199, Institutional Component of an APV…………………………………………7-3 98 7.7. Coding Cancelled APVs...... 7-3 99 7.8. Procedures Not Performed in the APU...... 7-4

100Chapter 8 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 101 SCENARIOS...... 8-1 102 8.1. Use of the “MAIL” Function...... 8-1 103 8.2. For Clinic Use Only, an ADM function...... 8-1

10 ii 11 12 TABLE OF CONTENTS 13 14 104 8.3. Additional Provider...... 8-1 105 8.4. Remote Professional Services………………………………………….……...…….8-1 106 8.5. Telehealth...... 8-53 107 8.6. Resident/GME Services...... 8-8

108Chapter 9 PROFESSIONAL CODING FOR INPATIENT ENCOUNTERS...... 9-1 109 9.1. Background…………………………………………………………………………..9-1 110 9.2. Definitions………………………………………………………………………...…9-1 111 9.3. Inpatient Professional Services Data Capture……………………………………….9-4 112 9.4. Surgical Services…………………………………………………………………….9-7 113 9.5. Anesthesia Services………………………………………………………………….9-8 114 9.6. Inpatient Consults……………………………………………………………………9-8 115 9.7. Observation Status…………………………………………………………………...9-9 116 9.8. Newborn Early Hearing Detection & Intervention (EHDI)………………………....9-9 117

15 iii 16

118COPYRIGHT 119 120The American Medical Association (AMA) copyrights Current Procedural Technology (CPT). 121All rights reserved. No fee schedules, basic units, relative values or related listings are included 122in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. 123AMA assumes no liability for data contained or not contained herein. 124 125U.S. Government Rights 126This product includes CPT, which is commercial technical data, computer databases or 127commercial computer software or computer software documentation, as applicable, developed 128exclusively at private expense by the AMA, 515 North State Street, Chicago, IL, 60610. U.S. 129Government rights to use, modify, reproduce, release, perform, display, or disclose these 130technical data and/or computer databases and/or computer software and/or computer software 131documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1321995) and to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) 133(June 1995), as applicable, for U.S. Department of Defense procurements and the limited rights 134restrictions of FAR 52.227-14 (June 1987) and to the restricted rights provisions of FAR 13552.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable 136agency FAR supplements, for non-Department of Defense federal procurements.

17 iii 18 19 OVERVIEW 20 21 137Chapter 1 OVERVIEW 138 139This document provides guidance for Department of Defense (DoD) coding for professional 140services. The Military Health System (MHS) is shifting from capturing inpatient and 141outpatient clinical services to capturing institutional and professional services. MHS 142systems capture professional encounters in both outpatient and inpatient settings. 143 144Updating Guidelines—MHS Coding Guidance is reviewed and updated annually, or more 145frequently as needed, by the Unified Biostatistical Utility (UBU) Working Group. To 146suggest updates, contact the Service point of contact listed in section 1.7. Updates to coding 147guidance are on the UBU website, at the url: 148http://www.tricare.mil/ocfo/bea/ubu/index.cfm 149 150Guidelines effective immediately upon release for MTF use, effective 1 November for 151external Audits. 152 1531.1. Purpose 154In the simplest sense, coding is the numeric or alphanumeric representation of written 155descriptions. It allows standardized, efficient data gathering for a variety of purposes. This 156document supplements industry standards with MHS-specific guidance for coding 157ambulatory and professional service encounters. These guidelines are derived from the 158following source documents, but take precedence over them: 159 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- 160 CM); 161 Current Procedural Terminology (CPT), 4th Edition; 162 Centers for Medicare and Medicaid Services (CMS) Documentation Guidelines for 163 Evaluation and Management (E&M) Services; 164 Healthcare Common Procedure Coding System (HCPCS); 165 The American Hospital Association (AHA) Coding Clinic; 166 The American Medical Association (AMA) CPT Assistant; 167 The Coding Clinic for HCPCS. 168 169Coding serves a variety of purposes. While it can provide a detailed clinical picture of a 170patient population, it can also be useful in overseeing population health, anticipating 171demand, assessing quality outcomes and standards of care, managing business activities, and 172receiving reimbursements for services. 173 174When coding for DoD healthcare services, substitute the term privileged providers where 175the CPT manual description uses the term physicians. Privileges are granted by individual 176military treatment facilities (MTFs). Common examples of privileged providers are 177licensed physicians, advanced practice nurses, physician assistants, Independent Duty 178Corpsman (IDC), oral surgeons, optometrists, residents (other than post-graduate year one 179[PGY-1]), and physical and occupational therapists. 180

22 1 23 MHS Coding Guidance 24 March 2008 25 26 OVERVIEW 27 28 1811.2. Diagnostic Coding 182Diagnostic coding began as a means of gathering statistical information to track mortality 183and morbidity. Subsequent changes to add clinical information resulted in a coding 184structure that describes the clinical picture of a patient, as well as non-medical reasons for 185seeking care and causes of injury. Diagnosis codes are listed in the International 186Classification of Diseases, 9th revision, Clinical Modifications or, ICD-9-CM. 187 1881.3. Procedural Coding 189Healthcare Common Procedure Coding System (HCPCS) codes are grouped in two 190levels: 191 192 Level I HCPCS are commonly referred to as Current Procedural Terminology (CPT). 193 They form the major portion of the HCPCS coding system, covering most services 194 and procedures. CPT codes supersede Level II codes when the verbiage is identical. 195 196 Level II codes supersede level I codes for similar encounters, when the verbiage of 197 the level II code is more specific. HCPCS includes evaluation and management 198 services, other procedures, supplies, materials, injectables, and dental codes. Having 199 a code number listed in a specific section of HCPCS does not usually restrict its use 200 to a specific profession or specialty. 201 202HCPCS level I and level II codes, except for codes 99201–99499, are collected in the third 203data collection screen of the Ambulatory Data Module of the MHS’s computer system. 204 205Other Specifics Regarding HCPCS Level II Codes 206Equipment and durable supplies will only be coded if the equipment or supply item is 207issued to the patient without the expectation that the patient will return the item when no 208longer needed. For instance, if the patient is issued a C-PAP machine with the 209expectation the machine will be returned when it is no longer needed, issuance of the 210machine would not be coded. However, the personalized facemask would be issued with 211no expectation of return, and so would be coded. 212 213Pharmaceuticals and Injectables HCPCS Level II codes will only be used when the 214pharmaceutical or injectable is paid for directly from the clinic’s funds, and is not a 215routine supply item. If a drug is issued by the pharmacy to the patient, and the patient 216brings the drug to the clinic for administration, the drug will not be coded, as the 217pharmacy was the service issuing the drug. Inpatient ward stock will not be coded, as it 218is part of the institutional component and part of the diagnosis-related group (DRG). 219 220C Codes These codes are commonly referred to as pass-through codes. They are usually 221only available for a few years at which time the item is included in a procedure or no 222longer used. These tend to be for high-cost items. The item must be coded if it is paid 223for out of clinic funds. As with other drugs, do not code it if the pharmacy issued it to the 224patient. Frequently, coders will need to query the provider or the clinic supply custodian 225on the method of acquisition. 29 2 30 MHS Coding Guidance 31 March 2008 32 33 OVERVIEW 34 35 2261.4. Evaluation and Management (E&M) Coding 227In the DoD, the term evaluation and management codes refers to the CPT codes inclusive of 22899201–99499. These codes describe the non-procedural portion of services furnished 229during a healthcare encounter. They classify services provided by a healthcare provider and 230indicate the level of service. E&M codes are a subset of CPT codes (Level I HCPCS), yet 231are referred to as an E&M instead of as a CPT code to distinguish between E&M services 232and procedural coding. See Section 3 for details about E&M coding. 233 2341.5. Coding Table Updates 235ICD-9-CM diagnosis codes are updated annually in the Composite Health Care System 236(CHCS). These updates, which usually affect a portion of the codes, should be effective on 237or about 1 October of each year. Implementation by DoD MTFs is tied to release and 238distribution of CHCS file updates. Actual activation at a specific CHCS host and its client 239sites requires coordination among coders and CHCS administrators at their facilities. 240Mechanisms should be in place to ensure record completion by fiscal year end. Corrections 241may be needed to complete records once the new codes are available. 242 243CPT and HCPCS codes are updated annually about 1 January. Like the ICD-9-CM codes, 244implementation in DoD MTFs depends on a release of CHCS file updates and may therefore 245be later than in the private sector. There may be table updates performed as needed in 246addition to the annual releases. Even when a table update is required, records will need to 247be completed within the normal three working days for clinic encounters and fifteen days 248for same-day surgery or observation. Failure to have all prior year professional services 249(generates Standard Ambulatory Data Record [SADR]) coding complete before the tables 250update may result in situations where old codes are no longer available. Health Insurance 251Portability and Accountability Act (HIPAA) compliant billing requires use of the existing 252CPT or HCPCS code available at the time of the clinical service. 253 2541.6. Legal Reference 255The medical record is the legal record of care. When there is a difference between what is 256coded in the Ambulatory Data Module (ADM) and what is documented in the medical 257record, a coder may change a code to more accurately reflect the documentation. When this 258occurs, the coder must notify the provider. The provider is ultimately responsible for coding 259and documentation. 260 261While the data from the CHCS record can be used to create third-party claims, the medical 262record must support the coding in the claim. 263 2641.7. Getting Help on Coding Questions 265For questions on coding issues, please contact the Service Representative, as follows: 266 Army http://www.pasba3.amedd.army.mil 267 Air Force https://phsohelpdesk.brooks.af.mil or 1-800-298-0230 268 Navy https://dq.med.navy.mil/ dq/coding.htm 269

36 3 37 MHS Coding Guidance 38 March 2008 39 40 OVERVIEW 41 42 270System issues: For ADM functional software and technical support, contact the MHS Help 271Desk. 272 273MHS HELP DESK 274 CONUS 1-800-600-9332 OCONUS 866-637-8725 275 276This information is also available from www.mhs-helpdesk.com 277 2781.8. Purpose of Coding Reviews and Audits of Professional Services 279Coded data must be accurate, because they are used for clinical and business decisions 280and may be used for reimbursement. To attain the goal of quality data, review (or audit) 281processes need to be in place. Coding audits are currently required as a part of the 282Department of Defense Instruction (DoDI) 6040.40. Audits can be very informative and 283provide an objective and sometimes more knowledgeable review for facilities. After 284audits are completed, appropriate actions should be taken to improve coding quality 285based on issues identified. Common actions include updating data collection tools, 286giving feedback to providers and coders, educating providers on documentation and 287coding, training coders, providing access to current coding books, revising system 288templates, and developing system change requests to correct problems inherent in the 289hardware or software of the system. When errors are identified (e.g. wrong E&M, 290missing procedures, diagnosis not in correct series) they should be corrected.. 291 2921.8.1. Coding Audit Business Rules 293 2941.8.1.1. Random Record Selection 295The audit begins with the identification of all professional services encounters that 296occurred in the target product lines during the period to be audited. This includes all 297encounters in all clinics of privileged providers, including inpatient and outpatient 298professional services. Records should include records from clinics’ feeding data to the 299Clinical Data Repository (CDR), including geographically separated facilities. A 300systematic approach must be used to select encounters to be audited. If an MTF is 301selected for an external audit, the same records are reviewed as part of the internal audit. 302 3031.8.1.2. Availability of Documentation within the Facility 304Documentation is defined as a signed document for the professional encounter or for the 305institutional disposition for a period of service. The provider documentation is compared 306with the electronic data record. 307 3081.8.1.3. Obtaining the Documentation— the MHS Decentralized Medical Record 309The MHS has a decentralized medical record system. This means there may be multiple 310components stored in various areas that are easily and quickly retrievable and can be 311reassembled as one record. Most documentation can be found in the main outpatient 312medical record. For some patients, there are components of the medical record in dental, 43 4 44 MHS Coding Guidance 45 March 2008 46 47 OVERVIEW 48 49 313mental health, obstetrics, ambulatory procedure visits (APV), extended ambulatory 314record (EAR), and inpatient. 315 3161.8.1.3.1. Professional Services Documentation 317For facilities with Armed Forces Health Longitudinal Technology Application (AHLTA), 318formerly known as CHCS II as well as CHCS, documentation for inpatient professional 319services will be in the doctor’s notes portion of the paper inpatient record. Rounds 320appointments will not be documented in AHLTA. Laboratory tests, radiology studies, and 321prescriptions for inpatients will not be ordered in AHLTA. Documentation may be 322maintained in either a paper or an electronic record. 323 3241.8.1.3.2. Documentation in AHLTA 325

326 DoD Rule 327 328 Recording of documentation in AHLTA is not a separately codable 329 event. Encounters that do not meet minimum visit criteria are 330 administrative and are not a coded visit.

331 3321.8.1.4. Auditable Issues 333Auditable issues include availability of documentation, proper documentation, summary 334sheets being current, legibility, authorized abbreviations, and co-signatures of teaching 335providers. Proper documentation, at a minimum, includes the name of the treatment 336facility or location, clinic, date of the encounter, patient identifying data and provider 337signature, grade or rank, and profession on encounter sheet. Any history of illness or 338allergies that have no documented impact on patient care need not be coded and are not 339auditable. Use of 99499 is not auditable on TMA audits because of system discrepancies. 340 3411.8.1.5. Audit Assessment (Based on Coded Data from MHS Central Database) 342Medical record audits include ICD-9-CM diagnoses, the first listed E&M, and 343CPT/HCPCS procedure codes. No entry in the E&M field will be used for APV 344encounters unless an E&M service is provided that is significantly separate from the 345service provided. Linkage of diagnosis to CPT/HCPCS, modifiers and second or third 346listed E&M will not be addressed at this time, since these data elements do not pass 347through to the SADR and therefore are not available in an MHS central database. 348 3491.8.1.6. Audit Assessment (Based on Coded Data from MTF Server) 350These audits may also cover modifiers, quantities and linkage of diagnosis to 351CPT/HCPCS and additional E&M codes. 352 3531.8.1.7. TMA Audit Finding Reports 354The Services will receive a copy of the TMA Audit Findings as soon as they are 355available. 50 5 51 MHS Coding Guidance 52 March 2008 53 54 OVERVIEW 55 56 3561.8.2. Auditing Guidelines 357Records will be audited to the MHS Coding Guidance and then to generally accepted coding 358standards. Facilities should indicate in their compliance plan which set of CMS 359guidelines each clinical service will follow (e.g., primary care clinics will use 1995 and 360specialty clinics will use 1997) and how the encounter was audited (using the CMS 1995 361or 1997 E&M guidelines). Other references used when determining appropriate code 362assignment include AHA Coding Clinic and the AMA CPT Assistant. 363

1995 Documentation 1997 Documentation 364 Guidelines.pdf Guidelines.pdf 365 3661.8.2.1. MHS Data Collection Conventions 367To be valid, codes must meet the MHS Professional Services and Outpatient Coding 368Guidelines. The following, when noted during an audit, are not errors, but DoD-specific 369data collection conventions. Their presence will not cause an error to be indicated on the 370audit: 371 3721.8.2.1.1. DoD-Unique Coding Conventions 373Extenders (V70.5_1, Aviation Exam) or 99199 to indicate the institutional component of 374an APV, for example, are used to identify certain military requirements. 375 3761.8.2.1.2. Composite Health Care System (CHCS) limitations 377The same CPT code cannot be listed twice. For instance, coding medical direction of 378anesthesia and administration of anesthesia is currently not permitted. 379 3801.8.3. Data Collection Forms 381Facilities are encouraged to use the monthly audit form on the UBU website in 382completing the Monthly Data Quality Commander’s Statement or Service required forms. 383The UBU website is at http://www.tricare.osd.mil/org/pae/ubu/default.htm. 384 3851.8.4. Sample Instructions for Manual Audit 3861. On the Outpatient Coding Audit Worksheet, number (down a column, e.g., 1, 2, 3) and 387list all the diagnosis codes and CPT codes, including the first listed E&M code, present in 388the SADR for the encounter under review. If an E&M worksheet is completed, attach it 389to the audit worksheet. 390 3912. Secondary codes do not have to be sequenced in any order, except when 392manifestations are noted or the code is linked to a procedure. Align your secondary 393codes to the original (SADR) secondary codes so that a mismatch is not recorded because 394of a difference in sequencing among secondary diagnoses. However, if the original coder 395selected the correct primary diagnosis code, as determined by the audit, as a secondary 396diagnosis code, then it is an error in sequencing for the primary diagnosis. 397

57 6 58 MHS Coding Guidance 59 March 2008 60 61 OVERVIEW 62 63 3983. If the original codes are wrong or should be omitted, record a comment describing 399the reason the code is incorrect. The comment field is next to the field where the 400auditor’s codes are entered. Additional space is provided at the bottom of the form to 401continue a comment or to add general comments. When a comment is continued, append 402the line number to the information that is continued. 403 4044. If there are missed codes that should be added, put them in the blank numbered 405spaces, up to the maximum number allocated in the worksheet. If an original code is not 406correct, but a different code should have been added, and there are no remaining blank 407spaces, record the code next to the incorrect original code. 408 4095. After completing the review, check off whether the record has a pass or fail score. 410A pass means all of the codes are correct, supported by the documentation, and primary 411diagnosis selection is correct. A fail means there was at least one coding error, or the 412assignment of the primary diagnosis was incorrect. 413 4146. If documentation is unavailable, such as a missing anesthesia report, so a portion 415of the encounter cannot be coded, be sure to annotate which part of the documentation is 416missing. 417 4187. If a pathology/radiology report is unavailable to the coder at the time coding occurs 419then the results of the report may not be held against the facility at the time of auditing. 420Please refer to the date the report was transcribed and the date the encounter was coded in 421CCE to determine the appropriate dates to use for auditing purposes. 422 4231.8.5. Monthly Coding Audit Summary Report 424On the Monthly Coding Audit Summary Report, identify the number of records requested 425and the number of records received from the facility. 426 427  Identify the number of records received containing encounter documentation for 428 the encounter. 429  Document the number of records with illegible documentation. 430  Document the number of records with use of non-approved abbreviations or 431 acronyms. Abbreviations and acronyms are considered approved for this audit if 432 the term is completely spelled out initially, with the abbreviation listed 433 afterwards, if the term is on the approved list of MTF abbreviations or if the term 434 is on the DoD list of approved abbreviations. 435 4361.9. Health Insurance Portability and Accountability Act (HIPAA) 437HIPAA has standardized code sets for electronic transactions, including billing. ICD-9-CM, 438CPT, and HCPCS codes are all standardized code sets used in electronic billing. Unless a 439code is to be used to generate an electronic claim using a standardized code set, HIPAA 440does not affect coding. The MHS has non-standardized codes associated with ICD-9-CM in

64 7 65 MHS Coding Guidance 66 March 2008 67 68 OVERVIEW 69 70 441the form of DoD extender codes. MHS-defined codes, such as the extender codes, are not 442used in billing. Therefore, HIPAA does not apply to the extenders. 443 4441.10. Use of the Term SADR 445The Standard Ambulatory Data Record or SADR is a subset of outpatient data collected 446in the ambulatory data module (ADM) in the CHCS. Data collected for professional 447services in the MHS is referred to as coding a SADR. Data collected for inpatient 448institutional services in the MHS is referred to as coding a standard inpatient data record 449(SIDR). 450 451The SADR provides two electronic file transmissions. One is exported daily from ADM 452and sent to a central MHS database. A second file is transmitted to the Third-Party 453Outpatient Collection System (TPOCS). The TPOCS file is similar to the SADR, but 454includes multiple E&M, all CPT/HCPCS, modifiers, and quantities. The following items 455are not currently included in the SADR, but are collected in the ADM: 456 457  Modifier fields and unit fields, 458  Second and third E&M codes, 459  Link between diagnoses and procedures, 460  Diagnoses after the first four diagnoses, 461  Procedures after the first four procedures.

71 8 72 MHS Coding Guidance 73 March 2008 74 75 DIAGNOSTIC CODING 76 77 462Chapter 2 DIAGNOSTIC CODING 463 464ALL CODING MUST BE SUPPORTED BY THE DOCUMENTATION IN THE 465MEDICAL RECORD. 466 467This section provides ICD-9-CM coding guidelines for data collection in the DoD. The 468following guidelines pertain to professional services coding, which includes outpatient 469clinic, observation, APVs (same-day surgeries), and inpatient professional services. 470 4712.1. Code Taxonomy (Structure) 472ICD-9-CM codes are 3- to 5-digit numeric and alphanumeric codes. These codes are used 473to describe diseases, conditions, symptoms, and other reasons for seeking healthcare 474services. Some codes are modified for special use in the DoD. The first three digits usually 475represent a single disease entity, or a group of similar or closely related conditions. The 476fourth digit subcategory provides more specificity on the etiology, site, or manifestation. In 477some cases, fourth-digit subcategories have been expanded to the fifth-digit level to provide 478even greater specificity. 479 4802.1.1. Factors Influencing Health Status and Contact with Health Services 481ICD-9-CM codes beginning with the letter V are used when the patient seeks healthcare for 482reasons other than illness or injury. Examples include a well-baby exam or a physical. See 483section 2.2.8 in this chapter for more guidance. 484 4852.1.2. External Causes of Injury 486ICD-9-CM codes beginning with the letter E describe external causes of injury, poisoning 487and adverse reactions. They are used to describe where, why, and how an injury occurred. 488See section 2.2.9 in this chapter for more guidance. 489 4902.1.3. Not Otherwise Specified (NOS) 491Only use NOS codes when the documentation is insufficient to use a more specific code. 492This is synonymous with unspecified. 493 494 Example: A provider note indicates the patient has otitis media. Code 382.9, 495 unspecified otitis media, is the appropriate code if the diagnostic statement or record 496 lacks additional information, such as purulent or serous. 497 4982.1.4. Not Elsewhere Classifiable (NEC) 499Use NEC codes when there is no specific code in the classification system for the condition, 500even though the diagnosis may be very specific. 501 502 Example: 008.67 Enteritis due to Enterovirus NEC (Coxsackie virus, echovirus; 503 excludes poliovirus). In this example, this code would be reported even if a specific 504 enterovirus, such as echovirus, had been identified, because ICD-9-CM does not 505 provide a specific code for echovirus. 506 78 1 79 MHS Coding Guidance 80 March 2008 81 82 DIAGNOSTIC CODING 83 84 5082.2. Guidelines 509The following guidelines are to be followed when reporting diagnoses in ADM. The ICD- 5109-CM diagnostic codes are used for professional services furnished in both the inpatient and 511ambulatory setting. ICD-9-CM procedure codes are only used for inpatient institutional 512MHS coding and not professional services MHS coding. 513 5142.2.1. Prioritized Diagnoses 515The primary diagnosis is the reason for the encounter, as determined by the documentation. 516When a diagnosis has a codeable manifestation, co-morbid condition, or etiology, the linked 517codes should be sequenced together whenever possible (e.g., diabetic skin ulcer of the ankle, 518coded with 250.8x and 707.13). For some cases, ICD-9-CM conventions indicate that the 519underlying cause should be coded first, before a manifestation. In these instances, 520manifestations cannot be coded as a primary diagnosis. 521 522The chief complaint does not have to match the primary diagnosis. 523 5242.2.2. Pre-Existing Conditions 525Conditions or diseases that exist at the time of the encounter, but do not affect the current 526encounter are not coded. Documented conditions or diseases that affect the current 527encounter, are considered in decision making, and are treated or assessed, are coded. 528 5292.2.3. Specificity in Coding Classification 530Specificity in coding is assigning all the available digits for a code. Diagnostic codes should 531be assigned at the highest level of specificity. If a code has five digits, all five digits must be 532used. 533  Assign three-digit codes only if there are no four-digit codes within that code 534 category. 535  Assign four-digit codes only if there is no fifth-digit sub-classification for that 536 category. 537  Assign the fifth-digit sub-classification code for those categories where it exists. 538  Assign a DoD extender code if one exists (refer to the DoD Diagnosis Extender 539 section in 2.2.6). 540 541 Example: A patient is seen for abdominal pain in the upper right quadrant; no 542 specific cause has been determined. The appropriate diagnostic code would be the 543 five-digit code 789.01—other symptoms involving abdomen and pelvis, right upper 544 quadrant—as opposed to the four-digit code 789.0 (other symptoms involving 545 abdomen and pelvis, unspecified site). 546 5472.2.4. Selection of the Most Explicit Code 548Coding should be as explicit as the documentation permits. For instance, when the provider 549documents acute serous OM, code 381.01 acute serous otitis media, not 382.9 unspecified 550OM. 551 552 85 2 86 MHS Coding Guidance 87 March 2008 88 89 DIAGNOSTIC CODING 90 91 5532.2.4.1. Renewal/Replacement Prescription Refills 554Code V68.1 is the primary diagnosis when documentation only supports a prescription 555refill. In most cases, this is an administrative function. 556 557When a patient presents to a privileged provider and an assessment is made then the 558condition for which the assessment is being performed is your primary diagnosis and not 559the V code for prescription refill. The prescription refill V68.1 will not be used in this 560scenario. 561 5622.2.5. Unconfirmed Diagnosis 563When a provider is not certain of a diagnosis, capture the known manifestations, signs, 564symptoms, or abnormal test results. 565 566 Example: The diagnosis documented “rule out malignant neoplasm of the pancreas” 567 cannot be coded, as the diagnosis is unconfirmed. The documentation indicates a mass 568 on the pancreas. The terms mass and neoplasm are not synonymous. Therefore, the 569 most appropriate code would be 577.9, unspecified disease of pancreas. 570 571Although ADM permits designation of uncertain (unconfirmed) diagnoses with a U instead 572of a number, unconfirmed diagnoses are not traditionally coded. If a U designator is used 573for a diagnosis in ADM, those data are only available at the local server. The U-designated 574diagnosis cannot be the only diagnosis captured; there must be a primary diagnosis other 575than the U diagnosis. Currently, Air Force is the only Service that permits use of a U 576designator in ADM. 577 578 Example: A patient comes in with chest pain, and the provider wants to rule out 579 myocardial infarction. The provider documents the specific symptom of chest pain as 580 the primary diagnosis and documents the myocardial infarction code as an 581 unconfirmed diagnosis. The provider could document the myocardial infarction code 582 as an unconfirmed U diagnosis if that Service permits the designation. 583 584NOTE: For inpatient professional services, see Chapter 9. 585 5862.2.6. DoD Diagnosis Extender Codes 587A number of ICD-9-CM codes have been modified to meet the needs of the Services. These 588codes are referred to as DoD extender codes. The one-character extender is paired with a 589specific ICD-9-CM code to acquire a unique meaning. The DoD established extender codes 590to address a number of specific reporting requirements, including physicals, asthma, 591hepatitis, abortion, bacterial disease, and Gulf War-related diagnoses. If an extender has 592been established in accordance with specificity guidelines, the root code is no longer valid 593for use without an extender code. See Appendix D for a complete list of DoD Extender 594codes. Many coders annotate the DoD extender codes in their ICD-9-CM books so they do 595not overlook them when looking up codes to develop superbills. 596 597 92 3 93 MHS Coding Guidance 94 March 2008 95 96 DIAGNOSTIC CODING 97 98 5982.2.6.1. Asthma 599Currently there is no extender code to identify unspecified asthma. To capture this 600information, code to 493.xx_1 Asthma, mild. 601 6022.2.6.2. Acquired Absence of Body Part(s) or Organ(s) 603For population health purposes, use V45.71 and V45.77 with the appropriate extender code 604to capture acquired absence of body part(s) or organ(s). The extender portion of these codes 605is not auditable; as the codes are used for population health to exclude patients from 606preventive exams, such as mammograms. 607 6082.2.6.3. Reaction to Vascular Devices 609Codes for infection and inflammatory reactions to vascular devices and grafts, 996.62, are 610located in Appendix D. 611 6122.2.6.4. Traumatic Brain Injury (TBI) 613A list of TBI codes are located in Appendix D. 614 6152.2.6.4.1. 616TBI will be coded based upon documentation contained within the medical record for 617symptoms presenting after the acute phase of the injury. V15.5_* will be reported as a 618secondary diagnosis code followed by any late effect or manifestation codes. 619

620 DoD Rule 621 622 Code V15.5_* (and V70.5_* when TBI is related to deployment), 623 must be sequenced in the secondary diagnosis field (position 2-4) on 624 the SADR, to be followed by late effect and manifestation codes.

625 626 627NOTE: ICD-9-CM rules state that possible, likely or suspected TBI would not be 628coded on an outpatient basis. When a patient is treated as an outpatient and the 629provider documents the encounter as possible, likely, or suspected TBI, the 630informational needs of the MHS require for the encounter to be coded as if the 631patient actually had a documented history of TBI. 632 633When a TBI patient presents for treatment the provider must document the subjective and 634objective findings within the medical record. 635 636When an individual has a confirmed or suspected TBI, select one of codes listed below to 637be placed in a secondary diagnosis field (SADR position 2 – 4). If a patient has a 638confirmed injury to the brain such as a penetrating head wound, concussion, and/or is 639suffering from post concussion syndrome then codes from the V15.5_* will not be used. 640The following codes were made available for use as of 1 October 2007:

99 4 100 MHS Coding Guidance 101 March 2008 102 103 DIAGNOSTIC CODING 104 105 V15.5_1 PERSONAL HISTORY OF TBI, GLOBAL WAR ON TERRORISM (GWOT) RELATED, UNKNOWN LEVEL OF SEVERITY V15.5_2 PERSONAL HISTORY OF TBI, GWOT RELATED, MILD (GLASGOW COMA SCALE 13-15),LOC<1HR,POST TRAUMA AMNESIA<24HR V15.5_3 PERSONAL HISTORY OF TBI ,GWOT RELATED, MODERATE (GLASGOW COMA SCALE 9-12),LOC 1-24 HRS, POST TRAUMA AMNESIA 1-6 DAYS V15.5_4 PERSONAL HISTORY OF TBI, GWOT RELATED, SEVERE (GLASGOW COMA SCALE 3-8),LOC >24HRS,POST TRAUMA AMNESIA >6 DAYS V15.5_5 PERSONAL HISTORY OF TBI, GWOT RELATED, PENETRATING INTRACRANIAL WOUND V15.5_6 PERSONAL HISTORY OF TBI, NOT GWOT RELATED, UNKNOWN LEVEL OF SEVERITY V15.57 PERSONAL HISTORY OF TBI, NOT RELATED TO GLOBAL WAR ON TERRORISM, MILD (GLASGOW COMA SCALE 13-15),LOC<1HR,POST TRAUMA AMNESIA<24HR V15.5_8 PERSONAL HISTORY OF TBI, NOT RELATED TO GLOBAL WAR ON TERRORISM (GWOT), MODERATE (GLASGOW COMA SCALE 9-12),LOC 1-24 HRS, POST TRAUMA AMNESIA 1-6 DAYS V15.5_9 PERSONAL HISTORY OF TBI, NOT RELATED TO GWOT, SEVERE (GLASGOW COMA SCALE 3-8),LOC >24HRS,POST TRAUMA AMNESIA >6 DAYS V15.5_ PERSONAL HISTORY OF TBI, NOT RELATED TO GWOT, PENETRATING A INTRACRANIAL WOUND V15.5_ PERSONAL HISTORY OF TBI, UNKNOWN IF GWOT RELATED, B UNKNOWN SEVERITY LEVEL V15.5_ PERSONAL HISTORY OF TBI, UNKNOWN IF RELATED TO GWOT, MILD C (GLASGOW COMA SCALE 13-15),LOC<1HR,POST TRAUMA AMNESIA<24HR V15.5_ PERSONAL HISTORY OF TBI, UNKNOWN IF RELATED TO GWOT, D MODERATE (GLASGOW COMA SCALE 9-12),LOC 1-24 HRS, POST TRAUMA AMNESIA 1-6 DAYS V15.5_ PERSONAL HISTORY OF TBI, UNKNOWN IF RELATED TO GWOT, E SEVERE (GLASGOW COMA SCALE 3-8),LOC >24HRS,POST TRAUMA AMNESIA >6 DAYS V15.5_F PERSONAL HISTORY OF TBI, UNKNOWN IF RELATED TO GWOT, PENETRATING INTRACRANIAL WOUND 641 642 Example: A service member presents to the local MTF stating she is suffering from 643 headaches. She has a history of headaches dating back to an explosion occurring in 644 Iraq. Provider determines an injury occurred along with alteration of consciousness. 645 The provider determines the headaches are TBI related: 646 647 648 Primary diagnosis: 784.0 (Headache) 106 5 107 MHS Coding Guidance 108 March 2008 109 110 DIAGNOSTIC CODING 111 112 649 Secondary diagnosis: V15.5_1 (Personal History of TBI, Global War on 650 Terrorism (GWOT) Related, Unknown Level of severity): 651 V70.5_6 (Post deployment encounter) 652 653 Example: A service member presents to the MTF. He is depressed and has had 654 ringing in his ears for the past several months. The provider obtains the patient’s 655 history and notes the patient was involved in a motor vehicle accident while deployed 656 in Afghanistan. He struck his head on the steering wheel and lost consciousness for 657 ten minutes. The provider diagnoses the patient with depression and tinnitus; these 658 diagnoses are related to a TBI during his deployment to Afghanistan. The encounter 659 would be coded as follows: 660 661 Primary diagnosis: 311 (Depression) 662 Secondary diagnoses: 388.30 (Tinnitus) 663 V15.5_2 Personal History of TBI, GWOT Related, Mild 664 (Glasgow Coma Scale 13-15), LOC<1HR, Post Trauma Amnesia<24HR 665 V70.5_6 (Post deployment encounter) 666 667 Example: A family member presents to the MTF complaining of chronic neck pain 668 and vertigo following a motor vehicle accident two months prior to this encounter. He 669 experienced loss of consciousness for 25 minutes. The encounter would be coded as 670 follows: 671 672 Primary diagnosis: 723.1 (Neck Pain) 673 Secondary diagnoses: 780.4 (Vertigo) 674 V15.5_7 Personal History of TBI, not related to Global 675 War on Terrorism, Mild (Glasgow Coma Scale 13-15), LOC<1HR, Post Trauma 676 Amnesia<24HR 677 6782.2.7. Chronic Conditions 679

680 DoD Rule 681 682 When assessed by the clinician, assign “tobacco use” or “history of 683 tobacco use” codes (305.1 or V15.82) in order to manage our 684 population health. 685

686 687When a chronic disease is treated on an ongoing basis, it may be coded as often as treatment 688and care are provided to the patient for that condition. 689

113 6 114 MHS Coding Guidance 115 March 2008 116 117 DIAGNOSTIC CODING 118 119 690 Example: A patient is treated monthly with an epidural block and steroid injection 691 for chronic low back pain (724.2). The code for low back pain would be reported 692 each time the patient presented for care for this problem. 693 694A chronic condition not addressed during the encounter that does not affect the care 695provided during the visit should not be coded with the encounter. Remind providers that 696medical decision making can be supported for higher levels of service if providers properly 697document. 698 699 Example: The same patient listed above also has hyperlipidemia. The patient is 700 coming in for chronic low back pain, so unless hyperlipidemia is a factor in the care 701 received for low back pain, it does not get coded. 702 7032.2.8. V Codes—Factors Influencing Health 704DoD extender codes have been paired with selected V codes to further specify military 705unique services. The addition of DoD extender codes to the root code enables 706differentiation of the types of health assessments. The V codes are used to identify 707circumstances (diagnoses) other than disease, symptom, or injury that are the reason for an 708encounter, or that explain why a service or procedure was furnished. V codes are used to 709classify a patient in the following circumstances: 710 711When a person is not currently or acutely ill, but requires healthcare services for some 712purpose, such as preventive education and counseling or prophylactic vaccinations. 713 714 Examples: V04.2 would be used for the child receiving a measles vaccination in a 715 pediatric clinic; V65.3 would be used for the diabetic patient who receives dietary 716 counseling. 717 718 V04.89 would be used for Human Papilloma virus (HPV) vaccination of girls and 719 women 9-26 years old. Use procedure codes 90649 (HPV vaccine) and 90471 720 (administration). 721 722When a circumstance or problem influences the patient’s current illness or injury, but is not 723in itself a current illness or injury. 724 725 Example: A patient visits a provider’s office with a complaint of chest pain with an 726 undetermined cause; patient status is post open-heart surgery for mitral valve 727 replacement. Code 786.50 would be used to identify the chest pain, unspecified, and 728 code V43.3 would be used to identify the heart valve replaced by other means. 729 730When a person with a known disease or injury uses the healthcare system for specific 731treatment of that disease or injury: 732 733 Example: Encounter for occupational therapy for patient with cognitive deficits 734 secondary to an old cerebral vascular accident (CVA) would be coded V57.21, 438.0. 120 7 121 MHS Coding Guidance 122 March 2008 123 124 DIAGNOSTIC CODING 125 126 7352.2.8.1. DoD-Unique V-Code Guidance for Flyer Status 736The annual flight physical or aviation exam is coded using V70.5_1. Flyers returning to 737active flight status who have an appointment to evaluate their condition should be coded 738using V68.09 (medical certificate). 739 7402.2.8.2. DoD-Unique V-Code Guidance for Assessments, Exams, Education, and 741 Counseling 742DoD extender codes have been paired with selected V codes to further specify military 743unique services. The addition of DoD extender codes to the root code enables 744differentiation of the types of health assessments. See section 6.17. for E&M coding 745guidance. 746 747 V70.5_0 Armed Forces medical exam: This is the initial general 748 accession exam. For pre-enlistment, this initial qualifying 749 exam is a “yes” test that a person meets the requirements to 750 join the military. Excludes exams covered under V70.5_8 751 Special Program Accession Exam. 752 753 V70.5_1 Aviation Exam: Initial qualifying and any recurring aviation 754 exam. 755 756 V70.5_2 Periodic Health Assessments (PHA) or Prevention Assessment: 757 Includes service member PHA documented on DD2766. Also 758 use for a complete military physical exam which is not an 759 accession, occupational, separation, termination or retirement 760 exam. 761 762 V70.5_3 Occupational exam: Both initial qualifying and recurring 763 exams because the individual works in a specific occupation or 764 in support of occupational medicine programs (workers’ 765 compensation). Examples include: diving, firefighter, Personal 766 Reliability Program (PRP), protection of the president, crane 767 operator and submariner. For return to duty following a non- 768 aviation occupation-related condition, use V70.5_7. 769 770 V70.5_4 Pre-Deployment Related Encounter: Encounter related to a 771 projected deployment. Could include family members 772 experiencing a condition related to the projected deployment 773 of the sponsor or other family member. Excludes V70.5_D 774 which codes the encounter documented on the DD2795. 775 776 V70.5_5 Intra-Deployment encounter: Any deployment-related 777 encounter performed while individual (active duty [AD], 778 contractor, etc.) is deployed. Could include family members

127 8 128 MHS Coding Guidance 129 March 2008 130 131 DIAGNOSTIC CODING 132 133 779 experiencing a condition related to the deployment of the 780 sponsor or other family member. 781 782 V70.5_6 Post-deployment related encounter: Specifically performed 783 because an individual was deployed. Could include family 784 members experiencing a condition related to a prior 785 deployment of the sponsor or other family member. Excludes 786 V70.5_E and V70.5_F which code the encounters 787 documented on the DD2796 and DD2900. 788 789 V70.5_7 Duty Status Determination encounter: Used for service 790 members when the primary reason for being seen is to 791 determine the ability to perform their duties. Includes 792 determination or change in status of temporary or permanent 793 duty limitations, deployment limiting conditions, temporary 794 and permanent duty retirement list (TDRL/PDRL), medical 795 evaluation board (MEB) assessments, and return to duty 796 following pregnancy or surgery and treatment. See section 797 5.9.2.for MEB coding. Excludes return to flight/dive status 798 (e.g., upchit) which is V68.09. 799 800 V70.5_8 Special Program Accession Encounter: A special medical 801 examination on individuals being considered for special 802 programs prior to Service entry. Exams are usually for 803 officer candidates (Reserve Officer Training Corps [ROTC] 804 programs, college graduates, professional schools, etc.) 805 Other examples are DoD Medical Review Board exams, 806 Health Professional School Program (HPSP) exams, and 807 supplemental exams in support of Medical Examination 808 Processing Stations. 809 810 V70.5_9 Separation/Termination/Retirement Exam: Examination 811 performed at the end of employment and for retirement or 812 separation. 813 814 V70.5_A Health Exam of defined subpopulations: Performed on a 815 person in a specified group (refugees, prisoners, preschool 816 children, etc.) other than exams identified above. Includes 817 examinations related to the Exceptional Family Member 818 Program (EFMP) and Overseas Screening. This is not the 819 appropriate code for sport/school physicals, for such 820 guidance see 6.14.1.2.1. 821 822 V70.5_B Abbreviated Separation/Termination/Retirement Exam: This 823 code would be used when a partial examination is done 134 9 135 MHS Coding Guidance 136 March 2008 137 138 DIAGNOSTIC CODING 139 140 824 within a defined period after a complete examination as an 825 update. Guidance for abbreviated separation, termination or 826 retirement exam will be provided by each service. 827 828 V70.5_C Physical Readiness Test (PRT) Evaluation: Evaluation of service 829 member by a provider who is privileged to determine participation 830 in Physical Fitness Assessment program (PFA) or physical 831 conditioning. 832 833 V70.5_D Pre-Deployment Assessment: Documented on DD2795. 834 835 V70.5_E Initial Post-Deployment Assessment: Documented on DD2796. 836 837 V70.5_F Post Deployment Health Reassessment (PDHRA): Documented on 838 DD2900. 839 840 V70.5_G Other Exam Defined Population: To be used for Global War on 841 Terrorism (GWOT)/Wounded Warriors (WW). 842 8432.2.8.3. Deployment Related Assessments 844To proactively and reactively provide healthcare related to deployments, the DoD must be 845able to identify healthcare needs caused by deployments. Codes V70.5 4/5/6 may be used in 846the second, third, or fourth position to indicate some aspect or the encounter is deployment 847related for inpatient and outpatient reporting. Codes V70.5_4/5/6/D/E/F are to be used as a 848primary diagnosis for an exam, assessment, or screening encounter when the purpose of the 849encounter is specifically deployment related. 850 851Codes V70.5_4/5/6/D/E/F will be used in the subsequent diagnosis positions when the 852primary purpose of the encounter was not specifically deployment related, but “deployment 853related” concerns were found that should be coded as additional diagnoses. 854 855 Example: An AD member who recently returned from deployment presents to the clinic 856 for an evaluation of a rash. The provider evaluates the patient and diagnoses the patient 857 with cutaneous leishmaniasis related to his recent deployment to Iraq. The primary 858 diagnosis in this scenario is 085.9 (unspecified cutaneous leishmaniasis) and the 859 secondary code would be V70.5_6. If during this encounter the provider discovers that 860 the patient has not completed his DD2976 and has the patient complete it, then V70.5_E 861 should be added as an additional diagnosis. 862 8632.2.8.4. Reporting Scenarios for V70.5 Extender Codes. * 864 865PRT (V70.5_C) 866Prior to doing Physical Readiness Testing all service members must complete a PRT 867screening questionnaire. If all answers are “no” the member is not referred for further 141*www.pdhealth.mil 142 10 143 MHS Coding Guidance 144 March 2008 145 146 DIAGNOSTIC CODING 147 148 868follow up and completes the PRT. There is no medical encounter or coding. If any 869answers are “yes” the member comes in for a medical evaluation. 870 871 1. Service Member has a known medical problem, example post ACL repair. 872Provider does not do an exam of the Service Member. Service Member is issued a 873waiver from PRT. Use ICD-9 code V 70.5_C as the primary diagnosis and the medical 874problem(s) as secondary. 875 876 2. Service Member is referred for additional assessment based upon answers on 877the PRT questionnaire. Provider reviews assessment and determines Service Member is 878cleared for PRT. Use E&M 99420 and ICD-9 code V70.5_C. For example, the member is 879referred based solely on their age, but are otherwise healthy with no complaints, the 880provider finds them fit to complete the PRT. 881 882 3. Service Member is referred for medical evaluation based upon answers on the 883PRT questionnaire. Provider reviews the assessment and finds the patient requires further 884evaluation and management. The encounter should be coded based on documentation and 885code V70.5_C as primary and other diagnoses as secondary. 886 887Pre-deployment (DD Form 2795) (V70.5_D) 888Collection of this information is for military readiness to ensure assessment is done 889prior to deployment. 890 891 1. The DD Form 2795 is determined to be a negative assessment and is reviewed 892only by a non-privileged provider, and the form is filed. Code the ICD-9 code V70.5_D 893under the technician’s name. 894 895 2. The privileged provider reviews the form and makes a final medical disposition. 896Code E&M 99420 and the ICD-9 code V70.5_D. 897 898 3. The provider identifies, addresses and documents a medical problem. The 899encounter should be coded based on documentation and code V70.5_D as primary and 900other diagnoses as additional. 901 902Post Deployment Assessments (V70.5_E/F) 903Exams will always be conducted by a face to face encounter with a privileged 904provider. 905 906 Initial Post Deployment (DD Form 2796) (V70.5_E) 907 908 1. If the purpose of the encounter is to complete the DD Form 2796 by the 909privileged provider and no medical conditions are found, code V70.5_E first and use 91099420 for the E&M. 911 2. If the purpose of the encounter is to complete the DD Form 2796 and 912assessment and medical evaluation identifies medical conditions requiring treatment, 149 11 150 MHS Coding Guidance 151 March 2008 152 153 DIAGNOSTIC CODING 154 155 913code V70.5_E first and then code appropriate ICD9 codes. Use 99420 for the E&M code 914and additional E&M based on the documentation with modifier 25. 915 916 3. If during an encounter for other reasons, it is determined that a required DD 917Form 2796 has not been completed, code the appropriate ICD9 code for the principal 918reason for the visit and use code V70.5_E in the first four diagnosis codes. Use 919appropriate office visit E&M code based on the documentation. 920 921 Post Deployment Health Reassessment (PDHRA) (DD Form 2900) (V70.5_F) 922 923 Encounters involving completion of the DD Form 2900, should be coded in the 924same manner as specified for DD Form 2796 Initial Post-Deployment Assessment, 925substituting V70.5_F in place of V70.5_E. 926 927Scenarios for coding primary complaints that are deployment related. 928 Type of Example Primary 2nd, 3rd or 4th Dx Patient Diagnosis Code Symptoms, New onset bed wetting of 5-yr- 788.36 (nocturnal V70.5_4 Pre- old boy whose mother is about enuresis) Deployment- to leave on 12 month Related deployment. Asymptomatic AD soldier recently returned V65.5 (person V70.5_ 6 Concerned, from deployment. Pregnant with feared Post- wife has concerns about complaint) Deployment- depleted uranium exposure. Related Symptoms, 13-yr-old girl with significant 783.21 V70.5_ 5 Intra- weight loss. Mother suspects (abnormal weight Deployment- concern is related to father’s loss) Related current deployment to Iraq.

Symptoms, 23-yr-old Marine developed 692.6 (contact V70.5_ 5 Intra- poison ivy rash while deployed. dermatitis caused Deployment- by plants) Related Medically 49-yr-old retired beneficiary 799.8 (other ill- V70.5_ 6 Unexplained has been evaluated over 3 defined Physical months (5 visits) for conditions and Symptoms, intermittent joint pain, unknown causes Deployment- intermittent vertigo and severe of morbidity) Related fatigue. Patient says he believes he was exposed to something in Kuwait on

156 12 157 MHS Coding Guidance 158 March 2008 159 160 DIAGNOSTIC CODING 161 162 mission two years ago. Work- up to date is complete, but negative. 929 930This guidance is subject to change. More detailed information on program management is at 931http://www.pdhealth.mil/. 932 9332.2.8.5. V68.09 Issue of Medical Certificates 934Medical certificates are frequently completed as part of an examination or physical. Use 935code V68.09 when there is no medical indication for the encounter, the patient’s reason for 936the encounter was solely to obtain a medical certificate; there is not another more 937appropriate code to reflect the primary reason for the encounter, and no symptoms, 938conditions, or diseases were evaluated or treated. See Section 6.6 Flight Medicine Services 939for an example involving flight medicine ground testing. The code V68.09 would not be 940used, for instance, when a student needs a sports physical, as there is a more appropriate 941code to reflect the reason for the visit, V70.3—other medical exam for administrative 942purpose. 943 9442.2.8.6. Case Management Services 945The Case Management coding and reporting framework can be found in Appendix E. 946 9472.2.9. External Cause of Injury—E Codes 948E codes should be used only for the first encounter at the MTF for treatment of an 949injury. If the patient was treated at a local civilian emergency department and 950received follow up or after care at the MTF, the first encounter at the MTF should 951have an E code. Providers should be taught always to document when initial care 952is received elsewhere. For follow-up care without documentation of the initial 953visit, assume the patient was initially treated at the MTF and do not use an E code. 954 955An E code should be used with any diagnosis that indicates an injury, poisoning, 956or adverse effect with an external cause. In general, when the diagnosis code is in 957the range of 800–999, and V71.3–V71.6, at least one E code should be entered on 958the ADM record the first time the patient is seen for the condition. An example of 959when an E code would not be used for the codes listed above would be in 960conjunction with 917.2, blister without mention of infection, caused by walking in 961new shoes without wearing socks. 962 963As many E codes should be assigned as necessary to fully explain each cause. All 964ICD-9-CM codes describing the reason for treatment must precede the E codes. If 965only one E code can be reported in ADM, assign the E code most related to the 966primary diagnosis or injury. Use the full range of E codes to completely describe 967the cause, the intent, and the place of occurrence, if applicable, for all injuries, 968poisoning, and adverse effects of drugs. 969Owing to limited number of reporting fields (currently four diagnoses) in the 970SADR extract, the E codes may not be reported upward. The E codes should be 163 13 164 MHS Coding Guidance 165 March 2008 166 167 DIAGNOSTIC CODING 168 169 971assigned after the more critical injuries are listed. Only use E codes for external 972causes of injury. There is no additional code for most repetitive stress injuries 973and other injuries, such as knee pain owing to obesity or back pain caused by 974pregnancy. 975 9762.2.10. Child and Adult Abuse Guidelines 977Child and adult abuse codes may only be documented in ADM when substantiated. 978 979When the cause of an injury or neglect is intentional child or adult abuse, the first listed E 980code should be assigned from categories E960–E968 (Homicide and Injury Purposely 981Inflicted by Other Persons), except category E967. An E code from category E967 982(Child and Adult Battering and Other Maltreatment), should be added as an additional 983code to identify the perpetrator, if known. 984 985In cases of neglect, when the intent is determined to be accidental, E code E904.0 986(Abandonment or Neglect of Infant and Helpless Person) should be the first listed E code 987(not the primary diagnosis). 988 9892.2.11. M Codes: Morphology of Neoplasm’s 990The morphology of neoplasm is not collected in the ADM. 991 9922.2.12. Abortions 993The number of legal—elective or therapeutic—and illegal abortions performed in DoD 994MTFs must be reported to Congress annually. Use of the 635, 636, and 637 codes should 995be carefully scrutinized. Coding personnel will not use 635–638 without authorization 996from their supervisor. Some of the basic rules that apply include the following: 997 998  Fifth-digit-1, incomplete, indicates that all of the products of conception have 999 not been expelled from the uterus prior to the episode of care. 1000  Fifth-digit-2, complete, indicates that all of the products of conception have 1001 been expelled from the uterus. 1002  Code 635 requires additional code to identify the reason for the abortion. Codes 1003 from categories 640–648 and 651–657 (with fifth digits 3) may be used as 1004 additional codes with an abortion code to indicate the complication leading to 1005 the abortion. 1006  Codes from the 660–669 series are not to be used for complication leading to the 1007 abortion. 1008  Retained products of conception following an abortion: Subsequent encounters 1009 with the diagnosis of retained products of conception following a spontaneous or 1010 legally induced abortion are assigned the appropriate code from category 634, 1011 spontaneous abortion, or 635, legally induced abortion, with a fifth digit of 1 1012 (incomplete). This advice is appropriate even when the patient was discharged 1013 previously with a diagnosis of complete abortion.

170 14 171 MHS Coding Guidance 172 March 2008 173 174 DIAGNOSTIC CODING 175 176 1014  A patient who has an abortion performed outside the MTF and presents for 1015 treatment without complications is assigned code V58x. To treat a complication 1016 following an abortion, code the complication using 639x codes. Category code 1017 639 is to be used for all complications following complete abortions. Code 639 1018 cannot be assigned in the presence of codes 634–638. 1019  Illegally induced abortion (636): Not performed within prescribed statutes, 1020 performed by an unqualified individual, or performed at an unauthorized 1021 location. Do not use in DoD. 1022  Unspecified abortion (637): No details about the abortion are available. Do not 1023 use in DoD. 1024  Failed abortion (638): The elective procedure failed to evacuate or expel the 1025 products of conception (fetus) and the patient is still pregnant. 1026  If a code from 636 or 637 must be used, supervisor approval must be 1027 obtained and the supervisor must contact his/her Service coding 1028 representative prior to assignment. 1029 1030As with all coding, it is important to select the correct 3rd, 4th, and 5th digits, as applicable. 1031Use DoD-unique code extenders 0 (elective), 1 (therapeutic), 2 (elective, terminated 1032elsewhere), or 9 (unspecified) with abortion codes 635 and 638. 1033 1034Do not use unspecified abortion codes in DoD. 1035 1036When using the code for abortions incomplete with other specified complications, an 1037additional code is required to describe the other specified complication. 1038 1039If a patient has an abortion at the MTF or elsewhere and returns for care after the abortion, 1040with no problems present, the code is V58.49, after care, following surgery. 1041 10422. 2.13. Abortion with Live-Born Fetus 1043When an attempted termination of pregnancy results in a live-born fetus, assign code 1044644.21, Early Onset of Delivery, with an appropriate code from category V27, Outcome of 1045Delivery. The procedure code for the attempted termination of pregnancy should also be 1046assigned. 1047 10482.2.14. Closing Out an Encounter for Lack of Documentation 1049When there is an indicator that an encounter occurred (e.g., documented technician 1050screening, a prescription, laboratory test or radiology study associated with the 1051encounter), but the provider’s documentation of the encounter is not available, code the 1052encounter V68.89, unspecified administrative purpose. If there is no indication of an 1053encounter within 45 days, cancel the appointment in CHCS. 1054 10552.2.15. HIV 1056Return visit for results of HIV serology test will be assigned to code V65.44, HIV 1057counseling. For inconclusive findings, an additional code of 795.71, Nonspecific 1058serologic evidence of human immunodeficiency virus (HIV) would be used. 177 15 178 MHS Coding Guidance 179 March 2008 180 181 DIAGNOSTIC CODING 182 183 1059

184 16 185 MHS Coding Guidance 186 March 2008 187 188 189 EVALUATION AND MANAGEMENT (E&M) CODING 190 191 1060Chapter 3 EVALUATION AND MANAGEMENT (E&M) CODING 1061 1062ALL CODING WILL BE SUPPORTED BY THE DOCUMENTATION IN THE MEDICAL 1063RECORD.

1064 DoD Rule 1065 1066 AHLTA Documentation: Autocite information will not be considered 1067 when determining the appropriate ICD-9-CM, E&M, and/or CPT code to 1068 be assigned to the encounter, unless you assume the entire note or 1069 acknowledge the pertinent findings within the body of the providers’ notes. 1070

1071 1072NOTE: This section refers to coding collected in the second data collection screen of the ADM. 1073Only E&M codes 99201–99499 may be entered in this screen. There are other E&M codes, most 1074frequently used in mental health, optometry or ophthalmology, physical therapy, and occupational 1075therapy. Refer to separate sections on E&M codes outside the 99201–99499 range. 1076 1077Facilities should indicate in their compliance plan which set of CMS guidelines each clinical 1078service will follow. Indicate how the encounter was audited—using the CMS 1995 or 1997 1079E&M guidelines. 1080 1081NOTE: Chapter 3 is organized as follows: Section 3.1. gives general information on E&M coding 1082in the MHS. Sections 3.2. to 3.8. cover categories of E&M codes. The paragraphs follow the 1083numbering sequence in the CPT. For instance, paragraph 3.2. provides MHS information on codes 108499201–99215; paragraph 3.3 gives MHS information on the next category in the CPT, codes 108599217–99236. 1086 10873.1. Evaluation and Management Coding – 99201-99499 1088E&M codes, a subset of CPT codes, identify the location, type, and overall complexity of a 1089patient encounter. Modifiers clarify the E&M services provided, but their use is limited by MHS 1090systems. 1091 10923.1.1. Determination of Level of E&M Code 1093The three key elements in selecting the appropriate complexity of the E&M code are history, 1094examination, and medical decision making. These components must meet or exceed the minimum 1095requirements specified in the E&M guidance of CPT. When determining the level of history for an 1096E&M code, the documented elements in the History of Present Illness (HPI) may also be counted in 1097the Review of Systems (ROS) and the Past Family Social History (PFSH) when appropriate. If 1098nausea, vomiting, and diarrhea is documented in the HPI, it is not necessary to re-document 1099“nausea, vomiting, and diarrhea” in the ROS section in order to count it in both elements of the 1100history component. There are four contributory factors: nature of presenting illness, coordination of

192 1 193 MHS Coding Guidance 194 March 2008 195 196 197 EVALUATION AND MANAGEMENT (E&M) CODING 198 199 1101care, counseling, and time. More E&M documentation guideline information is on the CMS 1102website at http://www.cms.hhs.gov/. 1103 11043.1.1.1. Chief Complaint /HPI/ROS/PFSH 1105The reason for the encounter, called the chief complaint, should always be noted in the encounter 1106documentation. This requirement can be met by printing out the reason entered by the appointment 1107clerk in the computer system. If the chief complaint is not what the appointment clerk entered, (e.g., 1108patient told clerk the appointment was for abdominal pain, but when the patient met the provider, 1109the patient expressed concerns about a sexually transmitted disease), the correct chief complaint 1110must be documented. All parts of the history (HPI, ROS, PFSH) and the chief complaint may be 1111documented by other staff members or the patient. Only those parts of the HPI that are actually 1112documented by the provider may be used in calculating the level of the encounter. Any 1113documentation, from provider, staff member, or patient, may be used to calculate the level of the 1114encounter for the ROS and PFSH. 1115 1116To certify that the provider reviewed the information documented by others, there must be a 1117notation supplementing or confirming the review. 1118 1119In AHLTA, support staff can document subjective and objective information. Providers can take 1120ownership of that documentation and modify it. When the provider takes ownership of another’s 1121documentation, these elements are considered the provider’s documentation and are included in the 1122calculation of the E&M code. When ROS and PFSH information are documented by support staff 1123and the provider does not take ownership of that documentation, the provider must document his 1124review of that information and agreement or disagreement with that information. When support 1125staff document HPI information, the provider must take ownership of that documentation. Failure to 1126do so will result in the AHLTA E&M calculator erroneously including the support staff HPI 1127documentation in the E&M code calculation. 1128 11293.1.2. Coding E&M in ADM 1130An E&M code is no longer required for each encounter. Up to three E&M codes may be entered. 1131Use of 99499 is not auditable on TMA audits. Modifiers should be assigned where appropriate. 1132 11333.1.3. Privileged Providers 1134A privileged provider may use any E&M code that accurately reflects the services rendered and 1135documented. Privileged provider encounters with such limited documentation as to only support a 113699211 will be coded with a 99211. A privileged provider is an independent practitioner who is 1137granted permission to provide medical, dental, and other patient care in the granting facility, within 1138defined limits, based on the individual’s education, licensure, experience, competence, ability, 1139health, and judgment. Resident physicians are not independent practitioners, although they are 1140included in the scope of privileged providers for this document. 1141 1142NOTE: Navy coding guidance for IDCs and Air Force coding guidance for IDMTs are in 1143Appendix B. 1144 200 2 201 MHS Coding Guidance 202 March 2008 203 204 205 EVALUATION AND MANAGEMENT (E&M) CODING 206 207 11453.1.4. Non-Privileged Providers (Nurses and Technicians) 1146Non-privileged providers are normally restricted to using E&M code 99211 to document face-to- 1147face encounters in which no procedure is performed (e.g., counseling or education by a technician 1148or offering a service or supply item that does not have a specific code). 1149The following clinic services are not considered codeable events: 1150 1151  TB test reading 1152  Patient who presents for an order for pregnancy test only 1153  Blood pressure checks per patient request 1154  Patient who presents to pick up a prescription refill 1155 11563.1.4.1. 5 Day BP Checks 1157Nurses/technicians will use the vital signs module to collect the data for the 5 day blood pressure 1158checks. 1159 1160 Day 1: Create encounter and document vital sign in vital signs module (use E&M 99211) 1161 1162 Day 2 - 5: Append day 1 encounter and update vital signs in the vital signs module 1163 11643.1.5. Encounter Duration 1165 11663.1.5.1. When Time Is Not a Dominant Factor 1167Time is not a dominant factor for assigning the appropriate E&M code in most scenarios. The 1168time frames identified in E&M code descriptions represent a general range of time that will vary 1169depending on actual clinical circumstances. The severity of illness as documented by history, 1170examination, and medical decision making should determine the choice of office visit or 1171consultation E&M code. 1172 11733.1.5.2. Counseling and Coordination Exception 1174Counseling and coordination are exceptions to the time factor in selecting the E&M code. Time is a 1175determining factor when counseling or coordination of care consumes more than 50 percent of the 1176time a provider spends face-to-face with the patient, the family, or both. 1177

1178 DoD Rule 1179 1180 AHLTA Documentation: When a provider selects greater than 50% of 1181 time spent “counseling and/or coordinating care” and also selects the 1182 appropriate amount of floor time (face to face) then time in and time out 1183 requirement has been met. 1184

208 3 209 MHS Coding Guidance 210 March 2008 211 212 213 EVALUATION AND MANAGEMENT (E&M) CODING 214 215

1185 Documentation must indicate specifics on the discussion of why the 1186 additional time was necessary, what occurred during that time, and how 1187 much time was spent. 1188 1189 Note: “counseled on condition” is not acceptable documentation.

1190 11913.1.5.3. Other Specific Exceptions 1192Specific exceptions when time is always a factor are prolonged services, critical care, discharge 1193services, and patient transport. Time plays a role in the extended duration of the encounter. 1194Extended time may be identified in two ways, modifier -21 (Prolonged E&M Services), or E&M 1195codes 99354–99357 (Prolonged Services). Modifier -21 is used to designate the total duration of 1196provider–patient face-to-face time when it exceeds the typical time of encounter. Modifier -21 can 1197only be used with the highest level E&M code (e.g., 99215, 99245). Codes 99354–-99357 are used 1198when treatment exceeds the E&M code by more than 30 minutes. Codes 99354–99357 can be used 1199as add-on codes with any level of E&M service. Modifier -21 and codes 99354–99357 cannot be 1200used with the same encounter. Documentation must support the need for additional time, as well as 1201the time of the encounter (e.g., time in and time out). 1202 12033.1.6. New and Established Patients 1204To recognize the different levels of service between a patient who has not received care in a practice 1205(and therefore needs more explanations about the operation of the practice) and an established 1206patient (who is aware of the practice’s routines), there are different coding categories. 1207 12083.1.6.1. New Patient 1209A new patient is one who has not received any professional services from the provider or another 1210provider of the same specialty who belongs to the same group practice in the previous three 1211years. 1212 1213A new patient may receive initial professional services as an inpatient or outpatient. 1214Subsequent professional services would be coded as an established patient. The 1215encounter that determines a new patient is the first encounter a patient has that meets the 1216criteria above and meets the requirements of a visit. Occasions of service are not coded 1217as a new patient encounter. A common error in the DoD is coding a newborn as a new 1218patient at its first well-baby visit with the pediatrician involved with the delivery and 1219initial hospitalization. The first well-baby visit would be as an established patient.

216 4 217 MHS Coding Guidance 218 March 2008 219 220 221 EVALUATION AND MANAGEMENT (E&M) CODING 222 223 1220 12213.1.6.2. Established Patient 1222An established patient is one who has received professional services from the provider or another 1223provider of the same specialty who belongs to the same group practice in the previous three 1224years. A common error in DoD is an optometrist new to the facility coding all patients as new. 1225The patients who had been seen in the clinic by the previous optometrists in the prior three years 1226are all established patients to that optometry clinic. 1227 12283.1.6.3. Determining New versus Established based on Documentation 1229New and established patients are determined based on documentation. If the documentation does 1230not specifically indicate new or established and the record is not available to review for previous 1231encounters, verify prior encounters in ADM. If, after research, the status of the patient cannot be 1232determined, the encounter will be coded as an established patient. 1233 12343.2. Office Outpatient Services, 99201–99215 1235These codes are used when a privileged provider collects a medically related history, performs an 1236exam, and makes a medical decision in a DoD healthcare facility on a patient who is not admitted as 1237an inpatient to a healthcare facility. 1238 12393.2.1. Shared Medical Appointments (SMA) 1240SMAs are visits when multiple patients meet with the provider and a behaviorist at the same 1241encounter. A list of chief complaints is compiled. All patients are present for those parts of the 1242examination not requiring privacy. The provider examines each patient individually and addresses 1243the patient’s issues. Immediately after completing the encounter with each patient, the provider 1244documents the encounter while the behaviorist furnishes general education or counseling. When the 1245provider completes the documentation, the provider starts the next patient’s exam. This continues 1246until all patients are evaluated and treated. SMAs usually take 60–90 minutes to complete. SMAs 1247are coded based on documentation. Only one encounter per patient will be completed. The 1248appropriate E&M code will be assigned according to the documentation (i.e., prevention/office 1249visit). The modifier TT, indicating individualized services with multiple patients present, is used 1250when available in the ADM. 1251 12523.3. Hospital Observation Services 99217–99220 and 99234–99236 1253Patients are in observation to determine whether they should be admitted to the hospital, transferred 1254to another facility or sent home. This is an unplanned service. Patient stays in observation status 1255should not exceed 48 hours. Follow MTF guidance for notification when observation exceeds 48 1256hours. 1257 12583.3.1. Doctor’s Orders 1259The doctor must specifically write an order to place a patient in observation. Observation cannot be 1260initiated based on standing orders. 1261 1262 1263 224 5 225 MHS Coding Guidance 226 March 2008 227 228 229 EVALUATION AND MANAGEMENT (E&M) CODING 230 231 12643.3.2. Observation Time 1265Observation time begins at the clock time appearing on the nurse’s initial admission or observation 1266note. Observation ends at clock time documented in the doctor’s discharge orders. If there is no 1267time on the doctor’s discharge orders, the time the nurse signs off on the doctor’s orders is used. 1268 1269NOTE: A SADR is required for each date of service. 1270 1271The table below summarizes the appropriate use of E&M codes for observation care. 1272 1273 E&M Codes for Observation Services LENGTH OF OBSERVATION (CALENDAR DAY OF OBSERVATION E&M CODES DAYS OR DATES) SERVICE FOR ACUITY LOW MODERATE HIGH Initial observation care when length of stay exceeds Day 1 99218 99219 99220 calendar day of admission to observation. Observation care services provided when patient is Day 1 99234 99235 99236 admitted and discharged on same calendar day of service. Observation care on a day not the admission and not Middle 99212 99213-99214 99214- the discharge day. days 99215 Observation care services provided on day of discharge Day 2 or 3 99217 99217 99217 (unless day of discharge is day of admission) across 2 (date of or more calendar days, but not exceeding a total of 48 discharge) hours of observation care. 1274 1275The following G codes will not be used in the MHS at this time: 1276 1277 G0378 Hospital Observation Services, per hour 1278 1279 G0379 Direct admission of patient for hospital observation care in the result of a direct 1280 admission to “observation status” without an associated emergency room visit, hospital 1281 outpatient clinic visit or critical care service on the day of initial observation services. 1282 1283The following services are not qualified as outpatient observation services: 1284  Those that exceed 48 hours, unless an exception is deemed necessary after a medical 1285 necessity review. 1286  Those not reasonable or necessary for the diagnosis or treatment of the patient but 1287 provided for the convenience of the patient, his or her family, or a physician or provider 1288 (e.g., after an uncomplicated treatment or procedure; physician or provider is busy when 1289 patient is ready for discharge; patient awaiting placement in a long-term care facility). 1290  Inpatient services. 1291  Services associated with ambulatory procedure visits. 1292  Routine preparation services furnished prior to testing and afterwards during recovery 1293 (e.g., patients undergoing diagnostic testing in a hospital outpatient department).

232 6 233 MHS Coding Guidance 234 March 2008 235 236 237 EVALUATION AND MANAGEMENT (E&M) CODING 238 239 1294  Observation concurrent with treatments such as chemotherapy. 1295  Services for postoperative monitoring. 1296  Any substitution of an outpatient observation service for a medically appropriate 1297 inpatient admission. 1298  Services ordered as inpatient services by the admitting physician or provider but reported 1299 as outpatient observation services by the hospital. 1300  Standing orders for observation following outpatient services. 1301  Discharges to outpatient observation status after an inpatient hospital admission. 1302 1303NOTE: For OB observation see section 6.10.4.1.1.1. 1304 13053.3.3. Observation to Admission 1306When a patient is admitted from observation status, the ADM record for the observation care should 1307be closed out with a disposition type of admitted. 13083.3.4. Observation to Ambulatory Procedure 1309When a patient is referred from observation to an ambulatory procedure unit (APU) or another 1310MTF, the ADM record for the observation care is closed out with disposition type of immediate 1311referral. 1312 13133.3.5. Admission from Clinic to Inpatient 1314If a provider admits a patient to his/her service from the clinic, make a copy of the visit notes and 1315add it to the inpatient record. The provider, or another provider from the same service, should 1316document additional services (e.g., H&P, visits, procedures) performed on that date of service in the 1317inpatient record. Combine the documentation from the clinic visit and the additional services 1318performed to code the initial inpatient E&M visit in addition to any procedures (CPT-4 and/or 1319HCPCS codes). To close out the clinic encounter, enter disposition “admitted.” Enter appropriate 1320diagnosis codes that represent the reason for the patient’s admission. 1321 1322If a provider sends the patient from the clinic to the hospital and another service admits the patient, 1323the clinic provider may code the clinic visit separately from the initial inpatient visit based upon the 1324documentation in the clinic record only. 1325 13263.3.6. Admission from Emergency Department (ED) 1327The emergency department provider codes the services provided. The emergency department 1328physician’s services are not included in the initial inpatient E&M of the admitting service. The 1329original emergency department notes and any additional services provided on that date of service 1330should be combined in the inpatient medical record. The encounter should be closed out with 1331disposition type “admitted.” The emergency department E&M should be coded separately under 1332BIAA for the initial ED visit. 1333 13343.4. Hospital Inpatient Services 1335See Chapter 9. Professional Coding of Inpatient Consults and Rounds (RNDs). 1336

240 7 241 MHS Coding Guidance 242 March 2008 243 244 245 EVALUATION AND MANAGEMENT (E&M) CODING 246 247 13373.5. Emergency Department 1338Code procedures performed by the emergency department staff, such as infusions, injections and 1339medications, EKG tracings, in addition to professional services. For consultation or referral 1340within the ED, see section 4.8. Not all services provided in the ED constitute use of an ED 1341E&M code(Office visit). 1342 1343The following G codes will not be used in the MHS at this time: 1344 1345G0380 Level 1 hosp type B emergency visit 1346G0381 Level 2 hosp type B emergency visit 1347G0382 Level 3 hosp type B emergency visit 1348G0383 Level 4 hosp type B emergency visit 1349G0384 Level 5 hosp type B emergency visit 1350 13513.6. Telephone Services 1352 1353NOTE: Code selection has changed and is now based on minutes of medical discussion. 1354 1355The following (Do not assign) list applies to privileged and non privileged providers. 1356 1357 DO NOT ASSIGN TELEPHONE SERVICES CODES FOR: 1358  Telephone services referring to an E&M service performed and reported by the same 1359 provider occurring within the past 7 days 1360  Telephone services ending with a decision to see the patient within 24 hours or next 1361 available urgent visit appointment 1362  Telephone services occurring within the post operative period of the previously 1363 completed procedure 1364  New patient interaction 1365  Provider to provider interaction 1366  Provider to commander interaction 1367  Leaving messages on answering machines 1368  Scheduling/Billing/Administrative issues 1369  Communication of non-clinical information 1370  Telephone services completed by residents that are PGY-1’s 1371  Any other administrative issues 1372  Providing test results 1373 13743.6.1. Privileged Provider 1375Telephone services are a patient initiated interaction between a privileged provider (to include 1376IDC’s) and an established patient. Documentation must contain evidence of medical decision 1377making by a licensed provider directly responsible for the management of the patient’s care. These 1378encounters are reviewed for appropriate clinical documentation by Service audits. Privileged

248 8 249 MHS Coding Guidance 250 March 2008 251 252 253 EVALUATION AND MANAGEMENT (E&M) CODING 254 255 1379providers, including residents beyond post-graduate year one (PGY1), may choose from the three 1380E&M codes for telephone services. (99441 – 99443) 1381 1382Code telephone services with E/Ms for privileged providers and residents beyond PGY-1. Below 1383are the new telephone services codes. 1384 138599441 Telephone evaluation and management service provided by a privileged provider to an 1386established patient, parent, or guardian not originating from a related E/M service provided within 1387the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 1388available appointment; 5-10 minutes of medical discussion 1389 99442 ; 11-20 minutes of medical discussion 1390 99443 ; 21-30 minutes of medical discussion 1391 1392For online E&M service (99444), see section 8.5.6. 1393 13943.6.2. Non Privileged Provider 1395Telephone services are a patient initiated interaction between a non privileged provider, (to 1396include IDMT’s) and an established patient. Documentation must contain evidence of 1397assessment and management of a patient’s care. These encounters are reviewed for appropriate 1398clinical documentation by Service audits. 1399 140098996 Telephone assessment and management service provided by a non privileged 1401provider to an established patient, parent, or guardian not originating from a related assessment 1402and management service provided within the previous seven days nor leading to an assessment 1403and management service or procedure within the next 24 hours or soonest available appointment; 14045-10 minutes of medical discussion 1405 98967 ; 11-20 minutes of medical discussion 1406 98968 ; 21-30 minutes of medical discussion 1407 1408For online assessment and management service (98969), see section 8.5.6. 1409 14103.7. Provider (privileged and non privileged) Initiated Telephone Calls 141199499 is to be used for provider initiated telephone calls. Use 99499 as the E&M in the T-CON* 1412module, and the diagnosis as the reason for the call.

256 9 257 MHS Coding Guidance 258 March 2008 259 260 261 CONSULTATION 262 263 1413Chapter 4 CONSULTATION 1414 1415THIS SECTION HAS CODING INFORMATION BASED ON THE SPECIALTY 1416CLINIC THAT PROVIDES SERVICES. 1417 14184.1. Consultation Guidelines 1419For consults, two providers are involved. The provider requesting the consult is the requesting 1420provider. The provider furnishing the consult is the consulting provider. 1421 14224.2. Consult versus Referral 1423 14244.2.1. Consult 1425A consult is a request for advice or opinion from a provider. This professional service may occur 1426in both inpatient and outpatient settings. A consulting provider may initiate diagnostic or 1427therapeutic services. Consults are coded from 99241 to 99255. For additional information on 1428inpatient consults, see section 9.5. 1429 14304.2.2. Referral 1431When the referring provider, in writing, transfers complete responsibility of treatment for a 1432specific or suspected problem, the receiving provider may not code a consult. Outpatient 1433referrals are coded using E&M codes for office visits as the new provider assumes full control of 1434the patient. Inpatient referrals require the patient be transferred to the new service, at which time 1435the new service begins using the appropriate Inpatient Hospital Services codes. 1436 1437 Example: 1438 Consult: A family practitioner asked a pulmonologist’s opinion about treatment 1439 options for a patient newly diagnosed with left lower-lobe pneumonia and cough. 1440 1441 Referral: A family practitioner requests that a pulmonologist take over treatment of a 1442 patient newly diagnosed with left lower-lobe pneumonia. The chart notes indicate the 1443 family physician will continue to manage the patient’s leukemia (initial reason for 1444 admission). 1445 14464.3. Documentation for Consultation 1447Documentation in the medical records should list the following: 1448  The request for the consult from the attending provider. 1449  The reason for the consult, documented by the attending provider in the patient’s medical 1450 record. 1451  A written report to the requesting provider for opinion or treatment advice from the 1452 consulting provider. It is not necessary for an auditor to locate a separate report if there is 1453 documentation on the SF600 encounter that a report was sent to the requesting provider. 1454  Three elements required in any consultation documentation: the history, physical exam, 1455 and medical decision making. 1456 264 1 265 MHS Coding Guidance 266 March 2008 267 268 269 CONSULTATION 270 271 14574.3.1. Documentation for Consultation in a Shared Medical Record 1458In an emergency department or inpatient or outpatient setting in which the medical record is shared 1459between the referring physician and the consultant, the request may be documented as part of a plan 1460written in the requesting physician’s progress note, an order in the medical record, or a specific 1461written request for the consultation. In these cases, the report may consist of an appropriate entry in 1462the common medical record. 1463 14644.3.2. Examples That Are Not Consults 1465The following examples do not satisfy the criteria for consultation: 1466  Standing orders in the medical record for consultation. 1467  No order documented for a consultation by the requesting provider. 1468  No written report sent back to the requesting provider from the consultation. 1469  Statements in the medical record such as, “Patient referred by Dr. Jones for consultation.” 1470 1471Use of the SF 513 Consultation does not, in and of itself, constitute a consultation service. 1472Referrals are frequently made using the SF 513. 1473 1474 CONSULTATION VS REFERRAL CONSULTATION REFERRAL Suspected problem or known problem Known problem Opinion or advice only sought Transfer of partial or total patient care for the specific problem Written request for opinion or advice received Patient appointment made for the purpose of from attending provider, including specific providing treatment, diagnostic, or therapeutic reason the consultation is required services Primary (attending) provider will decide who Provider is managing the known problem from will manage patient care the beginning Recommended documentation: Please Recommended documentation: Patient examine patient and provide me with your referred to your office for evaluation and opinion on his/her condition. The following treatment of his/her condition diagnostic/therapeutic treatment has been initiated/recommended 1475 14764.4. Consultations That Require More Than One Encounter 1477For outpatient coding, use the 9924x series for the initial visit and treatment. Any follow up care 1478resulting from the initial consult will be coded as an established patient office visit. For inpatient 1479coding use the 9925x series for the initial consult and subsequent hospital care codes (9923x) for 1480all additional encounters. 1481 14824.5. Clearing Patients for Specialty Care 1483When a consultation is requested to clear a patient for a specialty procedure (e.g., air 1484evacuation), it is coded using the office consultation E&M codes, 99241–99245 when clearance 1485is given in the clinic. If clearance is given during an inpatient stay, use codes 99251–99255 as 1486applicable. 1487 272 2 273 MHS Coding Guidance 274 March 2008 275 276 277 CONSULTATION 278 279 14884.6. Preoperative Consultation 1489The appropriate consultation code (99241–99255) may be reported for a preoperative 1490consultation performed by any provider, including a patient’s primary care provider, at the 1491request of a surgeon, as long as all consultation requirements are met and the service is medically 1492necessary. 1493 1494In reporting the diagnosis, it is important to remember that the role of each code is to explain 1495why a service was provided. In reporting preoperative clearance, the first diagnosis code would 1496be the code for preoperative examination (e.g., V72.81–V72.84). Additional ICD-9 codes for the 1497condition(s) that prompted surgery and for conditions that prompted the preoperative medical 1498evaluation should also be documented and reported. The underlying condition determines the 1499medical necessity for the preoperative clearance. Other diagnoses and conditions affecting the 1500patient may also be documented and reported if appropriate. 1501 1502 Example: 1503 V72.81 Preoperative cardiovascular examination 1504 336.13 Anterior sub capsular polar senile cataract-Reason for surgery 1505 401.1 Essential hypertension benign-Underlying condition, why medical 1506 clearance was needed. 1507 15084.7. Emergency Department 1509 15104.7.1. Referrals 1511The emergency department provider requests the specialist take over care or a portion of care. 1512The emergency department does not intend for the patient to receive follow-up care in the 1513emergency department. To code emergency department services with separate specialist 1514services, two ADM records will be created. 1515 1516An appointment will be generated in the emergency department. The emergency department 1517provider will document services provided. In the documented plan of care, the emergency 1518department provider will indicate a portion or all of the care will be transferred to the specialist. 1519The emergency department provider will generally use a code in the 99281–99285 series and 1520collect the care in code BIAA of Medical Expense and Performance Reporting System 1521(MEPRS). 1522 1523The specialist will document services in a separate document. The specialist will have an 1524appointment generated in the clinic, usually a walk-in. The appointment will be marked kept, 1525which will generate a report to be completed in the ADM. This report will be separate from the 1526ADM report generated in the emergency department. The specialist will usually code an office 1527visit range of 99201–99215 in the specialist’s outpatient clinic MEPRS. 1528 1529If the specialist admits the patient, there would not be a clinic appointment generated, but the 1530documentation would become part of the inpatient record and collected in the inpatient 1531professional service rounds appointment. 280 3 281 MHS Coding Guidance 282 March 2008 283 284 285 CONSULTATION 286 287 15324.7.2. Consultations 1533For a consultation in the emergency department, see section 4.8. A separate encounter will be 1534created when the emergency department physician requests a consultation. 1535 1536Use codes 99241–99245 to document consultant services when the consultant is called to the 1537emergency department to render a consultation at the request of the emergency department. The 1538consultant will report his/her work in his/her specialty MEPRS clinic. The level of consultation 1539is based on the documentation in the medical record. Documenting the problem(s) to be 1540evaluated establishes the medical necessity for the consultation. The specialist will evaluate the 1541patient and provide separate written documentation furnishing recommendations on the patient’s 1542care. 1543 15444.8. Coding Consults in AHLTA 1545In AHLTA, using the MEDCIN module, to code the consult correctly instead of a referral, the 1546provider must switch the SERVICE TYPE from OUTPATIENT VISIT to OUTPATIENT 1547CONSULT. Consultation results documented in AHLTA, are considered to meet the render and 1548report requirements. 1549

288 4 289 MHS Coding Guidance 290 March 2008 291 292 PROCEDURAL CODING 293 294 1550Chapter 5 PROCEDURAL CODING 1551 1552ALL CODING WILL BE SUPPORTED BY THE DOCUMENTATION IN THE MEDICAL 1553RECORD. Specific uses of procedural coding are listed under specialty chapters in Section 7. 1554 15555.1. Procedures 1556The term procedures include E&Ms not in the 99201–99499 range, such as mental health, physical 1557therapy, occupational therapy and optometry or ophthalmology evaluations. Procedures also 1558include supplies and durable equipment. Procedure codes are entered in the CPT/HCPCS 1559Description position on the ADM screen. CPT procedure codes (00100–99199 and 156099500+,Category II and Category III) and all of the HCPCS Level II codes are entered in the 1561CPT/HCPCS Description position. All procedure codes will be entered before the anesthesia code 1562for APVs. The last code listed for the institutional component of the APV will always be 99199 . 1563 1564ICD-9-CM procedure codes are not used when coding professional services. The ICD-9-CM 1565diagnosis that shows the medical necessity for a procedure must be linked to the procedure. The 1566codes for diagnostic radiology and laboratory procedures (other than those done and interpreted in 1567the clinic such as obstetric ultrasounds and KOH tests) should only be added to the encounter when 1568performed in the clinical setting. 1569 1570 Example: A child presents with ear pain. Because the tympanic membrane cannot be 1571 seen because cerumen is impacted, cerumen is removed. The primary diagnosis is otitis 1572 media (1). The secondary diagnosis is impacted cerumen (2). The procedure for 1573 removal of impacted cerumen, one or both ears, is coded with the CPT code 69210 and 1574 matched to impacted cerumen secondary diagnosis. 1575 15765.1.1. Minimize Use of Unlisted Procedure Codes 1577Efforts should be made to minimize use of unlisted procedure codes. In CPT, unlisted codes 1578usually end in 99. In HCPCS, unlisted codes are less consistent in their numbering and may 1579have any numbering convention (e.g., Q4050 Unlisted Cast Supplies), though the terminal digit 1580is frequently a 9. 1581 15825.1.2. Non-Privileged Provider Procedures 1583When a non-privileged provider is granted permission by the MTF to do a procedure, the procedure 1584code may be used to reflect nurse or technician services. Common examples are physical therapy 1585technicians performing physical therapy procedures and technicians removing warts. In these cases, 1586the technicians may only furnish the service if working under the written orders of a privileged 1587provider. 1588 15895.2. Modifiers 1590Modifiers are used to indicate a service or procedure has been performed, but was altered by some 1591specific circumstance. Modifiers are two-character codes added to the E&M or CPT/HCPCS 1592procedures. They are alpha, numeric, or alphanumeric codes. Modifiers and their associated 1593nomenclature are derived from two sources—CPT and HCPCS. In CPT books, there are four 1594groups of modifiers. 295 1 296 MHS Coding Guidance 297 March 2008 298 299 PROCEDURAL CODING 300 301 15955.2.1. CPT Modifiers 1596The first list, usually referred to as Modifier starts with the modifier 21. These modifiers are for 1597professional services. At this time, the MHS does not code the institutional component of services 1598separately (except for the 99199 code for the institutional component of ambulatory procedure 1599visits). All the modifiers in Appendix A are appropriate for MHS coding. 1600 16015.2.2. CPT Anesthesia Physical Status Modifiers 1602The second group, usually referred to as Anesthesia Physical Status Modifiers starts with the 1603modifier P1. These modifiers are now available for use. 1604 16055.2.3. CPT Modifiers Approved for Ambulatory Surgery Hospital Outpatient Use 1606The third group of modifiers usually has a header something like Modifiers Approved for 1607Ambulatory Surgery (ASC) Hospital Outpatient Use. This list starts with the modifier 25; modifier 160827 is in the list. In the civilian sector, coding for an ASC or for a hospital would be for the 1609institutional component of the services. Modifiers 27, 73 or 74 are not to be used for professional 1610services coding. 1611 16125.2.4. HCPCS Level II Modifiers 1613The fourth list usually has a title such as Level II (HCPCS/National) Modifiers. These codes, found 1614in Appendix A are used for professional services and should be used as applicable. 1615 16165.2.5. Unavailable Modifiers 1617Not all modifiers are available at this time in ADM and AHLTA. Modifiers that can be used are in 1618Appendix A. In general, modifiers in the Modifiers and Level II (HCPCS/National) lists in CPT 1619books are available. Usually modifiers only found in the HCPCS book are not available. Up to 1620three modifiers may be used for each procedure. Modifiers changing the amount of a service (e.g., 1621bilateral, professional component, surgical care only) should be sequenced before those describing 1622the type of provider (e.g., anesthesiologist, certified registered nurse anesthetist [CRNA]), midwife). 1623Modifiers describing anatomic locations (e.g., right, left) should be coded after modifiers describing 1624type of provider. The most common modifier coding error in the MHS is missing an RT or LT 1625finger, toe, or eyelid modifier. 1626 16275.2.6. Modifier -32 Mandated Services 1628The intent of this modifier is to define when another entity has a mandate, not when an entity is 1629following its own regulations. Therefore, it is inappropriate to use this code for encounters such 1630as flying physicals, hearing conservation screenings or newborn hearing screenings and 1631premarital laboratory testing. 1632 16335.3. Bundled Procedures and Global Procedures 1634 16355.3.1. Bundled procedure codes should be used whenever possible. Bundled services are a set of 1636medical or surgical services wrapped in a group package. The components listed in a particular 1637service are considered integral to the procedure and should not be billed separately. An example of 1638this is a sigmoidoscopy with removal of foreign body. The code 45332 captures both procedures. 1639 302 2 303 MHS Coding Guidance 304 March 2008 305 306 PROCEDURAL CODING 307 308 16405.3.2. Global and Bundled Procedures 1641Global procedures are similar to bundled procedures. Global surgical packages have one code for 1642all three parts: preoperative services, the procedure, and uncomplicated postoperative care--a 1643package deal. The global package includes low-level patient monitoring and topical anesthesia. A 1644common error is using an E&M to code uncomplicated postoperative services already included in a 1645global procedure. The code 99024 reflects uncomplicated, routine postoperative care during the 1646global period. When a patient has had surgery at another facility, the first follow-up at the new 1647facility will be coded with the surgical procedure code and modifier -55 (postoperative care only). 1648Code 99024 is for all subsequent uncomplicated encounters. Complicated postoperative services 1649are coded to the appropriate postoperative complication codes and E&M services. 1650 16515.3.2.1. Obstetrical Coding. 1652See section 6.9. 1653 16545.4. Clinical Pharmacists 1655 1656 DoD Rule 1657 1658 Anticoagulation INR lab tests review may be reported with appropriate diagnosis 1659 code. E&M codes are reported only once at the end of the 90 day time frame. 1660 Pharmacists will code 99363 or 99364 once the 90 day time frame has elapsed. If 1661 the services performed occur for less than 60 days each encounter must be coded 1662 using 99211. 1663 INR lab test will be reported on each encounter if performed in the B MEPRS 1664 clinic. 1665 1666 1667Clinical pharmacists are privileged to provide patient care independently outside the pharmacy 1668environment. These providers are usually doctors of pharmacy or pharmacists with extensive 1669training that covers a particular range of disease processes for which they are credentialed to 1670manage pharmacologically in a clinical setting. See Service-specific guidance for privileging 1671procedures. Pharmacists will use Medication Therapy Management CPT codes (99605–99607) for 1672patient treatment other than coagulation therapy. These are face-to-face timed codes that must 1673include the following documented elements: review of the pertinent patient history; medication 1674profile; recommendations for improving health outcomes and treatment compliance. 1675 16765.5. Chaplains and Pastoral Counselor 1677Chaplain and pastoral counselor services will always be non-count. On occasion, chaplains 1678document in the hard copy medical record to communicate with medical providers. In this case, it is 1679inappropriate to code in ADM as only Defense Health Program (DHP) funded visits should be 1680collected in CHCS or AHLTA. To document in AHLTA as a communication tool, the documenter 1681must be able to enter the provider (usually with nurse or technician permission). Use the provider 1682specialty code of 900 (technician) until the code Pastoral Counselor 076 is available. No workload

309 3 310 MHS Coding Guidance 311 March 2008 312 313 PROCEDURAL CODING 314 315 1683will be credited for pastoral care. The usual diagnosis would be V62.89, Other, religious or spiritual 1684problem or V62.6, Refusal of treatment for reasons of religion or conscience. 16855.6. Electrocardiogram (ECG or EKG) Services 93000–93042 1686ECG/EKG has a global code (93000, 93040) when the tracing, interpretation, and report are 1687completed in the same clinic. When the tracing (technical component) is performed in the 1688cardiopulmonary lab or other clinic, code 93005 or 93041 for the tracing only. The provider 1689privileged to interpret and report the ECG/EKG uses 93010 or 93042 after a report is completed to 1690code the professional component. Interpretation only without a report is not a codeable event. An 1691example of an interpretation would be an emergency department physician interpreting, but not 1692creating a report for ECG tracing performed in the ED. This should be included in the medical 1693decision-making portion of the E&M code. 1694 1695NOTE: Although the interpretation does not have to be on a separate page, the summary of findings 1696must contain sufficient detail that a conclusion of the significance of the findings can be made 1697without the tracing itself being available. Documentation must include descriptive or tabular 1698summary including information such as PR, QRS, QT intervals, rate, rhythm, axis, ST segment 1699changes, along with an interpretation of these findings. Simple notations in the E&M visit notes, 1700such as "EKG-neg" or "EKG-acute MI", are not adequate documentation. 1701 1702 Example: ECG/EKG ordered and read by the same provider in conjunction with a visit. 1703 The provider would capture the tracing, as well as the interpretation and report for the ECG 1704 along with the visit and code 93000 or 93040, as appropriate. The technician performing the 1705 test could be included as an additional provider in ADM. 1706 1707 Example: ECG/EKG performed in a central cardiopulmonary lab and interpreted by a 1708 provider. Currently there is no module to capture and code these procedures. NOTE: For 1709 ADM reporting, the MTF may establish a non-count clinic, non-count appointment 1710 type in CHCS using DDA and capture the CPT tracing only code. The interpretation 1711 and report will be captured by the provider doing the initial interpretation in their B 1712 MEPRS clinic. 1713 17145.7. Laser Tattoo and Hair Removal 1715For laser removal of tattoos code to ICD-9-CM 709.09, use procedure code 17999. For laser hair 1716removal of pseudofolliculitis barbae (shaving bumps) code to ICD-9-CM 704.8 and procedure code 171796999. 1718 17195.8. On Call 1720On call codes will not be used. To enter an encounter in the ADM, a patient must be associated 1721with the procedure code. On call is not for a specific patient. 1722 17235.9. Medical Evaluation Boards (MEB) 1724 17255.9.1. Board Participation Not Codeable 1726Participation on the board is an administrative service and is not codeable. Time spent participating 1727on an MEB is not collected in the B*** MEPRS, but in the FEDA MEPRS. 316 4 317 MHS Coding Guidance 318 March 2008 319 320 PROCEDURAL CODING 321 322 1728 1729 17305.9.2. MEB Services 1731The MEB may originate from different sources; the privileged providers performing evaluations for 1732a specific condition will be coded as an office visit, based on the documentation. The MEB 1733initiating provider will assess the patient and request necessary consults. The consults (e.g., mental 1734health evaluations, neurology, and orthopedics) will be coded based on the documentation. The 1735package development by the MEB initiating provider, which incorporates all the consults and other 1736documentation, will be coded with the 99455 or 99456 codes. The package development codes 173799455 or 99456 documentation will include the following: completion of a medical history, 1738commensurate with patient’s condition; performance of an examination commensurate with the 1739patient’s condition; formulation of a diagnosis, assessment of capabilities and stability and 1740calculation of impairment; development of future medical treatment plan; and completion of 1741necessary documentation/certificates or reports. When the MEB meets, the primary provider 1742presents the case, and the board makes a recommendation. MEB services do not include ongoing 1743treatment for any disability-related condition. 1744 1745 DoD Rule 1746 1747 If the package development which is coded using 99455 or 99456 takes more than 1 1748 hour of the provider’s time, use the appropriate face to face prolonged services 1749 99354-99357 or non face to face prolonged services 99358- 99359 codes. 1750 1751 For inpatients receiving an MEB, generate an encounter in the provider’s B clinic. 1752 1753 17545.10. Records Review 1755Records review for peer review and the Medical Record Review Committee are administrative 1756activities. There are no CPT/HCPCS codes for administrative records review. 1757 17585.11. Injections and Infusions 1759To capture the immunization administration for vaccines or toxoids, report the appropriate age- 1760specific codes in cases where the physician provides face-to-face counseling of the patient or family 1761during administration of the vaccine. For services provided by technicians or nurses, use the code 1762range 90471–90474 and the immunization product code 90476–90749. 1763 1764If a significantly identifiable E&M service is performed with a vaccine or toxoid procedure, the 1765appropriate E&M service code should be reported in addition to the vaccine or toxoid 1766administration. 1767 1768For injections/immunization administration, documentation must include at a minimum, method of 1769administration, unit(s), and substance. 1770

323 5 324 MHS Coding Guidance 325 March 2008 326 327 PROCEDURAL CODING 328 329 1771For infusions, documentation must include at a minimum, start and stop times, method of 1772administration, unit(s) and substance. 1773It is insufficient to simply select corresponding CPT codes in AP section of AHLTA note. Although 1774this information may be reported in a different system, documentation must be contained in the 1775note. 1776 17775.12. Cast or Splint Application 1778All casts and splints applied will be coded when not bundled with another procedure on the ordering 1779privileged provider’s SADR, with the technician listed as a secondary provider. When applying 1780other than the initial cast or splint, also use the casting and splint codes Q4001–Q4051. 1781 17825.13. Tobacco Use Cessation 1783Use code 99406 for smoking and tobacco use cessation counseling visit; 3-10 minutes and 99407 1784for smoking and tobacco use cessation counseling greater than 10 minutes. If an assessment of 1785tobacco use was conducted, use 1000F. Use 1034F to report smoking use and 1035F for tobacco 1786use. Use the appropriate ICD-9-CM diagnosis code 305.1. 1787 17885.14. Physician’s Voluntary Reporting Program Codes 1789Codes G8006–G8186 were not available in AHLTA prior to publication of this edition of the MHS 1790Coding Guidance.

330 6 331 MHS Coding Guidance 332 March 2008 333 334 SPECIALTY CODING 335 6.1 Anesthesia 336 1791Chapter 6 SPECIALTY CODING 1792 1793THIS SECTION HAS CODING INFORMATION BASED ON THE SPECIALTY 1794CLINIC THAT PROVIDES SERVICES. 1795 17966.1. Anesthesia 1797 17986.1.1. Basic Tenets of Professional Services Anesthesia Coding 1799Anesthesia procedures are coded when local anesthesia is supplemented, or when 1800regional, monitored anesthesia care or general anesthesia is performed by a person other 1801than the provider performing the surgical procedure. 1802  Regional anesthesia is the use of anesthetic agents with or without sedation to 1803 provide pain relief or the loss of sensation to a specific area of the body, such as 1804 epidural anesthesia or a brachial plexus block. 1805  General anesthesia is the total loss of consciousness and reflexes caused by the 1806 administration of drugs and inhalation agents. 1807  Monitored anesthesia care (MAC) is intra-operative monitoring by an 1808 anesthesiologist or CRNA of the patient’s vital signs, in anticipation of possible 1809 need to transition to general anesthesia. The patient maintains an airway and 1810 responds to verbal stimuli, except possibly for brief periods of time (e.g., fewer 1811 than 60 seconds). 1812 18136.1.2. Reporting B MEPRS for Anesthesia Services 1814The professional component of anesthesia services will be captured on the lead surgeon’s 1815ADM encounter. The anesthesia code will be sequenced after all procedures performed 1816by any surgeons and before the 99199 code for the institutional component of the APV. 1817Procedures performed by the surgeon should be linked to the surgeon. Procedures 1818performed by the anesthesia provider should be linked to the anesthesia provider. 1819

1820 DoD Rule 1821 1822 Anesthesia services will be reported in MTFs when performed by a 1823 provider other than the surgeon using anesthesia procedure CPT 1824 codes: 00100–01999. 1825 1826 MTFs will list anesthesiologists or CRNAs as additional providers 1827 on the surgeon’s record in the ADM. 1828 1829 For Air Force specific guidance, contact the Service representative.

1830 18316.1.3. E&M Coding 1832 18336.1.4. Providers 337 1 338 MHS Coding Guidance 339 March 2008 340 341 SPECIALTY CODING 342 6.1 Anesthesia 343 18346.1.4.1. Anesthesia Performed by a Provider Other than the Surgeon 1835When the provider administering and monitoring the anesthesia is a provider other than 1836the surgeon (e.g., another physician, anesthesiologist, or CRNA), the anesthesia services 1837will be reported using anesthesia procedure CPT codes: 00100–01999. 1838 18396.1.4.2. Anesthesia Performed by Provider Also Performing Surgical Procedure 1840When the provider performing the surgical procedure also administers and monitors the 1841anesthesia, a surgical CPT procedure(s) code and not an anesthesia code is applied. 1842Append modifier -47 to the surgical procedure code. 1843 18446.1.5. Gathering Documentation 1845Medical records will be reviewed for the anesthesia provider’s documentation 1846supporting the use of regional, MAC, or general anesthesia. Generally, these 1847anesthesia services can be found on DA Form 7389 for the Army or OF 517 for 1848the Navy and Air Force. 1849 18506.1.5.1. When Not to Code for Anesthesia Services 1851 18526.1.5.1.1. Types 1853Anesthesia services are NOT coded when the procedure is performed using the following 1854types of anesthesia: 1855 1856  topical; 1857  local infiltration of anesthetic agents to a limited area, such as those used for 1858 minor procedures like biopsies, and the excision of skin tumors and lesions; or 1859  metacarpal, metatarsal, or digital block. 1860 18616.1.5.1.2. Procedures 1862Anesthesia guidelines in the CPT coding manual and the National Correct Coding 1863Initiatives (NCCI) provide guidance on the services that are inclusive to the provision of 1864anesthesia, and therefore are not coded separately. They are: 1865 1866  normal pre- and post-anesthesia visits; 1867  provision of fluids or blood; 1868  normal monitoring of vital signs, EKG, pulse oximetry, capnography (blood 1869 carbon dioxide concentration), and mass spectrometry; 1870  laryngoscopy for placement of airway and placement; and 1871  nerve stimulation to determine level of consciousness. 1872 18736.1.5.1.3. Moderate Sedation (Previously Termed Conscious Sedation) 1874Clinicians use moderate sedation to achieve a medically controlled state of depressed 1875consciousness while maintaining the patient’s airway, protective reflexes, and ability to 1876respond to stimulation or verbal commands. Review CPT code descriptions to avoid 1877unbundling as some procedures (e.g., some endoscopies) include moderate sedation.

344 2 345 MHS Coding Guidance 346 March 2008 347 348 SPECIALTY CODING 349 6.1 Anesthesia 350 1878Moderate sedation is reported when the physician performing the surgical procedure also 1879provides the moderate sedation. Moderate sedation requires an independent observer be 1880present to assist the physician in monitoring the patient’s level of consciousness and 1881physiologic status. Report moderate sedation on the surgeon’s ADM entry in the 1882appropriate MEPRS code. 1883 18846.1.6. Additional Anesthesia Procedures 1885Other forms of monitoring by anesthesia personnel will be coded on the surgeon’s ADM 1886encounter when they are done by an anesthesia provider. These codes should be linked to 1887the anesthesia provider. For example: 1888 1889  Central venous puncture (CVP) line insertion, 1890  Intra-arterial lines, 1891  Swan–Ganz catheters, 1892  Emergency intubation, 1893  Critical care visits and 1894  Transesophageal echocardiography. 1895 18966.1.7. Coding Anesthesia 1897 18986.1.7.1. Coding with a Crosswalk 1899Anesthesia can be coded in a number of ways. A crosswalk between surgical procedures 1900and anesthesia is available from a variety of sources, including the American Society of 1901Anesthesiologists (www.asahq.org) or the Coding Compliance Editor (CCE). When a 1902crosswalk is not available, follow the steps below. 1903 19046.1.7.2. Coding without Crosswalk: 1905 1. Identify all surgical procedures performed. 1906 2. Refer to the main term, anesthesia, in the CPT index. 1907 3. Search for a sub-term to indicate the anatomic site of the procedure or 1908 the actual procedure performed. 1909 4. Reference the code or codes noted in the index’s tabular portion of the 1910 CPT codebook. 1911 5. Read and apply any notes in the index or in the tabular portion of the 1912 CPT codebook. 1913 6. If multiple anesthesia services are performed in the same session, the 1914 anesthesia procedure with the highest base unit will be determined (see 1915 the “Relative Value Guide,” published by the American Society of 1916 Anesthesiologists). 1917 7. To calculate the base units for multiple anesthesia services, see section 1918 6.1.8 Base Unit in this document. 1919 8. At this time the MHS cannot accommodate modifiers for anesthesia. 1920 Therefore, the MHS does not report medical direction or supervision.

351 3 352 MHS Coding Guidance 353 March 2008 354 355 SPECIALTY CODING 356 6.1 Anesthesia 357 1921 9. Assign codes for any qualifying circumstances, if applicable. See section 1922 6.1.14. Reporting Qualifying Circumstances in this document. 1923 19246.1.8. Base Unit 1925A base unit reflects the difficulty (or level of acuity) of the anesthesia service. The base 1926unit includes the initial anesthesia assessment to determine if the patient is an anesthesia 1927candidate. It also includes the following services, usually provided on the day of surgery: 1928 1929  preoperative visit, 1930  postoperative visit, and 1931  administration of fluids or blood products incident to the anesthesia care and 1932 interpretation of non-invasive monitoring. 1933 1934Each anesthesiology CPT code is assigned a base unit value in the Medicare Relative 1935Value Guide. It is available at the CMS Website: 1936(http://www.cms.hhs.gov/center/anesth.asp) in Appendix A, Chapter 8, Medicare 1937Carriers Manual, Part 3. 1938 19396.1.9. Single Code Exceptions for Anesthesia 1940There are exceptions to the inclusion of all anesthesia procedures performed during the 1941same surgical session under one code. The exceptions are the anesthesia add-on codes 1942for the excision or debridement of burns (that accommodates percentage of body surface) 1943and obstetrical anesthesia (that allows for time). The anesthesia add-on codes have 1944separate base units. All add-on codes are reported in addition to the principal procedure 1945code(s). They are never used as the first-reported or solo code. 1946 19476.1.10. Identifying Type of Provider 1948When available in the MHS systems, an HCPCS level II modifier identifies the provider 1949as an anesthesiologist or CRNA. The modifier indicates whether the CRNA provider is 1950or is not under the medical direction or supervision of an anesthesiologist. Additionally 1951the modifier indicates the number of cases directed or supervised by a provider. The 1952physician or anesthesiologist and the anesthetist both report their services with the 1953appropriate modifier. 1954 19556.1.11. Cancelled Procedure 1956If the surgical procedure is cancelled or terminated prior to the induction of 1957anesthesia or the administration of drugs or medication (e.g., day before or morning 1958of the surgery), but there has been a pre-surgical anesthesia assessment, then the 1959anesthesia clinic will create and complete the ADM record in the B MEPRS, then 1960code the pre-anesthesia evaluation using a consult code (e.g., 99241) based on the 1961documentation of the initial anesthesia assessment to determine if the patient was an 1962anesthesia candidate. 1963

358 4 359 MHS Coding Guidance 360 March 2008 361 362 SPECIALTY CODING 363 6.1 Anesthesia 364 1964If the surgical procedure is cancelled or terminated after preparation of the patient for 1965anesthesia, assign the anesthesia code for the anticipated surgical procedure. At this time, 1966the unit’s field automatically fills with a unit of 1 when a code in the 00100–01999 range 1967is used. Therefore, minutes of service cannot be reported in the ADM. Anesthesia 1968personnel do collect and report minutes of anesthesia service in MEPRS. 1969 19706.1.12. Aborted Procedure 1971If the surgical procedure is cancelled or terminated (not patient elective) after the surgical 1972procedure has started, assign the appropriate anesthesia code for the procedure in the 1973routine manner, based on the actual procedure performed. Do not use modifier -53 on 1974anesthesia codes. Modifier -53 would be used on the surgical procedure code. 1975 19766.1.13. Monitored Anesthesia Care (MAC) 1977MAC entails intra-operative monitoring of the patient’s vital physiological signs in 1978anticipation of the need for administration of general anesthesia or in the event the patient 1979develops physical complications from the surgical procedure. To report MAC, the 1980anesthesia provider must: 1981 1982  provide a pre-anesthesia evaluation and examination; 1983  prescribe the anesthesia plan; 1984  dispense any oral or parenteral anesthesia drugs to the patient; 1985  provide intra-procedural monitoring of patient’s vital signs, maintenance of the 1986 patient’s airway, and continual evaluation of vital functions; 1987  conduct any postoperative care needed; and 1988  maintain adequate medication and ensure pharmacological equipment is readily 1989 available at all times. 1990 1991Because MAC requires at least the same level of monitoring as that of general anesthesia, 1992it is treated the same as general anesthesia except that the appropriate modifiers should be 1993coded when they become available in the DoD system. Medical necessity must be 1994documented to support the need for MAC. 1995 19966.1.14. Reporting Qualifying Circumstances 1997Additional codes are needed to report unusually difficult circumstances for anesthesia 1998administration. The qualifying circumstances codes are in the Medicine Section of the 1999CPT. They are also listed in the beginning of the Anesthesia Section of the CPT coding 2000manual. These codes are not stand-alone codes. More than one qualifying circumstance 2001code can be used if applicable.

365 5 366 MHS Coding Guidance 367 March 2008 368 369 SPECIALTY CODING 370 6.1 Anesthesia 371 Qualifying Circumstances Description +99100 Anesthesia for patient of extreme age, under 1 year and over 70 (List separately in addition to code for primary anesthesia procedure). +99116 Anesthesia complicated by use of total body hypothermia (List separately in addition to code for primary anesthesia procedure). +99135 Anesthesia complicated by use of controlled hypotension (List separately in addition to code for primary anesthesia procedure). +99140 Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure). 2002 20036.1.15. Postoperative Pain Management 2004 20056.1.15.1. Overview 2006The most common techniques for postoperative pain control are patient-controlled 2007analgesia (PCA), epidural analgesia, and nerve blocks. Postoperative pain management 2008is only reported when the attending surgeon requests, in writing, that the anesthesia 2009provider performs significant, separately identifiable services, such as ongoing critical 2010care services, postoperative pain management services, or extensive unrelated ventilator 2011management. 2012 20136.1.15.2. Patient Controlled Analgesia 2014PCA therapy is a technique for pain management that involves self-administration of 2015intravenous drugs through an infusion device. When PCA is initiated in the recovery 2016room by an anesthesiologist as part of the anesthesia time, the initial set-up time for PCA 2017may be incorporated into the total number of anesthesia time units reported. 2018 20196.1.15.3. Epidural 2020Epidural analgesia involves the administration of a narcotics drug through an epidural 2021catheter. Insertion of an epidural catheter should be reported as a separate procedure 2022code. Management of epidural or subarachnoid drug administration (CPT code 01996) is 2023reported on dates of service after the date of the surgery. Management of epidural or 2024subarachnoid drug administration is limited to one unit of service per postoperative day, 2025regardless of the number of visits necessary to control the catheter per postoperative day. 2026Postoperative pain management services are generally provided by the surgeon, who is 2027reimbursed under a global payment policy related to the procedure and is reported by the 2028anesthesia provider only when separate, medically necessary services are required that 2029cannot be rendered by the surgeon. The surgeon is responsible for documenting in the 2030medical record the reason care is being referred to the anesthesia provider. 2031 20326.1.15.4. Nerve Block 2033A nerve block injection involves injection of an anesthetic agent into or around a given 2034nerve. When an injection or block is administered postoperatively by an anesthesia 372 6 373 MHS Coding Guidance 374 March 2008 375 376 SPECIALTY CODING 377 6.1 Anesthesia 378 2035provider in the recovery room as part of the anesthesia time, any additional time required 2036for the injection may be included in the total number of anesthesia minutes reported. 2037 20386.1.16. Physical status modifiers are used in the civilian sector but not currently used in 2039DoD. 2040 20416.1.17. Anesthetic Agents 2042Anesthetic agents, as well as other medications (e.g., anti-emetics, antibiotics) are part of 2043the institutional component of the surgery. They are not coded separately.

379 7 380 MHS Coding Guidance 381 March 2008 382 383 SPECIALTY CODING 384 6.2 Audiology 385 20446.2. Audiology 2045 20466.2.1. Evaluation & Management (E&M) Rules 2047E&M codes are not appropriate for routine audiology encounters for procedures. The 2048medical E&M components of an outpatient office visit are already included in the special 2049procedures codes listed in the Special Otorhinolaryngologic Services subsection. 2050 2051Encounters with patients for whom no procedure is done are reported with an E&M code 2052(99201–99205 or 99211–99215) based on the chief complaint, history, exam, and 2053decision making documented in the medical record. 2054 20556.2.2. Diagnosis Coding Rules 2056

2057 DoD Rule 2058 2059 Deployment-related encounters will code one of the following: V70.5_4 for 2060 pre-deployment, V70.5_5 during deployment, or V70.5_6 for post- 2061 deployment related conditions. See section 2.2.8.2.

2062 20636.2.2.1. Extender Codes 2064 2065See Appendix D for a complete list of all extender codes. 2066 2067V72.1 Examination of Ears and Hearing 2068  V72.11* 0 Encounter for Hearing Examination Following Failed Hearing 2069 Screening. 2070  V72.11* 1 Encounter for Hearing Examination Following Failed Hearing 2071 Screening, Otoscopic Exam Done 2072  V72.11* 2 Encounter for Hearing Examination Following Failed Hearing 2073 Screening, Otoscopic Exam Not Performed 2074  V72.19* 0 Other Examination of Ears and Hearing 2075  V72.19* 1 Other Examination of Ears and Hearing, Otoscopic Exam Done 2076  V72.19* 2 Other Examination of Ears and Hearing, Otoscopic Exam Not 2077 Performed 20786.2.2.2. Hearing Conservation Program (HCP) 2079HCP guidelines in DA Pam 40–501 or other Service guidelines require all military and 2080civilian personnel who routinely work in noise-hazardous areas to have reference (base 2081line), annual, and terminal audiograms. 2082 2083 2084 2085

386 8 387 MHS Coding Guidance 388 March 2008 389 390 SPECIALTY CODING 391 6.2 Audiology 392

2086 DoD Rule 2087 2088 Hearing Conservation Program services are coded in a Special Program 2089 service in an F MEPRS clinic (FBN*).

2090 2091Hearing tests performed in other than an audiology clinic or for HCP, are reported in the 2092clinic where the test or procedure is performed. These examination encounters are coded 2093according to the table below. The table includes only codes for HCP encounters leading 2094to referral to an audiology clinic. 2095 2096 DoD Rule 2097 2098 Official ICD-9-CM coding guidelines state that both V70 and V72 codes 2099 are only listed first. Code V72 excludes V70.5. However, for the DoD to 2100 identify the specific type of HCP exam, particularly those with an 2101 identified significant threshold shift (STS), or permanent threshold shift 2102 (PTS), both codes are reported in the order shown for HCP exams.

2103 2104 HEARING CONSERVATION PROGRAM (HCP) TABLE ICD-9-CM E&M CPT Encounter Type Diagnosis Codes Procedure Codes Codes Accession exam in basic training with V70.5_8 and N/A 92552 (Individual), no abnormalities V72.1* 92559**(Group)

Accession exam in basic training with V70.5_8 and N/A 92552 (Individual), abnormalities V72.1*, plus 92559**(Group) 794.15*** Exam at start of routine employment V70.5_3 and N/A 92552 (Individual), involving hazardous noise with no V72.1* 92559**(Group) abnormalities Exam at start of routine employment V70.5_3 and N/A 92552 (Individual), involving hazardous noise with V72.1*, plus 92559**(Group) abnormalities 794.15*** Annual exam with no identified STS V70.5_3 and N/A 92552 (Individual), V72.1* 92559**(Group)

2105

393 9 394 MHS Coding Guidance 395 March 2008 396 397 SPECIALTY CODING 398 6.2 Audiology 399 Annual exam with an initial STS V70.5_3 and N/A 92552 (Individual), identification V72.1* plus 92559**(Group) 794.15*** Annual exam with a previously V70.5_3 and N/A 92552 (Individual), confirmed PTS 388.1X* or 92559**(Group) 389.XX*

Follow-up 1 or 2 for STS identified 794.15*** N/A 92552 (Individual), during current annual or follow-up 1 92559**(Group) exam Termination exam at end of V70.5_9 and N/A 92552 (Individual), employment or separation from active V72.1* 92559**(Group) duty 2106 2107* Indicates there are various 4th and 5th digits or extender codes that may be assigned to indicate a specific 2108condition or encounter 2109** For patients tested using Defense Occupational and Environmental Health Readiness System-Hearing 2110Conservation (DOEHRS-HC). 2111*** Code to be used by non-professionals (e.g., technicians, nurses, volunteers). Only physicians or 2112audiologists may diagnose noise-induced hearing loss. 2113 2114NOTE: 99078 may be used as an additional code if physician education services are 2115provided in a group setting. 2116 21176.2.2.3. Hearing Loss Caused by Injury 2118Initial encounters for hearing loss acquired from performance of duties, but not 2119associated with physical trauma to the head will be identified with the appropriate E code 2120as a secondary diagnosis. E codes are only used for the first encounter for the condition 2121that was caused by the situation described by the E code. There is an injury or accident 2122field in the ADM that should be answered yes each time the patient is seen for a condition 2123caused by an accident or injury. 2124 2125 E923.8 Other Explosive Material—explosions not a result of war 2126 operations 2127 E928.1 Exposure to Noise 2128 E993 Injury Caused by War Operations by Other Explosion— 2129 including accidental explosion of own weapon 2130 E995 Injury Caused by War Operations by Other and Unspecified 2131 Forms of Conventional Warfare—for hearing losses caused 2132 by exposure to other noises during war operations 2133 21346.2.2.4. Early Hearing Detection and Intervention (EHDI) 2135EHDI will not be coded on the SIDR. EHDI screening exams and interventions are coded 2136according to the table below. The table includes only codes for EHDI encounters. 2137 2138

400 10 401 MHS Coding Guidance 402 March 2008 403 404 SPECIALTY CODING 405 6.2 Audiology 406 2139 NEWBORN EARLY HEARING DETECTION AND INTERVENTION 2140 Encounter Type ICD-9-CM CPT CPT Diagnosis E&M Procedure Codes Codes Codes Newborn hearing screening with no V72.1** If 92586 or abnormalities performed in audiology applicable, 92587 clinic*** 99xxx Newborn hearing screening with V72.1** and N/A 92586 or 92587 abnormalities performed in audiology 794.15* or clinic*** 389.XX** Follow-up with no abnormalities 794.15 N/A 92585 and 92588 Follow-up with abnormalities 389.XX* N/A 92585 and 92588 Intervention 1 389.XX* N/A 92590, 92591, or 92700 Intervention 2 389.XX* N/A 92590, 92591, or 99002 1st follow-up to intervention 389.XX* N/A 92590, 92591, 92594 or 92595 2141* Code to be used by non-professionals (e.g., technicians, nurses, volunteers). 2142** Indicates there are various 4th and 5th digits that may be assigned to indicate a specific 2143condition or encounter 2144*** Initial screening exam for patients not tested in the hospital prior to discharge from birth 2145episode. 2146 21476.2.3. Procedural Coding Rules 2148 21496.2.3.1. CPT procedure Codes for Audiology 2150These services are in the Special Otorhinolaryngologic Services subsection of the 2151Medicine section (92502–92700). Codes in the 92500 series do not require the 2152supervision of a physician. Tests in this series can be performed by a qualified 2153audiologist, but diagnostic procedures must be ordered by a physician. 2154 21556.2.3.2. Cerumen Removal 2156Removal of cerumen is considered integral to audiology services. Instillation of drops, 2157minor scraping, or simple irrigation is bundled into the evaluation portion of audiology 2158service. If a physician removes impacted cerumen before audiology testing, the 2159physician should use code G0268. In all other circumstances, use 69210 for removal of 2160impacted cerumen. Removal of cerumen to see the tympanic membrane is included in 2161the E&M component. The physician or audiologist may report separate E&M service 2162with modifier -25. 2163 21646.2.3.3. Tinnitus 2165Audiologists are qualified to evaluate, diagnose, develop management strategies, and 2166provide treatment and rehabilitation for tinnitus patients. Diagnostic audiologic testing 2167for tinnitus is reported with CPT code 92625. 407 11 408 MHS Coding Guidance 409 March 2008 410 411 SPECIALTY CODING 412 6.2 Audiology 413 21686.2.3.4. Hearing Equipment Services 2169Services related to fitting, providing or repairing hearing supplies and equipment, 2170excluding implantable bone conduction devices, are reported with HCPCS Level II codes 2171V5008–V5299. 2172 21736.2.4. Other Audiology Guidance 2174 21756.2.4.1. Documentation of Hearing Conservation 2176The results of administering all aspects of monitoring audiometry with the DOEHRS HC 2177equipment is documented by completion of the following: 2178 2179 DD Form 2215 Reference Audiogram 2180 DD Form 2216 Hearing Conservation Data 2181 21826.2.4.2. Dispositions or Referrals 2183DOEHRS HC software will automatically determine if an Occupational Safety and 2184Health Administration (OSHA)-reportable hearing loss (RHL) is present and will provide 2185disposition instructions. 2186 21876.2.5. Modifiers 2188 TC Technical Component is used by technicians who perform tests in a 2189 different clinic than the one used by the audiologist who interprets 2190 the test and renders a report. 2191 26 Professional Component is used by the audiologist who only 2192 interprets tests performed elsewhere and provides a report. 2193 52 Reduced Service is used when audiologic function tests (except 2194 92559) are performed on one ear only.

414 12 415 MHS Coding Guidance 416 March 2008 417 418 SPECIALTY CODING 419 6.3 Chiropractic Services 420 21956.3. Chiropractic Services 2196 21976.3.1. E&M Rules 2198 21996.3.1.2. Initial Encounter for a Problem 2200If chiropractic manipulative treatment (CMT) was furnished during the initial encounter, 2201indicating the chiropractor accepted the patient for treatment of the problem, and a 2202separately identifiable chiropractic evaluation was conducted, use an E&M code, usually 2203in the new or established office visit codes (9920x/9921x) with a modifier -25, along with 2204the CMT procedure code (98940–98943). 2205 22066.3.1.3. Referrals 2207If there is a request for the chiropractor to evaluate and treat the patient, this is a referral. 2208CMT covers pre- and post services, including an assessment specific to CMT. The 2209documentation must reflect a history, exam or decision of something not related to the 2210CMT to use a separate E&M code. 2211 22126.3.1.4. Consult When CMT Not Appropriate 2213If there is a request for evaluation and advice, and the chiropractor determines that CMT 2214is not appropriate for the patient, and sends advice back to the provider who requested the 2215consult, and all other requirements for a consult are met, the consult codes (9924x) 2216should be used. 2217 22186.3.1.5. Consult When CMT Is Appropriate 2219When there is a request for evaluation and advice; the chiropractor determines that CMT 2220would be appropriate but has not yet begun it; the chiropractor sends advice back to the 2221consulting provider and meets all other requirements for a consult, the consult codes 2222(9924x) should be used. 2223 22246.3.1.6. CMT 2225When an encounter is for CMT and the evaluation is limited to reviewing data to ensure 2226CMT is still appropriate, there is no separately identifiable E&M and only the CMT code 2227should be used. 2228 2229 22306.3.1.7. Reevaluation 2231When there are separately identifiable E&M services beyond those needed for CMT, 2232such as when the chiropractor re-exams the patient to obtain objective measures of 2233progress, and the treatment plan is modified as necessary, a separate E&M coded (usually 2234from the established office visit range, 9921x) should be coded. 2235

421 13 422 MHS Coding Guidance 423 March 2008 424 425 SPECIALTY CODING 426 6.3 Chiropractic Services 427 22366.3.1.8. The AT Modifier 2237Use the AT modifier when the treatment is for active or corrective treatment, when the 2238documentation shows that treatment is medically reasonable or necessary under Medicare 2239rules. The AT modifier is not used for maintenance therapy, such as services that seek to 2240prevent disease, promote health, maintain or prevent deterioration of a chronic condition, 2241or enhance the quality of life. 2242 22436.3.2. Procedural Coding Rules 2244 2245 DoD Rule 2246 2247 The CMT procedure codes are 98940–98943. Use only one code per session 2248 unless both spinal and extra spinal are performed.

2249 22506.3.2.1. Manual Therapy Techniques 2251Manual therapy techniques are coded 97140. The provider uses his/her hands to perform 2252soft tissue massage and joint mobilization, manipulation, manual traction, or manual 2253lymphatic drainage to one or more areas. The code requires direct one-on-one contact 2254with the patient. 2255 2256See also HCPCS code S8990, physical manipulative therapy performed for maintenance 2257rather than restoration. 2258 22596.3.3. Modifiers 2260 25 Separate or distinct E&M services 2261 51 Multiple procedures (when unrelated procedures are done at the 2262 same encounter) 2263 59 Distinct procedural service (when one code is usually included in 2264 another but for an unusual reason both were done separately)

428 14 429 MHS Coding Guidance 430 March 2008 431 432 SPECIALTY CODING 433 6.4 Dialysis 434 22656.4. Dialysis 2266 22676.4.1. E&M Rules 2268E&M services associated with or related to the performance of dialysis, performed on the 2269same day as the dialysis, are included in the dialysis procedure; therefore, no separate 2270E&M code is reported. If there is a separately identifiable E&M, unrelated to the dialysis, 2271that E&M shall be coded based on documentation and appended with modifier 25. 2272 22736.4.2. Procedural Coding Rules. See 6.5.5 for a sample list of dialysis procedures. 2274 2275 DoD Rule 2276 2277 Dialysis, hemodialysis, and peritoneal dialysis are ancillary services. They 2278 should be given the appropriate procedure code 90918–90999 and should 2279 be coded in the D MEPRS.

2280 22816.4.2.1. Individual Dialysis Therapy Encounters 2282In the MHS, each encounter is coded. Therefore, except for the first encounter of the 2283month, each encounter is coded using an unlisted code of 90999 in the CPT/Procedure 2284field 2285 22866.4.2.2. Monthly Dialysis Codes 2287The monthly dialysis codes will always be used for the first dialysis of the new month to 2288reflect the previous month’s treatment. For instance, it will reflect 31 days for January 2289and 30 days for April. 2290 2291 DoD Rule 2292 2293 When a dialysis service is performed, no procedure codes will be reported, 2294 except for the first encounter of the month to reflect the previous month’s 2295 services. 2296 2297 Hint: To determine the number of dialysis encounters during the month, 2298 use the patient appointment history in AHLTA/CHCS.

2299 23006.4.2.3. Dialysis for Less than an Entire Month 2301Dialysis does not always begin the first day of the month. On the first dialysis of the 2302month following initial treatment, instead of the monthly code, use the per day codes to 2303reflect services from the start of care through the end of the prior month. Code 90925 2304should be reported for each day outside of inpatient hospitalization. 2305 2306 Example: A patient is admitted to the hospital on the 11th of the month and 2307 discharged on the 27th. On the first dialysis visit in the next month, code 90925 435 15 436 MHS Coding Guidance 437 March 2008 438 439 SPECIALTY CODING 440 6.4 Dialysis 441 2308 with a quantity of 13 for the days the patient was not an inpatient the prior month. 2309 (30 days in the month minus 17 days of hospitalization = 13 days). Report 2310 inpatient E&M services as appropriate. Dialysis procedures rendered during 2311 hospitalization are coded as part of the hospitalization. 2312 23136.4.2.4. Dialysis for Entire Month 2314To code dialysis, the first visit of the month will be used to record the appropriate 2315monthly or per day code for services the previous month. All other visits will use the 2316unlisted dialysis code of 90999 for the procedure. If any of the encounters of the prior 2317month were conducted by a non-privileged provider, the first encounter of the new month 2318must be collected in the DGB or DGD MEPRS, with the individual performing the 2319service that day listed as the provider. 2320 23216.4.2.5. Privileged Provider 2322If a privileged provider performs the dialysis, the provider’s name should be listed as the 2323primary provider. If a separately identifiable E&M service is performed, use the 2324appropriate E&M code with modifier -25. When a privileged provider furnishes a 2325dialysis service, the encounter will usually be collected in the BAJ MEPRS as a count 2326encounter. 2327 23286.4.2.6. Non-Privileged Provider 2329Dialysis procedures should only be conducted by a non-privileged provider following a 2330written treatment plan of a privileged provider. When a non-privileged provider 2331performs the dialysis, the non-privileged provider should be listed as the primary 2332provider. 2333 23346.4.2.6.1. Dialysis treatment is usually done by non-privileged providers whose time is 2335collected in the DGB or DGD MEPRS. Therefore, a “clinic” must be created in the DGB 2336or DGD MEPRS where appointments will be created and marked as kept and ADM 2337reports will be collected. When a non-privileged provider performs the service, the 2338encounter must be entered as a non-count encounter. 2339 23406.4.3. Diagnosis Coding 2341The first listed diagnosis, when the patient is only being seen for ongoing dialysis 2342treatment, is in the V56 category. A secondary diagnosis will be used to explain why the 2343dialysis is necessary, such as chronic kidney disease.

442 16 443 MHS Coding Guidance 444 March 2008 445 446 SPECIALTY CODING 447 6.5 End Stage Renal Disease 448 23446.5. End Stage Renal Disease Services (ESRD) (90918–90925, G0308, G0327) 2345 23466.5.1. Included Services 2347ESRD-related physician services include establishment of a dialyzing cycle, outpatient 2348evaluation and management of the dialysis visits, telephone calls and patient management 2349during the dialysis, provided during a full month. These codes are not used if a 2350hospitalization occurred during the month. 2351 23526.5.2. E&M Rules 2353The E&M services associated with or related to performance of dialysis for ESRD 2354services, when performed on the same day as the dialysis, are included in the ESRD 2355procedure. Therefore no separate E&M code is reported. If there is a separately 2356identifiable E&M, unrelated to the dialysis procedure, that E&M shall be coded based on 2357documentation and appended with modifier -25. 2358 23596.5.3. Procedural Coding Rules 2360In general, using ESRD codes is similar to using the dialysis codes in section 6.4. 2361Because ESRD is a Medicare-covered benefit there are specific HCPCS codes. These 2362codes (G0308–G0327) are more detailed and are used when the code requirements are 2363met. The HCPCS Level II codes are used in the same manner as the dialysis CPT 2364(HCPCS Level I) codes. ESRD services are usually captured in the BAJ* MEPRS 2365(Nephrology). 2366 2367 DoD Rule 2368 2369 When ESRD service is performed, no procedure codes will be reported, 2370 except for the first encounter of the month, to reflect the previous month’s 2371 services. 2372 2373 Hint: To determine the number of ESRD encounters during the month, use 2374 the patient appointment history in AHLTA/CHCS.

2375 23766.5.4. ESRD Diagnosis Coding 2377Use ESRD 585.6. Use V42.0 as an additional code to identify kidney transplant status if 2378applicable. 2379 23806.5.5. Dialysis and ESRD Procedure Code List. 2381End Stage Renal Disease Services (90918–90925) (G0308–G0327) 2382 238390918 ESRD-related services per full month; for patients less than 2 years of age, 2384including monitoring for adequacy of nutrition, assessment of growth and development 2385and counseling of parents. 2386

449 17 450 MHS Coding Guidance 451 March 2008 452 453 SPECIALTY CODING 454 6.5 End Stage Renal Disease 455 238790919 ESRD-related services per full month; for patients from 2 to 11 years of age, 2388including monitoring for adequacy of nutrition, assessment of growth and development 2389and counseling of parents. 2390 239190920 ESRD-related services per full month; for patients from 12 to 19 years of age 2392including monitoring for adequacy of nutrition, assessment of growth and development 2393and counseling of parents. 2394 239590921 ESRD-related services per full month; for patients 20 years of age and older. 2396 239790922 ESRD-related services (less than full month), per day; for patients under 2 years 2398of age. 2399 240090923 ESRD-related services (less than full month), per day; for patients from 2 to 11 2401years of age. 2402 240390924 ESRD-related services (less than full month), per day; for patients from 12 to 19 2404years of age. 2405 240690925 ESRD-related services (less than full month), per day; for patients 20 years of age 2407and older. 2408 2409G0308 ESRD-related services during the course of treatment, for patients under 2 years 2410of age, including monitoring for adequacy of nutrition, assessment of growth and 2411development and counseling of parents; with four or more face-to-face physician visits 2412per month. 2413 2414G0309 ESRD-related services during the course of treatment for patients under 2 years 2415of age, including monitoring for adequacy of nutrition, assessment of growth and 2416development and counseling of parents; with two or three face-to-face physician visits 2417per month. 2418 2419G0310 ESRD-related services during the course of treatment, for patients under 2 years 2420of age including monitoring for adequacy of nutrition, assessment of growth and 2421development, and counseling of parents; with one face-to-face physician visit per month. 2422 2423G0311 ESRD-related services during the course of treatment, for patients between 2 and 242411 years of age, including monitoring for adequacy of nutrition, assessment of growth 2425and development and counseling of parents; with four or more face-to-face physician 2426visits per month. 2427 2428G0312 ESRD-related services during the course of treatment for patients 2 to 11 years of 2429age, including monitoring for adequacy of nutrition, assessment of growth and 2430development and counseling of parents; with two or three face-to-face physician visits 2431per month. 456 18 457 MHS Coding Guidance 458 March 2008 459 460 SPECIALTY CODING 461 6.5 End Stage Renal Disease 462 2432G0313 ESRD-related services during the course of treatment, for patients 2 to 11 years 2433of age, including monitoring for the adequacy of nutrition, assessment of growth and 2434development, and counseling of parents; with one face-to-face physician visit per month 2435 2436G0314 ESRD-related services, during the course of treatment, for patients between 12 2437and 19 years of age, including monitoring for the adequacy of nutrition, assessment of 2438growth and development, and counseling of parents; with four or more face-to-face 2439physician visits per month. 2440 2441G0315 ESRD-related services during the course of treatment, for patients between 12 2442and 19 years of age to include monitoring for the adequacy of nutrition, assessment of 2443growth and development, and counseling of parents; with two or three face-to-face 2444physician visits per month. 2445 2446G0316 ESRD-related services during the course of treatment, for patients between 12 2447and 19 years of age, including monitoring for the adequacy of nutrition, assessment of 2448growth and development, and counseling of parents; with one face-to-face physician visit 2449per month 2450 2451G0317 ESRD-related services during the course of treatment, for patients 20 years of 2452age and older; with 4 or more face-to-face physician visits per month. 2453 2454G0318 ESRD-related services during the course of treatment, for patients 20 years of 2455age and over; with two or three face-to-face physician visits per month. 2456 2457G0319 ESRD-related services during the course of treatment, for patients 20 years of 2458age and over; with one face-to-face physician visit per month. 2459 2460G0320 ESRD-related services for home dialysis patients per full month; for patients less 2461than two years of age including monitoring for adequacy of nutrition, assessment of 2462growth and development and counseling of parents. 2463 2464G0321 ESRD-related services for home dialysis patients per full month; for patients two 2465to eleven years of age including monitoring for adequacy of nutrition, assessment of 2466growth and development and counseling of parents. 2467G0322 ESRD-related services for home dialysis patients per full month; for patients 12 2468to 19 years of age, including monitoring for adequacy of nutrition, assessment of growth 2469and development and counseling of parents 2470 2471G0323 ESRD-related services for home dialysis patients per full month; for patients 20 2472years of age and older 2473 2474G0324 ESRD-related services less than full month, per day; for patients under 2 years of 2475age. 2476 463 19 464 MHS Coding Guidance 465 March 2008 466 467 SPECIALTY CODING 468 6.5 End Stage Renal Disease 469 2477G0325 ESRD-related services less than full month, per day; for patients 2 to 11 years of 2478age. 2479 2480G0326 ESRD-related services less than full month, per day; for patients 12 to 19 years 2481of age. 2482 2483G0327 ESRD-related services less than full month, per day; for patients 20 years of age 2484and older.

470 20 471 MHS Coding Guidance 472 March 2008 473 474 SPECIALTY CODING 475 6.6 Flight Medicine Services 476 24856.6. Flight Medicine Services 2486NOTE: Referral to flying status includes air traffic control duty. Reference to air 2487crew member includes air traffic controller. 2488 24896.6.1. E&M Rules 2490 2491 DoD Rule 2492 2493 Annual/periodic flight exams are reported as comprehensive preventive 2494 medicine encounters (99384–99397). Treatment of conditions identified, 2495 regardless of whether they are pre-existing or identified in the course of the 2496 preventive medicine encounter, are coded separately per the instructions in 2497 the Preventive Medicine Services subsection of the CPT manual. To use 2498 the code range 99384–99397, an examination must be performed.

2499 25006.6.1.1. Encounters for Approval for Flying Status 2501Encounters that do not meet the requirements of a comprehensive preventive medicine 2502service are reported as either individual counseling preventive medicine services (no 2503medical problems and meets the requirements of preventive medicine counseling, use 2504codes 99401–99404) or as office visit or other outpatient services (for a medical issue, 2505use codes 99201–99215). When documentation supports only the use of a 99211, it is 2506appropriate for providers to use the 99211 code. 2507 25086.6.2. Diagnosis Coding Rules 2509

2510 DoD Rule 2511 2512 Annual flight exams are reported with V70.5_1 as the first listed diagnosis. 2513 Any pre-existing or newly diagnosed conditions are listed as additional 2514 diagnoses. 2515 2516 Encounters for post-deployment conditions (confirmed or suspected) will 2517 have the reason for the encounter listed in the primary diagnosis field with 2518 V70.5_6 listed as a secondary code. This rule takes precedence over any 2519 other diagnosis coding rule. 2520 2521 25226.6.2.1. The following information provides guidance on coding flight physicals: 2523 2524 1. Initial flight exam, no symptoms 2525 a. Diagnosis code: V70.5 1 Aviation exam 2526 b. E&M: 993xx Age-appropriate prevention exam 2527 c. CPT procedures *: 92552/3 Pure tone audiometry tests, air 477 21 478 MHS Coding Guidance 479 March 2008 480 481 SPECIALTY CODING 482 6.6 Flight Medicine Services 483 2528 93000** EKG, interpretation & report 2529 93005 EKG, tracing only 2530 93010 EKG, interpretation & report only 2531 d. Visual Screening 99173 Visual Acuity Screen 2532 * Procedures are coded if performed and properly documented in 2533 flight medicine clinic note(s). 2534 ** Choose appropriate EKG test performed in flight medicine clinic 2535 2536 2. Annual flight exam, normal, no symptoms (return to flight status) 2537 a. Diagnosis code: V70.5 1 Aviation exam 2538 b. E&M: 993xx Age-appropriate prevention exam 2539 c. CPT procedures *: 92552/3 Pure tone audiometry tests, air 2540 93000** EKG, interpretation & report 2541 93005 EKG, tracing only 2542 93010 EKG, interpretation & report only 2543 d. Visual screening 99173 Visual acuity screen 2544 * Procedures are coded if performed and properly documented in 2545Flight Medicine Clinic note(s). 2546 ** Choose appropriate EKG test performed in Flight Medicine Clinic 2547 2548 3. Annual flight exam with symptoms, disease found, or acute exacerbation of 2549 chronic condition 2550 a. Diagnosis codes: V70.5 1 Aviation exam 2551 xxxxx Code the symptom/disease found on 2552 examination 2553 b. E&M: 993xx Age-appropriate prevention exam. 2554 992xx Appropriate office encounter. Add 2555 modifier -25 to show a separate 2556 E&M service was provided. 2557 c. CPT Procedure: xxxxx List any procedures performed for 2558 the flight exam as outlined in 2559 Item 1. List any additional 2560 procedures performed 2561 that relate to the s 2562 symptom or disease found on 2563 examination. 2564 2565 4. Flight exam, chronic condition (not active or influencing flight status) 2566 a. Diagnosis code: V70.5 1 Aviation exam 2567 xxx.xx Code chronic condition (e.g., 2568 hypertension) 2569 b. E&M: 993xx Age-appropriate prevention exam 2570 c. CPT Procedures: xxxxx List any procedures performed for 2571 the flight exam as outlined in 2572 Item 1. 484 22 485 MHS Coding Guidance 486 March 2008 487 488 SPECIALTY CODING 489 6.6 Flight Medicine Services 490 2573 2574 5. Flight exam, active condition or disease influencing flight status 2575 a. Diagnosis code: xxx.xx Code active condition of 2576 symptom/disease that 2577 removed individual 2578 from flight status 2579 b. E&M: 992xx Appropriate office encounter 2580 c. CPT procedures: xxxxx List any procedures performed 2581 during office visit 2582 2583 6. Return-to-flight status, (after illness/injury) currently no symptoms 2584 a. Diagnosis code: V68.09 Medical certificate 2585 b. E&M: 9921x Appropriate E&M office visit 2586 2587 7. Flight Exam, waiver renewal (face-to-face) 2588 a. Diagnosis code: V68.09 Medical certificate (waiver) 2589 b. E&M: 992xx Appropriate office visit code 2590 99358/9* Prolonged services, non face-to-face 2591 c. CPT procedure: 99080 Special reports (service specific 2592 waiver report) 2593 2594 Prolonged services code would be assigned when the provider reviews records, tests 2595 and communications with professionals and family. This would be in addition to 2596 time spent with the patient—99358-first hour of review of tests and communication 2597 with other professionals and family. Code 99359 identifies any additional 30 2598 minutes. 2599 2600 8. Ground testing, no adverse effects of drugs 2601 a. Diagnosis code: V70.5 1 Aviation exam 2602 b. E&M code: 992xx Appropriate office visit 2603 (new/established) 2604 c. CPT procedure: None 2605 2606 9. Ground testing, with adverse effects of drugs 2607 a. Diagnosis code: 995.2 Adverse effect of correct drug 2608 properly administered 2609 780-789.xx Symptom code or appropriate ICD 2610 code to describe the drug 2611 interaction 2612 E930-E949.x Cause of injury code to identify the 2613 drug reaction 2614 b. E&M code: 9921x Appropriate Office Visit 2615 c. CPT procedure: List any procedures/counseling 2616 performed 2617 491 23 492 MHS Coding Guidance 493 March 2008 494 495 SPECIALTY CODING 496 6.6 Flight Medicine Services 497 2618 10. Incentive Flight/Chamber/Survival Training clearance encounters 2619 a. Diagnosis code: V70.5_1 Aviation exam 2620 V65.43 Counseling on injury prevention 2621 (survival training) 2622 b. E&M code: 99384/86 New patient preventive exam, 2623 OR 2624 99394/96 Established patient prevention exam

498 24 499 MHS Coding Guidance 500 March 2008 501 502 SPECIALTY CODING 503 6.7 Gynecology 504 26256.7. Gynecology 2626 26276.7.1. E&M Rules 2628 26296.7.1.1. Office Visit 2630The most common type of E&M is the office visit for a symptom, condition, or disease. 2631Office visits are coded 99201–99215. 2632 26336.7.1.2. Well Woman Exam 2634If a complete general physical exam is performed, use preventive medicine E&M codes 263599384–99387 for new patients and 99394–99397 for established patients. When a patient 2636is seen for a physical and has a separately identifiable symptom, condition, or disease that 2637requires significant time or resources, it should be documented and coded separately. 2638Append the modifier -25 to the appropriate office E&M. When a patient is seen for a 2639physical and a screening Pap smear is collected at the time, code the E&M and collect 2640Q0091 in the CPT/HCPCS field. 2641 26426.7.1.3. Counseling 2643Visits specifically for initial contraceptive management are coded to preventive 2644medicine. Should the encounter not include an exam, counseling is reported as 99401– 264599404. Subsequent visits for contraceptive management are reported as established 2646patient office visits. 2647 26486.7.2. Diagnosis Coding Rules 2649

2650 DoD Rule 2651 2652 Well-Woman Exams 2653 V72.31 Is reported for a complete physical exam with a gynecology 2654 component. 2655 Use these codes in addition to V72.31 when appropriate: 2656 V76.47 For post-hysterectomy patients 2657 V45.77 Acquired absence of the uterus 2658 Report the code(s) for any problem (s) also addressed during the 2659 encounter.

2660 26616.7.2.1. Screening Pap 2662When a screening Pap smear is done, one of the following diagnosis codes is reported 2663and linked to the HCPCS codes for the exam. 2664 2665 V67.01 Vaginal Pap Smear s/p hysterectomy for malignant condition 2666 (use additional codes for acquired absence of genital organs V45.77_x) 2667 V76.2 Cervical Pap Smear (Routine) 2668 V76.47 Vaginal Pap Smear s/p hysterectomy for non-malignant condition 505 25 506 MHS Coding Guidance 507 March 2008 508 509 SPECIALTY CODING 510 6.7 Gynecology 511 2669 (use additional codes for acquired absence of genital organs V45.77_x) 2670 V76.49 Special screening for malignant neoplasm, other sites. 2671 V15.89 Other specified personal history presenting hazards to health. 2672 (Used for women considered to be at high-risk for cervical cancer. 2673 Examples would be screenings for patients with early onset of sexual 2674 activity, patients exposed to DES in the womb, patients with more than 2675 five sexual partners in a lifetime, and patients who have had a sexually 2676 transmitted disease.) 2677 2678NOTE: If the original pap smear did not contain an adequate sample, and the patient 2679returns to obtain a new smear, code 795.08 nonspecific abnormal Pap smear of cervix, 2680unsatisfactory smear. 2681 2682An additional diagnosis code may be used to identify the high-risk factor, such as V69.2 2683“High-Risk Sexual Behavior.” 2684

2685 DoD Rule 2686 2687 Use Q0091 to code the collection of screening Pap smear. In the MHS, it is 2688 appropriate to code the V76 screening code when using the Q0091, 2689 including when this occurs during a well-woman visit, coded V72.31. 2690 2691 The collection of a diagnostic Pap is part of the exam component of an 2692 office visit and is not coded separately. 2693 2694 When a patient receives a breast and pelvic exam only and not enough of 2695 the health/preventive requirements to satisfy a physical, the G0101 2696 continues to be the most appropriate code.

2697 26986.7.2.2. Diagnostic Pap 2699Pap smears completed on women who have had previous cancer of the female genital 2700tract are diagnostic, not screening, Pap smears. They are for a medically necessary 2701reason, regardless of the presence or absence of symptoms. The appropriate personal 2702history diagnosis code is reported. 2703 2704 Example: V67.01 would be used for diagnostic vaginal pap smear s/p hysterectomy 2705 for malignant condition (use additional codes for acquired absence of genital organs 2706 V45.77_x) 2707 27086.7.2.3. Abnormal Followed by Normal Pap 2709If a woman has an abnormal Pap smear and then a follow-up Pap smear is normal, two 2710more Pap smears are usually done to confirm the normal result. These encounters will be 2711coded V72.32. 2712 512 26 513 MHS Coding Guidance 514 March 2008 515 516 SPECIALTY CODING 517 6.7 Gynecology 518 27136.7.2.4. Contraceptive Management 2714A code from V25 is used when a contraceptive management procedure or counseling is 2715done during an encounter. 2716 27176.7.2.5. Pregnancy Testing 2718Encounters for the purpose of pregnancy testing are to be coded as follows, based on the 2719results of the test or exam known at the time of the encounter. 2720 Results of Test and/or Exam Code(s) Positive V72.42 Negative without any related symptoms or diagnoses V72.41 Negative with any related symptoms or diagnoses Codes for symptoms or conditions and V72.41 Unconfirmed exam or test V72.40 2721 27226.7.3. Procedural Coding Rules 2723 27246.7.3.1. No Coding for Contraceptives 2725Contraceptive supplies or medications dispensed through the pharmacy are not coded. 2726 27276.7.3.2. Procedures for Implantable Contraceptive Capsules 2728These are coded in the Integumentary subsection (e.g., 11975, 11976, and 11977) of the 2729CPT manual. Non-implantable devices are in the Female Genital System subsection (e.g., 273058300). 2731 27326.7.3.3. Pelvic Exam under Anesthesia 2733This (57410) is commonly miscoded in the clinic setting. A pelvic is part of the exam 2734component of an office visit and the preventive medicine service (e.g., physical). There 2735is no separate code for a pelvic exam. 2736 27376.7.4. Modifiers 2738A -25 modifier is appended to the E&M code when a procedure is preformed as well as a 2739separately identifiable E&M. Do not use the -25 modifier with E&Ms done at the same 2740time as laboratory tests (e.g., KOH, wet prep).

519 27 520 MHS Coding Guidance 521 March 2008 522 523 SPECIALTY CODING 524 6.8 Mental Health 525 27416.8. Mental Health 2742 27436.8.1. Evaluation & Management (E&M) Rule

2744 DoD Rule 2745 2746 Air Force will follow guidance in the Behavioral Health Coding Handbook.

2747 27486.8.1.1. Mental Health Consults 2749Infrequently, mental health consults with only a history, exam, or decision (e.g., would 2750you recommend mental health therapy for this patient at this time for this condition?) 2751occur. If the encounter meets the requirements of a consult, use a consult code. See 2752Chapter 4 for information on consults. There may also be infrequent instances of a 2753“mini-mental status exam,” when an entire initial diagnostic interview cannot be 2754completed. These may be coded using an E&M. 2755 27566.8.1.2. Inpatient Treatment without Therapy 2757When treating inpatients and not providing therapy at the same time, inpatient E&M 2758codes are appropriate. See section 9 for other coding guidance on inpatient services. 2759 27606.8.2. Diagnosis Coding Rules 2761 27626.8.2.1. Diagnostic and Statistical Manual (DSM) 2763Mental health diagnoses are based on terminology and codes in the Diagnostic and 2764Statistical Manual of Mental Disorders (DSM IV). Although the terminology in ICD-9- 2765CM or CHCS does not always match the terminology in DSM IV, most of the codes are 2766the same. Most mental health codes are in the 290–320 range in ICD-9-CM. 2767 27686.8.2.2. Patients without Mental Disorder Diagnosis 2769Some encounters are with patients or clients who do not have a mental disorder 2770diagnosis. There are V codes that describe these encounters, such as: 2771  V40 Mental and behavioral problems 2772  V60.2 Financial problems 2773  V61 Other family circumstances, including 2774 o V61.10 Counseling for marital and partner problems 2775 o V61.49 Presence of sick or handicapped person in family or household 2776 o V62.82 Bereavement 2777  V71.09 Observation for other suspected mental condition 2778 2779 2780 2781

526 28 527 MHS Coding Guidance 528 March 2008 529 530 SPECIALTY CODING 531 6.8 Mental Health 532

2782 DoD Mental Health Extender Codes 2783 2784 Mental health diagnosis extender codes are a group of ICD-9 codes that 2785 have been modified to meet the needs of the Services. The extender is 2786 paired with an ICD code to acquire a unique meaning. Use the 2787 appropriate extender for the type of service provided. DOD mental health 2788 diagnoses extender codes can be used in any clinical setting.

2789 27906.8.2.3. DOD Mental Health Diagnoses with Extender Codes 2791 2792 V65.42_0 Alcohol education 2793 V65.42_1 Substance abuse counseling 2794 V65.49_1 Medication education 2795 V65.49_7 Occupational stress education 2796 V65.49_8 Mental health education 2797 V65.49_9 Other specified counseling 2798 V65.49_A Stress education 2799 V65.49_B Suicide education 2800 28016.8.3. Procedural Coding Rules 2802 28036.8.3.1. Four Code Groups for Mental Health 2804There are four major groups of procedure codes commonly used by mental health and life 2805skills providers. They are the psychiatry and biofeedback CPT codes 90801–90899; the 2806central nervous system assessments/tests CPT codes 96100–96117; health and behavior 2807assessment/intervention CPT codes 96150–96155; and the HCPCS H codes for alcohol 2808and drug abuse treatment services. 2809 28106.8.3.2. Initial Psychiatric Diagnostic Interview 2811These codes are used by all privileged mental health providers (e.g., social workers, 2812psychologists, psychiatrists) for the initial evaluation. The initial psychiatric diagnostic 2813interview codes will only be used on the initial encounter. If the privileged mental health 2814provider was unable to complete the psychiatric diagnostic interview examination at the 2815initial encounter, a code would be selected for the initial encounter specifically on the 2816basis of what services/procedures were performed. If an established patient presents with 2817a new mental health condition, a new psychiatric diagnostic interview may be required. 2818 28196.8.3.3. Therapy with E&M 2820The therapy with E&M codes are usually used only by psychiatrists and psychologists. 2821The E&M component should be documented separately and include the history, exam, 2822and decision making. For therapy, the time that face-to-face therapy started and time 2823ended should be documented, because the therapy codes are time based. Time spent 2824conducting the E&M component is not included in the therapy time.

533 29 534 MHS Coding Guidance 535 March 2008 536 537 SPECIALTY CODING 538 6.8 Mental Health 539 28256.8.3.4. 90862 Pharmacologic Management 2826This code is not used with any E&M or therapy code. It may be used by any provider 2827prescribing and managing psychopharmacological medication. It would be rare for a 2828non-mental health provider to use this code, as pediatricians managing a patient using 2829Ritalin would usually do more than just review and adjust the amount of medication. 2830 28316.8.3.5. 90885 Psychiatric Evaluation of Records 2832This code is included in the initial diagnostic interview and therapy codes and is not used 2833if codes 90801–90857 are used. Evaluation of all available applicable data is always part 2834of treatment. This code is for a paper review of the patient, without seeing or treating the 2835patient, to make a diagnosis. 2836 28376.8.3.6. 90887 Advising Family and Others How to Assist Patient 2838This code is used when a provider summarizes results to the family when the patient is 2839unable to communicate. It is not used in conjunction with 90801–90857. 2840 28416.8.4. Documentation 2842When both therapy and an E&M are provided in the same encounter, the E&M 2843documentation should be noted separately, after the end of the therapy note or on a 2844separate page. 2845 28466.8.5. Auditing and Coding 2847Mental health documentation coding and auditing will be performed in the mental health 2848clinic by coding professionals in order to meet privacy and disclosure requirements. 2849 2850DoD 6025.18R, para DL1.1.29. defines psychotherapy notes as, “Notes recorded (in any 2851medium) by a healthcare provider who is a mental health professional documenting or 2852analyzing the contents of conversation during a private counseling session or a group, 2853joint, or family counseling session and that are separated from the rest of the 2854individual’s medical record.” 2855 2856An entry in the hard copy outpatient medical record or AHLTA, about the mental health 2857encounter should include items excluded from the psychotherapy note as defined in DoD 28586025.18R, para DL1.1.29. “Psychotherapy notes exclude medication prescription and 2859monitoring, counseling session start and stop times, the modalities and frequencies of 2860treatment furnished, results of clinical tests, and any summary of the following items: 2861diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to 2862date.” 2863 2864This documentation should be sufficient to code a psychotherapy counseling encounter. 2865However, if E&M services are provided, additional documentation may be required for 2866auditing purposes. When outpatient documentation is sufficient, access to the separate 2867mental health record or psychotherapy note may not be necessary for auditing. When 2868such documentation is not sufficient, further documentation substantiating the coding will 2869be made available to the auditor. 540 30 541 MHS Coding Guidance 542 March 2008 543 544 SPECIALTY CODING 545 6.9 Nutritional Medicine 28706.9. Nutritional Medicine Encounters 2871 28726.9.1. Evaluation & Management (E&M) Rules 2873Nutritional medicine does not generate E&M services. 2874 28756.9.2. Privileged Providers, Dieticians 2876 28776.9.2.1. Physicians and Other Privileged Providers Not Registered Dieticians. 2878Privileged providers other than registered dieticians should use an office E&M (e.g., 287999201–99245) when coding consulting on nutritional therapy or intervention. These 2880privileged providers (not Registered Dieticians) should use the preventive medicine codes 2881(e.g., 99401–99412) when counseling individuals or groups on nutritional topics when 2882the patients do not have symptoms, conditions, or diagnoses related to the topics being 2883addressed. These privileged providers should use the group education code (99078) 2884when educating groups with symptoms, conditions or diagnoses related to the education 2885topic. 2886 28876.9.2.2. Registered Dieticians 2888 28896.9.2.2.1. Preventive Medicine 2890Registered dieticians may use the preventive medicine codes (99401–99412) when 2891providing counseling or risk-factor reduction interventions. To use these codes, the 2892patient should not have a symptom, condition, or diagnosis related to the topics covered. 2893For example, registered dieticians may teach a Healthy Heart eating group. 2894 28956.9.2.2.2. Telephone Consultation 2896Registered dieticians may use the appropriate telephone consultation code, as long as the 2897documentation reflects the encounter was for a new issue, providing additional 2898information on a nutrition-related topic. Telephone consults are not to be used for 2899administrative encounters, such as reminding patients of appointments. Telephone 2900consults are not to be used for continuations of previous encounters, such as providing 2901websites for help groups when information was not available at the previous encounter. 2902 29036.9.2.2.3. Outpatient Consultation 2904Both referrals and consults are requested using Standard Form (SF) 513. It is very 2905infrequent when a provider requests advice (a consult) from a registered dietician on 2906management of a medical condition (e.g., for this 211-pound male, which diet should I 2907use to treat him?). Usually, the provider refers (a referral) the medical nutritional 2908management of the patient to the registered dietician. The registered dietician’s medical 2909nutritional therapy should be coded using the 97802–97804 codes. 2910 29116.9.2.3. Non-Privileged Providers or Diet Technicians 2912All diet technician visits are coded with the procedure code. If the technician is involved 2913in the patient appointment conducted by a dietician (e.g. assesses the food diaries prior to 2914the group encounter, which the dietician will conduct), the technician is considered an

546 31 547 MHS Coding Guidance 548 March 2008 549 550 SPECIALTY CODING 551 6.9 Nutritional Medicine 2915additional provider in ADM and the dietician is credited with the visit(s). Merely 2916checking a patient in does not meet the requirement of an additional provider. 2917 29186.9.3. Diagnosis Coding Rules 2919An outpatient visit to a nutrition clinic is coded with the ICD-9-CM code V65.3, Dietary 2920Surveillance and Counseling. Other existing conditions would be coded as a secondary 2921or additional diagnostic code. With ADM version 3.0, up to four diagnosis codes may be 2922entered. 2923 2924 Examples of codes include the following: 2925  Colitis—558.9 2926  Diabetes mellitus—250.0_ (5th digit sub-classification 0–3) 2927 . Requires an additional code for diabetic manifestations (e.g., acute 2928 angle-closure glaucoma, 365.22; peripheral neuropathy, 355.8; 2929 skin ulcer of lower extremity, 707.10) 2930  Dermatitis caused by food (allergies)—693.1 2931  Pure hypercholesterolemia—272.0 2932 2933NOTE: Please review new BMI codes located in the 2007 ICD-9-CM: V85.0x- 2934V85.5x. 2935 2936When a patient is seen for the cause of his weight gain (thyroid, etc.), use code V77.8 2937special screening for obesity in addition to the overweight/obese ICD codes. 2938 29396.9.4. Procedural Coding Rules 2940 29416.9.4.1. Medical Nutritional Therapy (MNT) CPT codes 2942 29436.9.4.1.1. MNT; Initial Assessment and Intervention 294497802 is to be used only once each year, for initial assessment of a new patient, unless 2945the patient is seen for a different condition with different therapy requirements than the 2946prior initial assessment. Documentation must reflect the amount of face-to-face time 2947with the patient. Enter the number of units (each 15 minutes) in the unit field. 2948 29496.9.4.1.2. MNT, Reassessment, and Intervention 295097803 should be used when there is a change in the patient’s medical condition that 2951affects the nutritional status of the patient. Documentation must reflect the amount of 2952face-to-face time with the patient. Enter the number of units (e.g., if the reassessment 2953took 45 minutes, code a quantity of 3) in the unit field. 2954 2955NOTE: MNT CPT codes (97802–97804) cannot be used in conjunction with the 2956preventive medicine E&M codes (99401–99412). If the patient is receiving 2957medical nutritional therapy and risk-factor reduction nutritional guidance (e.g., 2958being briefed on low-sodium diet, but also receives counseling on general 2959nutritional topics), the entire time would be coded for the MNT.

552 32 553 MHS Coding Guidance 554 March 2008 555 556 SPECIALTY CODING 557 6.9 Nutritional Medicine 2960 29616.9.4.1.3. Registered Dieticians 2962These individuals should use the appropriate medical nutritional therapy code (97802– 296397804) when conducting nutritional assessments and specific diet training. As these 2964codes are time sensitive, the documentation must reflect the amount of time spent face-to- 2965face with the patient. Time spent reviewing the food diary with the patient would be 2966coded as part of the MNT encounter. 2967 29686.9.4.1.4. Certified Diet Technicians 2969These individuals should use the nutritional medicine codes 97802–97804 for MNT. 2970Diet technicians are authorized to provide instruction on those diets on which they 2971have been certified. 2972 29736.9.4.2. Education and Training for Patient Self-Management 2974Services prescribed by a physician and provided by a qualified nonphysician 2975healthcare professional designed to teach patients how to effectively self-manage 2976illness(es) or disease(s) including asthma and diabetes may be coded as follows when 2977a standardized curriculum is used: 2978 98960 Face-to-face with patient each 30 minutes; individual patient 2979 98961 2-4 patients 2980 98962 5-8 patients 2981 29826.9.4.3. Group Counseling Performed by a Non-Physician Provider (excludes 2983certified technicians) 2984Documentation of group counseling, per session, is required in each individual’s medical 2985record, along with topics addressed and any specific patient-related issues. 2986 2987  S9449 Weight management classes 2988  S9451 Exercise class, non-physicians 2989  S9452 Nutrition class, non-physician 2990  S9455 Diabetic management program, group session 2991  S9460 Diabetic management program, nurse visit 2992  S9465 Diabetic management program, dietician visit 2993  S9470 Nutrition counseling, dietician visit 2994 29956.9.5. Units of Service 2996 29976.9.5.1. Time Spent as Unit of Service 2998By marking the quantity column on the superbill, indicate the time spent with the patient 2999as units of service for CPT code assignment. Example: One 30-minute reassessment 3000visit equates to two units of service. 3001 3002 3003 3004

558 33 559 MHS Coding Guidance 560 March 2008 561 562 SPECIALTY CODING 563 6.9 Nutritional Medicine 3005 30066.9.5.1.1. Dietitian Outpatient Examples: 3007

3008 DoD Rule 3009 3010 Recording of documentation in AHLTA is not a separately codable 3011 event. Encounters that do not meet minimum visit criteria are 3012 administrative and are not a coded visit.

3013 30146.9.5.1.1.1. A dietitian teaches a 45 minute nutrition segment of a multidisciplinary 3015team diabetes education program (following the American Diabetes Association 3016standardized curriculum). The dietitian reviews the patient diet history questionnaire 3017which includes meds, labs, and exercise history. An individualized meal plan is provided 3018to each patient and explained during the class. All patients are scheduled to return for 3019two more follow-up visits to complete the series of classes. Once the class is completed, 3020the RD documents the patient condition/diagnosis, initial assessment, diagnosis, 3021counseling provided, and goals/action plan. Codes for example: 3022  ICD-9-CM: V65.3, additional diagnosis of diabetes 250.00 or other diabetes 3023 related medical condition code, obese or overweight code and BMI code (if 3024 patient overweight/obese) 3025  E&M: N/A 3026  CPT: 97804 with 3 units of service 3027 30286.9.5.1.1.2. A dietitian spends 45 minutes reading about an uncommon medical 3029condition and then develops a handout for a patient. The RD spends 30 minutes face-to- 3030face with the patient, discussing the information on the handout and providing detailed 3031diet instruction. After the appointment, the RD takes 15 minutes to input the note into 3032AHLTA. Codes for example: 3033  ICD-9-CM: V65.3 and the condition/diagnosis code 3034  E&M: N/A 3035  CPT code 97802 with 2 units of service. Only the actual face-to-face time with 3036 the patient is part of the procedural (MNT CPT) code. 3037 30386.9.5.1.1.3. A physician sends a request for assessment to the RD to see an 3039obese patient for weight loss and consideration for bariatric surgery. The RD 3040conducts a 60 minute in-depth assessment for the patient’s readiness for behavior 3041change, usual diet and exercise habits, measures current height and weight, and 3042provides diet education and written materials. Codes for example: 3043  ICD-9-CM: V65.3, obesity 278.02, V85.39 (BMI range 39.0-39.9) 3044  E&M: N/A 3045  CPT: 97802 with 4 units of service 3046

564 34 565 MHS Coding Guidance 566 March 2008 567 568 SPECIALTY CODING 569 6.9 Nutritional Medicine 30476.9.5.1.1.4. A dietitian teaches a 90 minute class on sports nutrition to a group 3048of eight. The patients’ height, weight, and BMI are calculated. The dietitian 3049works with each patient to determine estimated energy, protein, fluid, and 3050carbohydrate needs. Individualized documentation for each patient is entered into 3051AHLTA. Codes for example: 3052  ICD-9: V65.3 only 3053  E&M: 99412 preventive medicine group code 3054  CPT: no NMT CPT codes are used with a preventive medicine E&M code 3055 30566.9.5.1.2. Diet Technician Outpatient Examples 3057 30586.9.5.1.2.1. A diet technician teaches a one-hour group cholesterol class. The 3059technician has each patient fill out an information sheet, reviews each patient’s 3060laboratory values, and documents the visit by assessing the patient condition, 3061describing the education provided and educational materials, and the follow-up 3062plan. Codes for example: 3063  ICD9-CM: V65.3, dietary surveillance and counseling 3064  E&M: N/A 3065  CPT: 97804 with 2 units of service 3066 30676.9.5.1.2.2. The diet technician has a 30-minute follow-up visit with a patient 3068who attended the cholesterol class described above. The technician analyzes the 3069patient’s food diary, reviews any new relevant labs, provides specific 3070recommendations on dietary changes, and documents the visit. ICD9-CM code 3071V65.3, dietary surveillance and counseling. Codes for example: 3072  ICD-9: V65.3, dietary surveillance and counseling 3073  E&M: N/A 3074  CPT: 97803, reassessment and intervention, with 2 units of service 3075 3076NOTE: 99078 may be used as an additional code if physician education services are 3077provided in a group setting. 3078 30796.9.5.1.2.3. A diet technician teaches the 30-minute nutrition segment of an 3080obstetrics orientation. The diet tech assesses self-reported data on an SF 600 3081overprint for each attendee includes: current pregnancy weight, week’s gestation, 3082total weight gain compared to expected weight gain, and usual diet intake or food 3083frequently. The diet technician meets with each patient individually to ensure her 3084understanding of the assessment and nutritional recommendations. Codes for 3085example: 3086  ICD-9: V65.3 and applicable pregnancy code (e.g., V22.0, supervision of 3087 normal first pregnancy or V22.1, supervision of subsequent pregnancy) 3088  E&M: N/A 3089  CPT: 97804 with 1 unit of service 3090 3091 570 35 571 MHS Coding Guidance 572 March 2008 573 574 SPECIALTY CODING 575 6.9 Nutritional Medicine 3092 3093 30946.9.6. Inpatient Therapy Examples:

3095 DoD Rule 3096 3097 Inpatient nutrition consultation encounters are reported in ADM. When 3098 the screen prompts, Are you from the attending service? select no. This will 3099 create the encounter in ADM and will be reported in the B MEPRS. 3100 Nutritional screenings are not codeable services and will not be brought 3101 back as workload to the B MEPRS clinic. 3102

3103 31046.9.6.1. A physician consults an RD to assess an ICU patient with COPD with 3105acute exacerbation for alternate nutrition sources e.g. TPN (total parenteral nutrition). 3106The RD reviews the patient medical record, conducts a brief interview with the patient 3107and spouse, talks with the nursing staff about the patient’s usual oral intake, and then 3108make a detailed recommendation for TPN in the medical chart. The RD completes the 3109assessment in 45 minutes. Codes for this example: 3110  ICD-9-CM: V65.3, additional diagnosis code for current medical condition COPD 3111 491.21 3112  E&M: N/A 3113  CPT: 97802 with 3 units of service 3114 31156.9.6.2. The diet technician screens a cardiac patient and indicates the patient is 3116high nutrition risk due to post-CABG surgical procedure, recent weight loss and poor 3117appetite/intake. The diet tech refers the patient to the dietitian for further assessment and 3118intervention. The dietitian interviews the patient and family, reviews the medical record, 3119assesses the patient current condition and calorie needs, and makes recommendations to 3120the physician for a liberal diet. The nutrition screening and assessment process are 3121integral to the inpatient stay and are considered an institutional component of care, 3122therefore are not separately codeable. 3123 3124

576 36 577 MHS Coding Guidance 578 March 2008 579 580 SPECIALTY CODING 581 6.10 Obstetrics Services 582 31256.10. Obstetrics Services 3126 3127 NOTE: When a patient’s pregnancy is incidental to other services 3128 rendered, the provider must state the pregnancy does not affect care. 3129 Code the pregnant state with V22.2 diagnosis code. An incidental pregnancy 3130 cannot be the reason for the encounter, so V22.2 will not be the first listed 3131 diagnosis. Do not use the V22.2 code with obstetrical diagnostic codes from 630–677. Do not code the encounters with the 0500F or 0502F obstetrical 3132 procedure codes. 3133 3134 For instance, a three-months-pregnant patient breaks her wrist. This would be 3135 coded with an office visit E&M; an E code for the fracture, the V22.2 code for the diagnosis, and a procedure code for treatment of the fracture. 3136 3137 31386.10.1. E&M Rules 3139

3140 DoD Rule 3141 3142 UNCOMPLICATED obstetric encounters do not have an E&M 3143 component in the 99201–99499 series. 3144 3145 Most obstetric encounters involving complications of pregnancy do have 3146 an appropriate E&M in the 99201–99499 series and the appropriate E&M 3147 should be entered in the E&M field.

3148

3149 DoD Rule 3150 3151 As policy, global OB codes that represent work in two different MEPRS 3152 codes and the bundled ante partum visit codes (59425 and 59426) are not 3153 coded in the ADM.

3154 3155To account for workload, the MHS cannot use the global codes. 3156 31576.10.1.1. Do not use the following codes: 3158 59400 Routine obstetric care including ante partum care, vaginal delivery (includes 3159 services in both the outpatient and inpatient MEPRS codes) 3160 59410 Routine obstetric care including postpartum care (includes services in both 3161 outpatient and inpatient MEPRS codes) 3162 59425 Ante partum care only, 4–6 visits (use 0500F, initial prenatal care visit, and 3163 0502F subsequent prenatal care, for ante partum encounters)

583 37 584 MHS Coding Guidance 585 March 2008 586 587 SPECIALTY CODING 588 6.10 Obstetrics Services 589 3164 59426 Ante partum care, 7 or more visits (use 0500F, initial prenatal care visit, and 3165 0502F, subsequent prenatal care, for ante partum encounters) 3166 59510 Routine obstetric care including ante partum care—Cesarean delivery 3167 (includes services in both outpatient and inpatient MEPRS codes) 3168 59515 Cesarean delivery—postpartum care (includes services in both outpatient 3169 and inpatient MEPRS codes) 3170 59610 Vaginal birth after a previous C-section (VBAC) delivery including ante 3171 partum, delivery, and post partum (includes services in both outpatient and 3172 inpatient MEPRS codes) 3173 59614 VBAC delivery and postpartum care (includes services in both the 3174 outpatient and inpatient MEPRS codes) 3175 59618 Attempted VBAC ante partum, delivery and postpartum care (includes 3176 services in both outpatient and inpatient MEPRS codes) 3177 59622 Attempted VBAC delivery and postpartum care (includes services in both 3178 outpatient and inpatient MEPRS codes) 3179 31806.10.1.2. Billing vs. Data Collection Codes 3181The codes listed above are a billing convention, as insurance companies do not want 13 3182separate bills for the professional services associated with a full-term pregnancy. The 3183codes listed above cannot be used for data collection when each encounter reflects 3184services provided. By using the new category II CPT obstetrical codes, obstetrical 3185encounters will be collected without unbundling the obstetrical global codes. 3186

3187 DoD Rule 3188 3189 Use the appropriate E&M for office visits/hospital when something other 3190 than uncomplicated, routine obstetrical care is furnished. 3191 3192 For first visit with nurse for screening, vaccinations and counseling, code 3193 services as appropriate. Code 99211 for face to face visit with no 3194 procedures.

3195 31966.10.2. Diagnosis Coding Rules 3197 31986.10.2.1. Fifth Digit Requirement for Obstetric Diagnoses 3199The range of diagnosis codes 640–648, complications mainly related to pregnancy, 3200requires a fifth digit. Follow ICD-9-CM coding guidance for reporting obstetric 3201diagnoses. 3202 Fifth Digits 3203 0 Unspecified episode of care 3204 1 Delivered this episode, may or may not have had ante partum condition 3205 2 Delivered the episode of care, had postpartum complication 3206 3 Ante partum care (patient still pregnant at end of this episode of care)

590 38 591 MHS Coding Guidance 592 March 2008 593 594 SPECIALTY CODING 595 6.10 Obstetrics Services 596 3207 4 Postpartum care (patient delivered during previous episode of care) 32086.10.2.2. Co-morbidities 3209Some obstetric cases have co-morbidities that influence the pregnancy. Ensure that the 3210pregnancy and manifestation codes are listed. 3211 32126.10.2.2.1. Example: A pregnant patient presents to the clinic with a diagnosis of 3213Type I diabetes, which complicates the pregnancy. This encounter is coded in the 3214following manner: 3215 Fifth Digits 3216 648.03 Current conditions in the mother classifiable elsewhere, but complicating 3217 pregnancy, childbirth, or the puerperium, diabetes mellitus 3218 3219 250.01 Type I diabetes, without mention of complication 3220 32216.10.2.3. Diagnosis codes 647–649 3222Coders unfamiliar with obstetrical coding should review the codes in the 647–649 range 3223and understand their application. If a patient 3 months pregnant sprains her ankle while 3224jogging, but it does not affect the pregnancy and the pregnancy does not affect the care, 3225the code 648.7X would not be appropriate. However, smoking is a systemic issue with 3226decreased oxygenization that will affect the pregnancy. A pregnant patient with tobacco 3227use disorder would usually be coded with 649.0X. 3228 32296.10.2.4. Congenital Anomalies 3230When the infant has a congenital anomaly, it is coded on the infant’s record, not the 3231mother’s. Be careful with the codes 740–759. For the mother’s record, consider 655, 3232known or suspected fetal abnormality affecting management of mother. 3233 32346.10.2.5. Outcome of Delivery Codes V27 3235These codes are used on the mother’s record at delivery, which is usually an inpatient 3236event. Therefore, the V27 codes would be in the A MEPRS SADR if delivered at an 3237MTF. This would be coded in ADM and will appear on the inpatient rounds encounter at 3238delivery. 3239 32406.10.2.6. Live-born Infants According to Type of Birth, Codes V30–V39 3241These codes are not used on the mother’s record. They are used in the infant’s record. 3242 32436.10.2.7. Pregnancy Testing 3244Encounters for the purpose of pregnancy testing are to be coded as follows, based on the 3245results of the test or exam that are known at the time of the encounter. 3246

597 39 598 MHS Coding Guidance 599 March 2008 600 601 SPECIALTY CODING 602 6.10 Obstetrics Services 603 Results of Test and/or Exam Code(s) Positive V72.42 Negative without any related symptoms or diagnoses V72.41 Negative with any related symptoms or diagnoses Codes for symptoms or conditions and V72.41 Unconfirmed exam or test V72.40 3247 32486.10.3. Procedural Coding Rules 3249

3250 Category II CPT obstetric coded 0500F, 0502F, 0503F and Level I CPT 3251 code 59430. 3252 3253 0500F Initial prenatal care visit. Reported for those portions of the first 3254 prenatal encounter that are routine for that point in the pregnancy, with 3255 health care professional providing obstetrical care. 3256 3257 0501F Prenatal flow sheet documented. Do not use, because the DoD will 3258 use 0500F, initial prenatal care visit, when the prenatal flow sheet is 3259 initiated and 0502F for each subsequent obstetrical encounter. 3260 3261 0502F Subsequent prenatal visits (continuing care). Use for subsequent 3262 obstetrical visits that are routine for that point in the pregnancy. This 3263 code does not include complications or issues not related to the pregnancy. 3264 3265 Use 0503F for one uncomplicated postpartum care encounter only. It is 3266 usually done six to eight weeks postpartum. Code all other postpartum 3267 complications with the appropriate established patient office visit E&M 3268 code. Use this code if the delivery and postpartum visit are performed by 3269 the same group practice. 3270 3271 Use 59430 if postpartum care is provided by a group other than the group 3272 practice that performed the ante partum care or delivery.

3273 32746.10.3.1. Obstetrical Services 3275Included are: obstetric care (routine and non routine), ante partum care, vaginal delivery 3276(with or without episiotomy or forceps) and postpartum care uses 0500F, 0501F, 0502F, 32770503F, and 59430. 3278 32796.10.3.2. Ante Partum Services 3280To document ante partum services, indicate the following when given: 3281  Pap Smear 3282  Monthly visit up to 28 weeks’ gestation, biweekly visit to 36 weeks’ gestation 3283 and weekly visits until delivery 3284  Initial history and physical exam (code 0500F) and subsequent history and 3285 physical examinations (code 0502F) 604 40 605 MHS Coding Guidance 606 March 2008 607 608 SPECIALTY CODING 609 6.10 Obstetrics Services 610 3286  Recording of weight, blood pressures, and fetal heart tones. When routine 3287 chemical urinalysis is done and interpreted in the clinic and is not bundled 3288 with routine obstetrical care, it may be coded using a laboratory code (e.g., 3289 81000 or 81002). 3290  For first visit with nurse for screening, vaccinations and counseling, code 3291 services as appropriate. Code 99211 for face-to-face visit with no procedures. 3292  0500F, initial prenatal care visit reported for the first prenatal encounter with 3293 healthcare professional providing obstetrical care. After confirmation of 3294 pregnancy, the 0500F code is the trigger code to indicate the start of the 3295 pregnancy episode. The code is not appropriate when the only prenatal 3296 service during an office visit is pregnancy test. 3297  0501F, prenatal flow sheet documented. Do not use. 3298  0502F, subsequent prenatal visits (continuing care) 3299  0503F, uncomplicated outpatient visit by the same group practice that 3300 performed the delivery until six weeks postpartum. The AMA uses this code 3301 to define the number of women who receive care on or between 21 and 56 3302 days after delivery. 3303  59430, uncomplicated outpatient postpartum follow-up by a group practice 3304 other than the group practice that performed the delivery. 3305 33066.10.3.3. The following is a list of services that reflect routine, uncomplicated care and 3307are included in the routine codes. 3308 3309Procedures outlined below, will not be coded separately. Positive findings during 3310screening will be coded. 3311 3312  Prenatal risk assessment checklist—administering and history taking, ordering 3313 applicable tests 3314 o Auscultation of fetal heart tones 3315 o Screening fundal height 3316 o Screening for hypertension (HTN) disorders 3317 o Assessing inappropriate weight gain 3318 o Educate about symptoms of preterm labor 3319 o Review for development of contraindications 3320 o Assessment of fetal kick counts 3321 o Routine ultrasound (weeks 16–24) 3322  Interventions at all visits 3323 o Screening for HTN disorders 3324 o Breast feeding education 3325 o Exercise during pregnancy 3326 o Influenza vaccine (season-related, 6–20 weeks) 3327  First visit with nurse (6-8 weeks)–Screening for 3328 o Tobacco use, alcohol use, drug abuse 611 41 612 MHS Coding Guidance 613 March 2008 614 615 SPECIALTY CODING 616 6.10 Obstetrics Services 617 3329 o Domestic abuse 3330 o Anti-D/non-anti-D antibodies 3331 o Rubella, varicella, hepatitis B, syphilis (RPR), asymptomatic bacteriuria 3332 o HIV counseling 3333 o Immunization–TB booster (1st trimester), hepatitis B (1st trimester) 3334  First visit with provider (10–12 weeks) 3335 o Assessing weight gain (inappropriate) 3336 o Auscultation fetal heart tones 3337 o Screening fundal height 3338 o Screening for gonorrhea and chlamydia 3339 o Screening for cervical cancer 3340 o Counseling for cystic fibrosis screening 3341  Weeks 16–24 3342 o Assessing weight gain (inappropriate) 3343 o Auscultation fetal heart tones 3344 o Screening fundal height 3345 o Screen for domestic abuse 3346 o Maternal serum analyte screening 3347 o Counseling for family planning 3348 o Educate regarding preterm labor 3349  Weeks 28–37 3350 o Assessing weight gain (inappropriate) 3351 o Auscultation fetal heart tones 3352 o Screening fundal height 3353 o Screen for domestic abuse (week 32) 3354 o Assess for preterm labor 3355 o Daily fetal movement counts 3356 o Screening for gestational diabetes 3357 o Iron supplementation 3358 o Anti-D prophylaxis for Rh-negative women 3359 o Screening for group B streptococcal (week 36) 3360 o Assessment of fetal presentation (week 36) 3361  Weeks 38–41 3362 o Assessing weight gain (inappropriate) 3363 o Auscultation fetal heart tones 3364 o Screening fundal height 3365 o Weekly cervical check (stripping) 3366 o Post-dates antenatal fetal testing 3367 33686.10.3.4. Codes for Medical Problems Complicating Pregnancy 3369All encounters for OB care will have a code from the 0500F series coded. Significant 3370separately identifiable medical conditions complicating obstetric management may 618 42 619 MHS Coding Guidance 620 March 2008 621 622 SPECIALTY CODING 623 6.10 Obstetrics Services 624 3371require additional resources and should be identified by using the E&M codes in addition 3372to those codes for maternity. Modifier -25 will not be assigned to an E&M in this chapter 3373only. These significant separately identifiable medical conditions will be coded when 3374documented in the medical record. Documentation must meet minimal requirements. 3375Procedures other than those routine procedures listed above should also be coded. 3376 3377Examples of complicating conditions are: 3378 Pre-existing diabetes 3379 Gestational diabetes mellitus (GDM) 3380 Pregnancy-induced hypertension or pre-eclampsia 3381 Fetal anomaly or abnormal presentation (older than or equal to 36 weeks) 3382 Multiples 3383 Placenta previa 3384 Chronic hypertension 3385 Systemic disease that requires ongoing care (e.g., severe asthma, lupus, 3386 inflammatory bowel disease) 3387 Drug abuse 3388 HIV (or abnormal screen) 3389 Age (<16 or >40 years at delivery) 3390 Past complicated pregnancy 3391 Prior preterm delivery (<37 weeks) 3392 Prior preterm labor requiring admission (e.g., early cervical change) 3393 Intrauterine fetal demise—10 weeks after cardiac activity was first noted 3394 Prior cervical or uterine surgery 3395 Fetal anatomic abnormality (e.g., open neural tube defects in prior child or first- 3396 degree relative) 3397 Abnormal fetal growth 3398 Preterm labor requiring admission (i.e., regular uterine contractions and cervical 3399 change) 3400 Abnormal amniotic fluid 3401 2nd or 3rd trimester bleeding 3402 Relative BMI <16.5 3403 Hematologic disorders 3404 Severe anemia (<24 percent hematocrit) 3405 Cancer 3406 Seizure disorders 3407 Recurrent urinary tract infections or stones 3408 Substance use disorders (alcohol or tobacco) 3409 Eating disorders 3410 Surgery 3411 Abnormal screen—antibody, hepatitis, syphilis, and Pap 3412 Abnormal maternal triple screen 3413 Current mental illness requiring medical therapy 3414 3415 Examples of separately reportable services: 625 43 626 MHS Coding Guidance 627 March 2008 628 629 SPECIALTY CODING 630 6.10 Obstetrics Services 631 3416 Additional non-routine Ultrasound 3417 Echocardiography 3418 Fetal biophysical profile 3419 Amniocentesis, cordocentesis 3420 Chorionic villus sampling 3421 Fetal contraction stress test 3422 Fetal nonstress test 3423 Hospital admission and observation for preterm labor, except within 24 hours of 3424 delivery 3425 Management of surgical problems arising during pregnancy (e.g., appendicitis, 3426 incompetent cervix, ruptured uterus) 3427 Insertion of cervical dilator by physician 3428 External cephalic version, if done in the clinic 3429 Administration of Rh immune globulin 3430 Cerclage of cervix, during pregnancy—vaginal or abdominal 3431 34326.10.3.5. Postpartum Care 3433 34346.10.3.5.1. Routine Postpartum Care 3435For postpartum encounters code 0503F/59430 in the CPT/HCPCS field code. Following 3436is a list of services that reflect routine, uncomplicated postpartum care and are included in 3437the routine codes. They will not be coded separately. 3438 3439 Postnatal tests—administering and history taking, ordering applicable tests 3440 o Pelvic exam 3441 o Breast exam 3442 Topics addressed: 3443 o Contraception 3444 o Postpartum depression, screening for 3445 o Sexual activity 3446 o Weight 3447 o Exercise 3448 o Woman’s assessment of her adaptation to motherhood 3449 34506.10.3.5.2. Non-routine Postpartum Care 3451Collection of Pap smears is not included and should be documented and coded separately 3452and appropriately with reason (e.g., high risk or not). Additional services may be 3453provided during a postpartum visit. 3454 3455Patients who present with a history of an abnormal Pap smear and are being seen for a 3456diagnostic Pap will require an added E&M code. If the obstetric follow up code 59430 is 3457used, then a modifier -25 will be required on the E&M code. 3458

632 44 633 MHS Coding Guidance 634 March 2008 635 636 SPECIALTY CODING 637 6.10 Obstetrics Services 638 3459Code non-routine postpartum issues separately. Treatment of these would be coded using 3460an E&M. A few examples: 3461  Disruption of wounds 3462  Infections of breast and nipples 3463  Disorders of lactation 34646.10.4. Inpatient Obstetric Coding. 3465For more guidance on inpatient coding, see section 9. This section addresses inpatient 3466professional services, including OB rounds and appointments that generate automatically 3467in the name of the attending provider. 3468 34696.10.4.1. Recording in MEPRS 3470To record the delivery, code inpatient professional services in the ACxx, AGxx or AHxx 3471MEPRS. After a patient is admitted, an inpatient rounds ADM record is generated each 3472inpatient day under the name of the attending physician. 3473 34746.10.4.1.1. Hospital Days prior to Delivery 3475 34766.10.4.1.1.1. OB Observation Status 3477Pre-term labor/Labor Observation 3478 3479 Patient is seen in the OB-GYN clinic or Emergency Department. The provider 3480writes an order to place the patient in observation status. Changing the patient from 3481observation status is a decision of the privileged provider. 3482 3483For normal, uncomplicated pre-natal care (which could include some labor) use 3484procedure code 0502F for encounters leading up to delivery. 3485 3486For problems other than normal pre-natal and labor care: 3487 3488 IF THERE IS NO ORDER FOR OBSERVATION: 3489 3490  For clinic services, use E/M code 9921X based on documentation. For 3491 Emergency department services, use E/M 9928x based on documentation. In 3492 those instances when a non-emergency service is provided by a non-emergency 3493 provider (e.g., obstetrician treats patient in the Emergency Department on a 3494 weekend when the OB clinic is closed), code the services as clinic services. 3495  If more than 70 minutes (99215= 40 minutes, modifier 21 = 30 minutes) is spent 3496 face-to-face with the patient AND THE TOTAL TIME AND PROVIDER’S 3497 ACTIVITIES DURING THAT TIME ARE DOCUMENTED in the medical 3498 record, code 99215 and 99354-99355 for clinic OR 99285 only for Emergency 3499 Department. 3500  Code for fetal stress/non-stress/monitoring in addition to the E/M code. 3501 3502 IF THERE IS AN ORDER FOR OBSERVATION:

639 45 640 MHS Coding Guidance 641 March 2008 642 643 SPECIALTY CODING 644 6.10 Obstetrics Services 645 3503 3504  Provider documents written order for observation, no delivery on same date of 3505 service (99218-99220). Diagnosis will reflect medical necessity. Observation 3506 services are outpatient services. Therefore, if the patient is observed for a 3507 condition not verified, code the symptoms. Do not use the V71 Observation for 3508 Condition not found. 3509  To generate a codable encounter, an appointment must be created manually for 3510 each day of observation. Contact your Service Representative for guidance on 3511 manual creation of codable observation encounters. 3512 3513  Provider documents written order for observation, no delivery on subsequent date 3514 of service, use E/M 99218-99220. 3515 3516  Provider documents written order for observation, no delivery, discharged same 3517 date of service, use E/M 99234-99236. 3518 3519  Provider documents written order for observation, no delivery, discharged on 3520 subsequent date of service, use E/M 99217 for the last day of observation. 3521 3522Scenarios: 3523Admit from observation/trial labor 3524 3525 Patient is in observation, is admitted and delivers the same date. 3526 1. Observation: close out the observation using the 0502F for routine prenatal and 3527labor. Complications are coded based on documentation. 3528 3529 2. Admission: the round (RND) encounter for this day may have an E/M based 3530on documentation and the procedure will be the delivery (vaginal 59409; cesarean section 353159514). This is an MHS deviation from civilian standards of coding. Refer to DoD Rule 3532for E/M in section 6.10.1.2. 3533 3534 Patient is in observation and is admitted and does not deliver during this 3535admission. 3536 1. Observation: close out the observation using the 0502F for routine prenatal 3537care and labor. Complications are coded based on documentation. 3538 3539 2. Admission: the RNDs encounter will be based on the documentation from the 3540time of admission. 3541 3542 Patient delivers on the second date of observation status. 3543 1. Observation: code the observation encounter for day 1 using the 0502F for 3544routine prenatal care and labor. Complications are coded based on documentation. 3545

646 46 647 MHS Coding Guidance 648 March 2008 649 650 SPECIALTY CODING 651 6.10 Obstetrics Services 652 3546 2. Code the observation encounter for day 2 using the 0502F for routine prenatal 3547care and labor. 3548 3549 3. Admission: the RNDs encounter will be based on the documentation from the 3550time of admission. Use appropriate delivery codes based on documentation. 3551 3552 3553 35546.10.4.1.1.2. Preterm Admission/Bed-Rest Admission 3555For problem pregnancies that need inpatient monitoring (pre-mature labor, diabetic 3556patient, toxemic, high blood pressure), the attending service will code one RNDs per day 3557for admission until date of delivery or discharge as follows: admission date (99221- 355899223) subsequent days (9923X), date of delivery (59XXX). 3559 3560 NOTE: Inpatient days post delivery, that are uncomplicated post partum days will 3561have the 99024 for the cesarean sections. For uncomplicated postpartum vaginal 3562deliveries, code 0503F. For complications, code the appropriate subsequent hospital 3563care code. 3564 35656.10.4.1.1.3. Labor 3566All E&M services prior to labor are considered ante partum care. If the delivery does not 3567take place until after the initial day of admission, delete the rounds encounter for the 3568initial day. For example, when a healthy-term, uncomplicated singleton female is 3569admitted at 1800 and delivers vaginally 12 hours later, the following codes are used: 3570delete the automatically generated rounds appointment for the day of admission and code 3571the delivery 59409 on the rounds appointment for the day of delivery. 3572 35736.10.4.1.1.4. Complicated 3574For complicated inpatient ante partum care, use the appropriate initial hospitalization and 3575subsequent hospitalization codes. 3576 35776.10.4.1.2. Delivery 3578On the day of delivery, use 3579 3580  59409 for vaginal delivery 3581  59514 for C-section 3582  59612 for successful vaginal delivery after previous C-section 3583  59620 for an attempted vaginal delivery after a previous C-section when 3584 ultimately the newborn is delivered C-section 3585 3586The delivery codes include: 3587  Management of uncomplicated labor, including fetal monitoring 3588  Placement of internal fetal or uterine monitors 3589  Catheterization or catheter insertion

653 47 654 MHS Coding Guidance 655 March 2008 656 657 SPECIALTY CODING 658 6.10 Obstetrics Services 659 3590  Preparation of perineum with antiseptic solution 3591  Forceps or vacuum extraction 3592  Delivery of placenta, any method 3593  Injection of local anesthesia 3594  Administration of intravenous oxytocin 3595 3596Code any other appropriate procedures done. 3597For complicated deliveries, use the appropriate procedure codes, e.g., surgical fixation for 3598prolapsed uterus. For medical complications, e.g., asthma, the provider would use the 3599appropriate E&M code. 3600 36016.10.4.1.2.1 Multiple Births 3602  For all newborns born vaginally, code 59409 (or 59612 for a vaginal birth after a 3603 previous C-section (VBAC) with a unit of the number of newborns. For instance, 3604 vaginally delivered twins would be coded 59409, unit of service 2. 3605  All newborns delivered C-section, code 59514 (or 59620 for a VBAC that results 3606 in a C-section), with a unit of service of 1. There is only one C-section. 3607  Multiple births with at least one vaginal and one C-section are coded with the 3608 appropriate type of vaginal birth code and the number of vaginal births using the 3609 unit’s field. Code the appropriate C-section code with a unit of service of 1 for all 3610 the infants delivered by the one C-section. 3611 36126.10.4.1.3. Associated C-section Procedures 3613Code both the C-section and the associated procedure (e.g., hysterectomy, tubal ligation). 3614 36156.10.4.1.4. Routine Post Partum Days 3616Code CPT 99024. For complications, code the appropriate procedure and E&M. 3617Add diagnosis for post partum condition. (V24.x)

660 48 661 MHS Coding Guidance 662 March 2008 663 664 SPECIALTY CODING 665 6. 11 Occupational Therapy 666 36186.11. Occupational Therapy 3619 36206.11.1. E&M Rules 3621E&M codes are not appropriate for occupational therapy. The evaluation and 3622management components of routine outpatient office E&Ms are included in special 3623occupational therapy evaluation (97003) and reevaluation (97004) procedural codes as 3624indicated below. 3625 36266.11.2. Diagnosis Coding Rules 3627 36286.11.2.1. Outpatient Occupational Therapy 3629All outpatient occupational therapy encounters for the purpose of receiving therapy are 3630always coded with the V57.21 as the first listed diagnosis unless the need for therapy is 3631related to a deployment. In that case, abide by the MHS Coding Guidance for 3632deployment related issues. 3633 36346.11.2.2. Occupational Therapy Evaluation 3635Occupational therapy encounters for the purpose of evaluation only or group educational 3636classes (no therapy done during the encounter) are not identified by V57.21. 3637 3638

3639 DoD Rule 3640 3641 V57.21 will be the first listed code for all occupational therapy encounters 3642 involving therapy only. The condition(s) for which the patient is receiving 3643 therapy are listed in the second or third position. Occupational therapy 3644 encounters for post-deployment therapy sessions have V70.5_6 as the third 3645 or fourth listed code. 3646 3647 If there is no therapy involved, V70.5_6 is still the first listed code with the 3648 patient’s physical condition listed second.

3649 3650NOTE: When a patient presents for evaluation and therapy is initiated on the same 3651day, do not use V57.21. Code the condition as primary diagnosis. 3652 36536.11.2.3. E Codes for Occupational Therapy 3654Occupational therapy encounters should not report E codes, as the occupational therapy 3655encounter will not be the initial medical encounter at the MTF for the injury. If it is 3656documented that the patient was initially seen for the injury at another MTF without 3657occupational therapy, and this is the initial encounter at this MTF, then the E code(s) 3658should be used. Most therapy encounters will not be for an acute injury (e.g., fracture). 3659In rare instances, treatment will be to address the immediate resulting limitations from the 3660injury (e.g., reduced movement of fingers following hand fracture). 3661 667 49 668 MHS Coding Guidance 669 March 2008 670 671 SPECIALTY CODING 672 6. 11 Occupational Therapy 673 36626.11.3. Procedural Coding Rules 3663CPT codes for occupational therapy procedures are in the Physical Medicine and 3664Rehabilitation subsection of the Medicine Section (97003–97799). Activities of daily 3665living (ADL) mock-ups for self-care home living are coded 97535 (and should not be 3666used for education activities, like teaching the person to self-administer diabetic 3667injections). 3668 3669Osteopathic Manipulative Treatment codes may be used by Physical Therapist if 3670authorized under their scope of practice (98925-98929). 3671 36726.11.4. Evaluations and Reevaluations 3673 36746.11.4.1. New vs. Established Patients 3675There is no distinction for new or established patients. Code either an: evaluation 97003 3676or reevaluation 97004 with or without modalities, or code just the modalities performed. 3677The initial assessment of the problem is used to determine the appropriate therapy and 3678prognosis. Various movements required for ADL are examined. Dexterity, range of 3679motion, and other elements may also be studied. Reevaluations are for subsequent 3680assessments to determine treatment success and make modifications as needed. 3681 36826.11.4.2. Reevaluation Is Part of Normal Service 3683Reevaluation is part of the normal pre- and post-service. As with an E&M service, these 3684evaluations should only be separately reported if the patient’s condition requires 3685significant, separately identifiable E&M services. 3686 36876.11.5. Modalities 3688 36896.11.5.1. Modalities Included in Evaluation, Reevaluation 3690Certain modalities (e.g., injection of anesthetic agents, range of motion measurements) 3691are included in the evaluation and reevaluation procedural codes. For a list of these 3692modalities refer to the National Correct Coding Initiative (NCCI) at the CMS Web. 3693http://www.cms.hhs.gov/NationalCorrectCodInitEd/ 3694 36956.11.5.2. One-on-One Contact 3696Therapeutic procedures (97110–97546) require direct (one-on-one) patient contact by the 3697provider. Basically, this means the provider must maintain visual, verbal, or manual 3698contact with the patient throughout the procedure. For a technician to code an encounter, 3699the technician must be working under a privileged provider’s plan of care. When the 3700occupational therapist is actively involved in the therapy and assisted by a technician, the 3701technician should be listed as an additional provider when coding the encounter. 3702 37036.11.6. Modifiers 3704The HCPCS modifier GO is used in the civilian sector by occupational therapy to 3705indicate that the therapy is being performed under an outpatient occupational therapy plan

674 50 675 MHS Coding Guidance 676 March 2008 677 678 SPECIALTY CODING 679 6. 11 Occupational Therapy 680 3706of care. It does not specify a therapist furnished the care. The GO modifier is not used in 3707the DoD system. 3708 37096.11.7. Documentation of Occupational Therapy 3710 37116.11.7.1. Requirements for CPT Code 3712To support a CPT code, at a minimum each occupational therapy note needs to include 3713therapist name, date, modality, treatment assessment (patient tolerated treatment), and 3714adjustment to the therapy plan. Documentation based on a checklist alone is not 3715sufficient for coding. 3716 37176.11.7.2. Required Elements 3718The following elements need to be recorded by the therapist (or technician), 3719  The specific modalities or procedures (supervised or attended), 3720  The body area involved, and 3721  The start and stop times or total time for each treatment. 3722 37236.11.7.3. Coding for Pregnant Patients 3724When a patient is pregnant, and the pregnancy affects the services provided (e.g., not 3725pregnancy incidental, coded V22.2), the patient’s last menstrual period and estimated 3726date of delivery need to be documented so they can be recorded in ADM. 3727 37286.11.8. Units of Service 3729 37306.11.8.1. Unit of Service Is 8-15 Minutes 3731Constant attendance modalities and therapeutic modalities include “each 15 minutes” in 3732the code descriptions. Therefore, one unit of service is reported for each 15 minutes of 3733therapy rendered per date of service. The table below is used to calculate units of service. 3734A minimum of eight minutes must be performed to qualify for 1 unit of service. 3735 37366.11.8.2. Reporting Time Intervals 3737For any single CPT procedure where unit of service is a factor, report time intervals for 3738units of service as follows: 3739 Unit of Service Greater than or equal to And fewer than 1 08 minutes 23 minutes total for all time-based modalities 2 23 minutes 38 minutes total for all time-based modalities 3 38 minutes 53 minutes total for all time-based modalities 4 53 minutes 68 minutes total for all time-based modalities 5 68 minutes 83 minutes total for all time-based modalities

681 51 682 MHS Coding Guidance 683 March 2008 684 685 SPECIALTY CODING 686 6. 11 Occupational Therapy 687 6 83 minutes 98 minutes total for all time-based modalities 7 98 minutes 113-minutes total for all time-based modalities 8 113 minutes 128-minutes total for all time-based modalities 3740 3741Units are calculated in the same manner for therapy that exceeds two hours. 3742 37436.11.8.3. Multiple CPT Procedures 3744For multiple CPT procedures performed on the same calendar day, the total number of 3745units does not equal the individual units of service for each service; rather, it equals the 3746units of service for the total treatment time. 3747 37486.11.8.4. Group Therapy 3749Multiple patients being given modalities or procedures during the same time are reported 3750as group therapy. (See 97150) 3751 37526.11.9. Inpatient Therapy 3753

3754 DoD Rule 3755 3756 Inpatient therapy consults will be reported in ADM. When the screen 3757 prompts Are you from the attending service? select NO. This will create the 3758 encounter in ADM. Therapy related to the patient’s reason for admission 3759 is not coded in the B MEPRS.

688 52 689 MHS Coding Guidance 690 March 2008 691 692 SPECIALTY CODING 693 6.12 Ophthalmology/Optometry 37606.12. Ophthalmology/Optometry 3761

3762 DoD Rule 3763 3764 Optometry clinic services are coded in an ambulatory service BHCx 3765 MEPRS clinic. Ophthalmology clinic services, including services for pay 3766 patients are coded in the ambulatory service BBDx MEPRS. 3767 3768 37696.12.1. E&M Rules 3770 37716.12.1.1. Optometrists 3772An optometrist seldom uses an E&M office visit code in the 99201–99215 range. 3773 37746.12.1.2. Ophthalmologists 3775Depending on the patient population and the number of associated optometrists, 3776ophthalmologists commonly have 30 percent to 40 percent of their visits coded with 3777E&M codes in the 99201–99499 range. Frequently, referrals are coded 99201–99215 and 3778consults use 99240–99245 codes. 3779 37806.12.1.3. An E&M code may be used when a patient is seen for a medical reason that 3781does not require any eye examination procedures. The most common instances when an 3782E&M code is used are: 3783  Limited exams that do not meet the exam elements of an intermediate eye exam, 3784 but do meet the elements of a low-level E&M code (e.g., follow-up contact lens 3785 visit). 3786  Highly complex or risk-prone exams that meet the documentation elements of a 3787 99204/14 or 99215 E&M encounter. 3788  Examinations for medical reasons when no eye procedures are performed (e.g., an 3789 acute care visit for a subconjunctival hemorrhage). 3790 37916.12.2. Diagnosis Coding Rules 3792 37936.12.2.1. Routine Exams Active Duty (DoD Unique Visits) 3794Encounters for DoD unique visits, such as aviation, military school screening, periodic, 3795or termination exams, are reported using V70.5 with the appropriate extender (e.g., 3796Aviation exam V70.5_1). Any condition diagnosed during the examination is listed as an 3797additional diagnosis. 3798 V CODES DESCRIPTION V70.5 0 Armed Forces Medical Examination V70.5 1 Aviation Examination V70.5 2 Periodic Prevention Examination V70.5 3 Occupational Examination V70.5 4 Pre-Deployment Examination 694 53 695 MHS Coding Guidance 696 March 2008 697 698 SPECIALTY CODING 699 6.12 Ophthalmology/Optometry V70.5 5 During Deployment Examination V70.5 6 Post-Deployment Examination V70.5 7 Fitness for Duty Examination V70.5 8 Accession Examination V70.5 9 Termination Examination 3799

3800 DoD Rule 3801 3802 Encounters for post-deployment related conditions have V70.5_6 as the 3803 primary diagnosis and the patient’s physical condition listed second.

3804 38056.12.2.2. Routine Exams 3806 38076.12.2.2.1. Diagnosis Coding Based on Documentation 3808Other than the DoD-required first-listed codes, diagnosis coding in optometry and 3809ophthalmology is based on documentation. If the patient’s reason for the encounter is 3810vision problems (e.g., myopia, presbyopia), that will be the first listed code. If the 3811patient’s reason for the encounter is “here for annual exam,” the most appropriate V code 3812would be used. 3813 38146.12.2.2.2. Routine Eye Exams 3815For non-active duty patients without any complaints or previously diagnosed 3816ophthalmologic conditions, routine exams are coded V72.0, and any condition identified 3817during the exam is an additional diagnoses. 3818 V 65.5 Feared Complaint—No symptoms 3819 V 67.59 Condition Resolved 3820 V 68.0 Driver’s Test 3821 V 72.0 Exam of Eyes and Vision 3822 V20.2 Routine infant or Child health check 3823 38246.12.2.2.3. Routine Exams with Complaints 3825For routine exams (reason for encounter), with complaints or ophthalmologic conditions, 3826the most appropriate V code would be the first-listed code with the applicable codes for 3827the complaints or conditions listed as additional codes. 3828 367.1 Myopia 3829 367.21 Astigmatism, regular 3830 367.4 Presbyopia 3831 379.90 Disorder of the Eye—Unspecified 3832 379.91 Pain in or Around Eyes 3833 379.99 Other Ill-Defined Disorder of Eyes 3834 38356.12.2.2.4. Non-Routine Encounters 3836Diagnostic codes are to be used at their highest level of specificity (fourth and fifth 3837digits) and explicitness (e.g., chronic, acute, regular, irregular) to support medical

700 54 701 MHS Coding Guidance 702 March 2008 703 704 SPECIALTY CODING 705 6.12 Ophthalmology/Optometry 3838necessity for procedures such as extended ophthalmology. Fourth and fifth digits should 3839be used when available. 3840 38416.12.2.2.5. Special Screening for Glaucoma 3842See glaucoma screening below for documentation requirements. 3843 38446.12.2.2.6. Diabetic Retinopathy 3845Code 250.5x first, then use one of the following codes: 3846 362.01 Background diabetic retinopathy 3847 362.02 Proliferative diabetic retinopathy (NOS) 3848 362.03 Nonproliferative diabetic retinopathy (NOS) 3849 362.04 Mild nonproliferative diabetic retinopathy 3850 362.05 Moderate nonproliferative diabetic retinopathy 3851 362.06 Severe nonproliferative diabetic retinopathy 3852 362.07 Diabetic macular edema 3853 38546.12.3. Procedural Coding Rules 3855 38566.12.3.1. Optometrists 3857Optometrists usually use the ophthalmology codes in the 92002–92396 range (e.g., 3858diagnosis and treatment) as well as the HCPCS codes V2020–V2799 and various other 3859HCPCS codes. The most commonly used codes by optometrists are 92002–92014 for eye 3860exams and 92015 for refractions. Optometrists associated with a refractive surgery program 3861who do postoperative assessments will also frequently use 99024, postoperative follow-up 3862visit. 3863 38646.12.3.2. Ophthalmologists 3865Ophthalmologists also code a number of visits using the 92002–92014 ophthalmologic 3866services codes, the diagnosis and treatment codes 92015–92396, and surgical eye and ocular 3867adnexa codes 65091–68899. Ophthalmologists also frequently perform refractive surgery, 3868coded S0800–S0830. Refractive surgery procedures tend not to have RVUs assigned by the 3869CMS as they are not a CMS-covered benefit. It is very important that these services be 3870coded correctly as they are specifically evaluated to determine the effectiveness of various 3871refractive surgery programs. 3872 38736.12.3.3. Use of 92002–92499 Codes 3874Usually optometrists and ophthalmologists use the 92002–92499 codes. When a technician 3875does a simple acuity or visual function, the procedure codes 99172 and 99173 are 3876appropriate. Dispensing glasses is a continuation of the visit when the glasses were 3877prescribed or ordered and is not coded separately. 3878 38796.12.4. Eye Exams 3880 38816.12.4.1. CPT Codes for New and Established Patients 3882CPT codes 92002, 92004, 92012, and 92014 for new and established ophthalmology or 3883optometry patients include an evaluation and management of a patient. These codes are 706 55 707 MHS Coding Guidance 708 March 2008 709 710 SPECIALTY CODING 711 6.12 Ophthalmology/Optometry 3884appropriate when the level of service includes several routine optometric or 3885ophthalmologic examination techniques, such as slit lamp examination, keratometry, 3886ophthalmoscopy, retinoscopy, tonometry, and sensorimotor evaluation that are integrated 3887with and cannot be separated from the diagnostic evaluation. 3888 38896.12.4.2. Documentation Guidelines for 92 Series Eye Exam and Treatment Codes: 3890 3891There is no specific history or medical decision-making guidelines for these codes. 3892There are 13 exam elements that must be documented to validate a coding level: 3893  Testing visual acuity 3894  Gross visual fields 3895  Eyelids and adnexae 3896  Ocular motility 3897  Pupils 3898  Iris 3899  Conjunctiva 3900  Cornea 3901  Anterior chamber 3902  Lens 3903  Intra-ocular pressure 3904  Retina 3905  Optic disc 3906 3907 If three to eight of these elements are documented, an intermediate exam (92012 or 3908 92002) should be coded. If nine or more of these elements are documented, a 3909 comprehensive exam (92014 or 92004) should be coded 3910 3911 If fewer than three of these elements are documented, the lowest level E&M code 3912 (based on the documentation) should be coded along with the primary diagnosis 3913 (reason for visit or chief complaint). 3914 3915 Note that some procedures are bundled-included as part of / the 92 series exam codes. 3916 This means you would NOT put a separate CPT code for these procedures if done as 3917 part of the exam using a 92 series exam code. The bundled procedures are: 3918  Amsler grid 3919  Brightness acuity test (BAT) 3920  Corneal sensation 3921  Exophthalmometry 3922  General medical observation 3923  Glare test 3924  History 3925  Keratometry 3926  Laser interferometry 3927  Pachymetry

712 56 713 MHS Coding Guidance 714 March 2008 715 716 SPECIALTY CODING 717 6.12 Ophthalmology/Optometry 3928  Potential acuity meter (PAM) 3929  Schirmer test 3930  Slit lamp tear film evaluation and transillumination 3931 3932NOTE: Corneal Pachymetry (76514) is separately reportable if a thorough 3933evaluation of the cornea is performed along with image documentation, 3934interpretation and report; no technical or professional modifiers should be 3935reported. Code 76514 is reported only once, since it is considered a bilateral service. 3936Therefore, if corneal pachymetry is performed on both eyes, modifier 50 would not 3937be used. 3938 3939 All other services, tests, or procedures performed can be added as additional CPT 3940 codes, e.g., contact lens fitting, photography and foreign body removal, including 3941 refraction. 3942 39436.12.4.3. Refraction Code 3944Any time refraction is performed, it is reported as an additional code, 92015 Refraction 3945(can only use once, no multiple units). 3946 39476.12.4.4. Dilated Retinal Exams for Diabetics, S3000 3948Diabetic indicator, retinal eye exam, dilated, bilateral. Diabetic patient exam encounters 3949with a dilated, bilateral retinal eye exam as part of the comprehensive exam should be 3950coded with additional code S3000 for the diabetic indicator. 3951 39526.12.4.5. Visual Screening 3953When doing an occupational health screening use 99172 and 99173 (screening codes) for 3954optometry. These codes are not to be used with 92002, 92004, 92012, and 92014 codes. 3955 39566.12.4.6. Fitting of Spectacles 3957Minimal documentation requirements for optometrist or technician for the use of codes 395892340-92342 include: measurements of anatomical facial characteristics, records the 3959laboratory specifications and performs the final adjustment of the spectacles to the visual 3960axes and anatomical topography. If the final adjustment is performed on a later date, use 3961V53.1. The supporting documentation must be contained within the medical record. 3962 39636.12.5. Glaucoma Screening (both military and nonmilitary) 3964 39656.12.5.1. Patients without a Primary Glaucoma Diagnosis 3966For patients without a primary diagnosis of glaucoma, glaucoma screening is reported 3967separately as V80.1. If this is part of an annual exam, list the annual examination V code 3968of V70.5__2 followed by V80.1 as the second diagnosis. 3969 39706.12.5.2. Patients at High Risk for Glaucoma 3971Charting documentation is specifically streamlined for the patient at high risk for 3972glaucoma. The history will include the obvious risk factors for glaucoma (age, race,

718 57 719 MHS Coding Guidance 720 March 2008 721 722 SPECIALTY CODING 723 6.12 Ophthalmology/Optometry 3973family history, trauma, corticosteroid use, and diabetes). Elements of the exam must be 3974clearly documented if glaucoma screening is the only ophthalmologic or optometric 3975service reported for high-risk patient’s code. 3976 G0117 Glaucoma screening for high-risk patients, furnished by an optometrist or 3977 ophthalmologist 3978 G0118 Glaucoma screening for high-risk patients, furnished under the direct 3979 supervision of an optometrist or ophthalmologist 3980 39816.12.5.3. Screening for Glaucoma 3982Glaucoma screening is defined to include: 3983  A dilated eye examination with an intraocular pressure measurement; and 3984  A direct ophthalmoscopy examination, or slit-lamp biomicroscopic examination 3985 39866.12.5.4. Glaucoma Screening for Diabetics 3987Glaucoma screening performed on diabetics during a general ophthalmologic exam is 3988identified with an additional HCPCS Level II code, S3000, diabetic indicator, retinal 3989eye exam, dilated, bilateral. This is for population health data collection purposes only, 3990not for reimbursement. 3991 39926.12.6. Coding for the Optometric or Ophthalmology Technician 3993 39946.12.6.1. When the technician provides services for a patient in conjunction with an 3995optometrist or ophthalmologist, the technician is reported in ADM as an additional 3996provider using the designation paraprofessional. Additional codes for any procedures the 3997technician performs (e.g., spectacle ordering, visual field) are to be reported. 3998 39996.12.6.2. When a technician provides services at a separate encounter, the correct 4000procedures (e.g. 99173, visual acuity screening) are entered in the CPT/HCPCS field . 4001 4002 Example: Patient seen by technician for vision exam portion of routine physical 4003 V70.5_2 Routine annual physical 4004 99173 Screening test of visual acuity 4005 40066.12.7. Refractive Surgery 4007

4008 DoD Rule 4009 4010 S0800 will be used for both LASIK and LASEK procedures until a code is 4011 created for LASEK procedures. 4012 4013 When available, use modifier -54 and -55 with S0800 and S0810 codes.

4015 4016Examples for lasik/lasek:

724 58 725 MHS Coding Guidance 726 March 2008 727 728 SPECIALTY CODING 729 6.12 Ophthalmology/Optometry 4017 4018Pre-op: 4019 Diagnosis 1: V72.83 Other Specified Pre-Op Exam 4020 E&M N/A 4021 Procedure Code(s) as applicable: 4022 92004 Comprehensive New 4023 92014 Comprehensive Established 4024 92015 Refraction (can only use once, no multiple units) 4025 S0820 Computerized Corneal Topography (Has been replaced with 4026 92025 and should be used if available.) 4027 76514 Pachymetry (no 50 modifier, code is automatically bilat.) 4028 4029 Diagnosis 2: Hypermetropia 367.0, Myopia 367.1, Astigmatism 376.2, etc. 4030 4031Procedure: 4032 Diagnosis: Hypermetropia 367.0, Myopia 367.1, Astigmatism 376.2, etc. 4033 E&M N/A 4034 Procedure Code(s) as applicable: 4035 S0800 LASIK 4036 S0810 PRK 4037 Use 50 modifier for bilateral, use 54 modifier if all f/u at another 4038 MTF 4039 Cannot use 65760 Keratomileusis or 92070 Therapeutic CL 4040Post-op: 4041 At same MTF: 4042 Diagnosis 1: V67.09 Follow-up Examination, Following Other Surgery 4043 E&M: N/A 4044 Procedure Code: 99024 (Exception: post-op complication, code diagnosis 4045 first and code as 92014 Comprehensive Established 4046 4047 Diagnosis 2: V45.69 Postsurgical State of the Eye and Adnexa 4048 4049 At different MTF: 4050 Diagnosis 1: V67.09 Follow-up Examination, Following Other Surgery 4051 E&M: N/A 4052 Procedure Code: S0800 or S0810 with 55 modifier for first f/u encounter, 4053 subsequent encounters 99024 (Exception: post-op complication, code 4054 diagnosis first and code as 92014 Comprehensive Established

4056 Diagnosis 2: V45.69 Postsurgical State of the Eye and Adnexa 4057 4058Pre-op Exams: 4059  The primary Dx code should be V72.83 “other specified pre-op exam”. 4060 Secondary are things like myopia, etc. The referral exam should be coded as a 4061 comprehensive eye exam (92004 for new patient or 92014 for prior patient).

730 59 731 MHS Coding Guidance 732 March 2008 733 734 SPECIALTY CODING 735 6.12 Ophthalmology/Optometry 4062  Corneal Topography: This actually had an “S” code of S0820- Computerized 4063 corneal topography, unilateral (had .35 MHS RVUs). It now has its own CPT 4064 code, 92025- “Computerized corneal topography, unilateral or bilateral, with 4065 interpretation and report. Intended to be reported when topography is not 4066 performed in conjunction with keratoplasty procedures (65710, 65730, 65750 and 4067 65755)”. However, this code is not available in the current version of AHLTA, so 4068 S0820 must still be used (See AHLTA sample below). Use 50 modifier if 4069 bilateral until the new code is in place. 4070  Pachymetry: When this is documented with interpretation it can be coded as 4071 76514. The requirement does not specify the exact instrument used, and 4072 “permanently recorded images are not required”. 4073 40746.12.7.1. V72.83 Other Specified Preoperative Exam 4075This code will be the first listed. The diagnosis that is the reason for the surgery will be a 4076secondary code, followed by any conditions that may affect treatment. 4077 40786.12.7.2. Postoperative Care 4079Postoperative care following eye surgery may be performed or shared between providers 4080(e.g., when the surgery is done at another facility). When one provider performs the 4081surgery, and postoperative care will be provided at a different MTF, the surgeon will 4082code the procedure followed by modifier -54 to indicate only performance of 4083intraoperative care, (e.g., S0810–54). The provider at a different MTF performing the 4084first episode of postoperative care codes the encounter using modifier -55, (e.g., S0810– 408555) postoperative. Additional uncomplicated follow-up care for this service is coded 4086with 99024, indicating subsequent visits within the 90-day global period. The provider 4087may be entitled to code additional services performed in the evaluation of a new patient 4088in accordance with procedural coding rules. When providing postoperative care, the date 4089of procedure is included in the documentation. 4090 40916.12.8. Extended Ophthalmoscopy with Retinal Drawing 4092 40936.12.8.1. Ophthalmoscopy 4094Extended (92225) and subsequent (92226) ophthalmoscopy are considered reasonable 4095and necessary services for evaluation of tumors of the retina and choroid (the tumor may 4096be too peripheral for an accurate photograph), retinal tears, detachments, hemorrhages, 4097exudative detachments, and retinal defects without detachment, as well as other ocular 4098defects when the patient’s medical record meets the documentation requirements set forth 4099in this policy. These codes are reserved for the meticulous evaluation of the eye and 4100detailed documentation of a severe ophthalmologic problem when photography is not 4101adequate or appropriate. 4102 41036.12.8.2. Frequency of Service 4104Frequency for providing these services depends on the medical necessity of each patient 4105and this, of course, relates to the diagnosis. A serious retinal condition must exist or be 4106suspected, based on routine ophthalmoscopy, which requires further detailed study. 4107 736 60 737 MHS Coding Guidance 738 March 2008 739 740 SPECIALTY CODING 741 6.12 Ophthalmology/Optometry 41086.12.8.3. Medical Necessity 4109In all instances, extended ophthalmoscopy must be medically necessary. It must add 4110information not available from the standard evaluation services or information that will 4111demonstrably affect the treatment plan. It is not medically necessary, for example, to 4112confirm information already available by other means. 4113 41146.12.8.4. Major Criteria 4115These criteria must be met: 4116 4117  A serious retinal condition is present based on ophthalmoscopy, which 4118 requires further study, such as the detailed study of pre-retinal membrane, a 4119 retinal tear detachment, a suspected retinal tear with sudden onset of 4120 symptomatic floaters or vitreous hemorrhage. 4121  Another diagnostic technique in addition to routine direct and indirect 4122 ophthalmoscopy is necessary and documented; for example 360º scleral 4123 depression, fundus contact lens, or 90-diopter lens. 4124  The technique and findings of the extended ophthalmoscopy must be 4125 documented, including a three-dimensional representation or an extended 4126 colored retinal drawing. Sketches and templates are not acceptable. The 4127 documentation of follow-up services (92226) must include an assessment of 4128 the change from previous examinations. 4129  Documentation supporting the medical necessity of this item, such as ICD-9 4130 codes, must be submitted with each encounter. 4131 41326.12.9. Modifiers 4133The most commonly used modifiers (and most frequently found to be missing in audits) 4134in optometry or ophthalmology are the LT for left and the RT for right when unilateral 4135codes are used; such as removal of foreign body. Many of the procedures for the eye are 4136inherently bilateral. When one of these procedures is done on only one eye, add modifier 4137-52, reduced services, as well as the modifier RT for right or LT for left. 4138

742 61 743 MHS Coding Guidance 744 March 2008 745 746 SPECIALTY CODING 747 6.13 Physical Therapy 748 41396.13. Physical Therapy—Coding for Physical Therapist or Technician 4140 41416.13.1. E&M Coding Rules 4142E&M codes are not appropriate for routine physical therapy (PT). The evaluation and 4143management components of an outpatient office E&M are already included in special 4144physical therapy evaluation and reevaluation procedural codes, as indicated below. 4145 41466.13.2. Diagnosis Coding Rules 4147 41486.13.2.1. Outpatient PT 4149Outpatient PT encounters for the purpose of receiving therapy are always coded with 4150V57.1 as the first listed diagnosis. 4151 4152NOTE: When a patient presents for evaluation and therapy is initiated on the same 4153day, do not use V57.1. Code the condition as primary diagnosis. 4154 41556.13.2.2. Evaluative PT 4156PT encounters for evaluation only, or for attending runner’s clinics, or group educational 4157classes, would not be identified by V57.1. Exercise counseling (e.g., runner’s clinic) is 4158an education V code, V65.41. If the purpose of the encounter is evaluation, use the 4159appropriate ICD-9-CM diagnosis or symptom code in the first SADR position. 4160

4161 DoD Rule 4162 4163 V57.1 will be the first listed code for all PT encounters involving therapy 4164 only. The condition(s) for which the patient is receiving therapy will be 4165 listed in the second or third position. PT encounters for post-deployment 4166 therapy sessions will have V70.5_6 as the third or fourth code.

4167 41686.13.2.3. Injuries 4169When functioning in the role of physician extender, physical therapists may render a 4170diagnosis. If this is the first time the patient has been seen at the facility for the current 4171injury, use the appropriate injury code followed by the appropriate E code. You must 4172also document date of injury. PT services are only coded with aftercare, follow-up care, 4173and pain-, muscle-, or joint-related diagnoses. 4174 4175Example: A patient comes in with back pain that is the result of lifting a heavy item. 4176The patient has not been seen in the ED or by any other provider for this pain. Physical 4177therapist examines the back and determines there is a strained muscle. PT evaluation was 4178done and therapy was not started that day. 4179 Codes: ICD-9 847.1 (thoracic back strain), E927 (lifting injury) 4180 E&M N/A 4181 CPT 97001 (evaluation)

749 62 750 MHS Coding Guidance 751 March 2008 752 753 SPECIALTY CODING 754 6.13 Physical Therapy 755 4182Example: Patient encounter for first PT session for a previously treated thoracic back 4183sprain. PT evaluation was conducted at the previous visit. Modalities provided to the 4184patient on this day were electrical stimulation and hot packs. 4185 Codes: ICD-9 V57.1, (physical therapy) 4186 847.1 (thoracic back strain) 4187 E&M N/A 4188 CPT 97014 (electrical stimulation) 4189 97010 (hot pack) 4190 41916.13.3. Procedural Coding Rules 4192CPT codes for rehabilitation procedures are in the Physical Medicine and Rehabilitation 4193subsection of the Medicine Section (97001—97799). A clinic visit for evaluation only 4194with no therapy is given a CPT code of 97001. For education by a non-privileged 4195provider (PT technician) the appropriate HCPCS S codes are S9451 exercise and S9454 4196stress management. 4197 41986.13.4. Evaluations and Reevaluations 4199There is no distinction for new or established patients. Code either an evaluation, 97001 4200or reevaluation, 97002 with or without modalities, or code just the modalities performed. 4201The initial assessment of the problem is to determine the appropriate therapy, the 4202increments, frequency, duration, and other factors necessary to enhance healing. 4203Reevaluations are for subsequent assessments to determine the success of the treatment 4204and make modifications as needed. 4205 42066.13.5. Modalities 4207Certain modalities are inclusive of the evaluation and reevaluation procedural codes. For 4208a list of these modalities you may refer to the NCCI. NCCI edits are at: 4209http://www.cms.hhs.gov/NationalCorrectCodInitEd/. Constant attendance modalities 4210(97032–97039) and therapeutic procedures (97110–97546) require direct, one-on-one 4211patient contact by the provider. Basically, this direct one-on-one contact requires that the 4212provider maintain visual, verbal, or manual contact with the patient throughout the 4213procedure. For a technician to code an encounter, the technician must be working under 4214a privileged provider’s plan of care. When the physical therapist is actively involved in 4215the therapy and assisted by a technician, the technician should be listed as an additional 4216provider when coding the encounter. 4217 42186.13.6. Units of Service 4219 42206.13.6.1. Time as Unit of Service 4221Constant attendance modalities and therapeutic modalities are each 15 minutes in the 4222code descriptions. Therefore, one unit of service is reported for each 15 minutes of 4223therapy rendered per date of service. The table below is used to calculate units of service. 4224A minimum of 8 minutes must be performed to qualify for 1 unit of service. 4225 4226 756 63 757 MHS Coding Guidance 758 March 2008 759 760 SPECIALTY CODING 761 6.13 Physical Therapy 762 42276.13.6.2. Reporting Time Intervals 4228For each CPT procedure where unit of service is a factor, report time intervals for units of 4229service as follows: 4230 Unit of Service Greater than or equal to Less than 1 08 minutes 23 minutes 2 23 minutes 38 minutes 3 38 minutes 53 minutes 4 53 minutes 68 minutes 5 68 minutes 83 minutes 6 83 minutes 98 minutes 7 98 minutes 113 minutes 8 113 minutes 128 minutes 4231 4232Units are calculated in the same manner for therapy that exceeds two hours. 4233 42346.13.6.3. Treatment Time for Multiple Procedures 4235For multiple CPT procedures performed on the same calendar day, the total amount of 4236treatment time determines the number of units for the day. Each modality and amount of 4237time needs to be documented, not a total time given for all modalities. A minimum of 8 4238minutes for each modality provided is needed in order to report time. 4239 42406.13.6.4. Group Therapy Procedures 4241Group therapy involves constant attendance by the physician or therapist, but by 4242definition does not require one-on-one patient contact by the physician or therapist. 4243Report code 97150 for each member of the group and provide documentation for the 4244therapies the patients received, including minutes of activity. 4245 42466.13.7. Modifiers 4247The HCPCS modifier GP is used in the civilian sector by physical therapy to indicate that 4248the therapy is being performed under an outpatient physical therapy plan of care. It does 4249not specify a therapist furnished the care. The GP modifier is not used in the DoD 4250system. 4251 42526.13.8. Documentation of Physical Therapy 4253 42546.13.8.1. Note Requirements 4255To support a CPT or HCPCS code, at a minimum each physical therapy note needs to 4256include therapist’s name, modality, treatment assessment (patient tolerated treatment), 4257and adjustment to the therapy plan. Documentation based on a checklist alone is 4258insufficient. 4259 42606.13.8.2. Required Elements 4261 The following elements need to be recorded by the therapist or technician 4262  The specific modalities or procedures (supervised or attended), 763 64 764 MHS Coding Guidance 765 March 2008 766 767 SPECIALTY CODING 768 6.13 Physical Therapy 769 4263  The body area involved, 4264  The start and stop times or total time for each modality, 4265  Access to a plan of care for reference to modalities and therapies being provided 4266 by the technician. 4267 42686.13.8.3. For pregnant patients, the date of the patient’s last menstrual period and 4269estimated date of delivery must be recorded in ADM. 4270 42716.13.9. Inpatient Therapy 4272Evaluations and Re-evaluations for physical therapy are coded in the B MEPRS. 4273Physical therapy modalities related to the admission are not coded.

770 65 771 MHS Coding Guidance 772 March 2008 773 774 SPECIALTY CODING 775 6.14 Preventive Medicine Services 776 42746.14. Preventive Medicine Services 4275There are two basic types of preventive medicine services, physicals or well-baby visits 4276and counseling or risk-factor reduction intervention. Section 6.14.1 is about physicals 4277and well-baby visits. Section 6.14.2 is about counseling and risk factor reduction 4278intervention. 4279

4280 DoD Rule 4281 4282 If an additional problem or issue is identified and treated, an additional 4283 office E&M code may be warranted. 4284 4285 If the encounter intent is preventive (e.g., a physical), code the preventive 4286 E&M encounter (e.g., 99384–7, 99394–7) first, even though problems or 4287 issues addressed constitute an additional problem-oriented E&M code 4288 (e.g., 99212) based on the separate problem-oriented documentation. 4289 Append modifier -25 to the problem-oriented E&M (e.g., 99212-25).

4290 42916.14.1. Physicals and Well-Baby Visits 4292 42936.14.1.1. E&M Rules 4294 42956.14.1.1.1. Categorization 4296Preventive medicine E&M services, such as physicals and well-baby checks, are 4297categorized by patient age and status. These E&M codes include a comprehensive 4298history and a comprehensive examination. The history obtained as part of the preventive 4299medicine service is not problem oriented and does not involve a chief complaint or 4300present illness. 4301 43026.14.1.1.2. Visit Comparisons 4303The following table provides preventive medicine visit comparisons: 4304 Preventive Problem Oriented Preventive Medicine Visit with Medicine Visit Visit Problem 993xx and 992xx with 99381–99397 99201–99215 modifier -25 Chief Healthy patient, Chief complaint Healthy patient with significant complaint absence of specified complaint complaints. Insignificant or trivial problem History Not problem Description of the Include history 1) related to oriented. history of present age/gender and 2) present illness No description of illness as present illness. appropriate for the Assessment of presenting problem pertinent risk factors 777 66 778 MHS Coding Guidance 779 March 2008 780 781 SPECIALTY CODING 782 6.14 Preventive Medicine Services 783 Preventive Problem Oriented Preventive Medicine Visit with Medicine Visit Visit Problem 993xx and 992xx with 99381–99397 99201–99215 modifier -25 Review of Comprehensive To the extent Combine system review and systems— system review. appropriate for the presenting problem past, family, Comprehensive past, presenting problem social history family, and social history Examination Extent of the Level of exam as Level of exam as appropriate to examination is based appropriate to evaluate the presenting problem on the age of the evaluate the 1) related to age/gender and 2) patient and risk presenting problem present illness factors identified Assessment Screening for Ancillary services Combination of screening and and plan ancillary services ordered for specific medical decision making without complaint. medical Typically related to problem(s). counseling, Medical decision- anticipatory making reflected guidance, risk factor reduction 4305 43066.14.1.1.3. Determining Proper Code Category 4307The issue is not how healthy the patient is, but rather how much work the provider does. 4308Use problem-oriented office visit codes when the documentation shows significant 4309medical decision making. 4310 4311Documentation points to preventive medicine codes when a patient presents for routine 4312services (annual exam) and documentation does not show that a significant problem is 4313addressed. Documentation points to preventive medicine codes when there are no patient 4314complaints, no symptoms, and no significant problem or abnormality is recorded. 4315 43166.14.1.1.4. A Physical and a Condition 4317Frequently, a patient will schedule an appointment but identify other issues at the 4318encounter that require medical intervention. When the condition requires significant time 4319and resources, it should be documented separately from the physical. There is usually a 4320second SOAP (Subjective, Objective, Assessment, Plan) note after the physical 4321documentation. Code the physical E&M (i.e., 99381–99397) linking the physical 4322diagnosis to the physical E&M. Then code an office visit E&M (e.g., 99212) with a 4323modifier -25, linking the medical condition to the office visit E&M. 4324 4325 Example: Well-baby visit with a second diagnosis of acute otitis media. The first 4326 E&M code, 993xx, would be linked to the well-baby visit (V20.2), while the 992xx- 4327 25 would be linked to the acute otitis media diagnosis (382.9).

784 67 785 MHS Coding Guidance 786 March 2008 787 788 SPECIALTY CODING 789 6.14 Preventive Medicine Services 790 43286.14.1.2. Diagnosis Coding Rules 4329 43306.14.1.2.1. The V codes identify diagnoses when a person is not currently or acutely ill, 4331but requires healthcare services. Some of the commonly used codes include: 4332 4333 V20.2 Well-baby examinations 4334 V68.09 Issue of medical certificate for full flying duties (FFD)/Return to 4335 flight status (RTFS) 4336 V70.3 Sports physicals/ school physicals 4337 V70.5_ _ 1 Annual flight examinations 4338 V70.5_ _ 4 Pre-deployment prevention examinations 4339 V70.5_ _ 6 Post-deployment prevention examinations 4340 V72.31 Annual GYN examinations 4341 43426.14.1.2.2. Post-Deployment Visits 4343The provider should assess if the visit is deployment related. All deployment-related 4344visits must have the deployment code listed in one of the first four positions. See section 43452.2.8.2. of this manual. The deployment related codes are V70.5_4/5/6. 4346 43476.14.1.3. Procedure Coding Rules 4348 43496.14.1.3.1. Immunizations 4350Those given at point of service (in the clinic performing the well-baby visit or other 4351physical) are coded on the same encounter as the physical. 4352 43536.14.1.3.2. Vision Screening 4354The 92xxx codes are inappropriate for vision screening in conjunction with a physical. 4355Possible codes are 99172 or 99173. 4356 43576.14.1.3.3. Blood Pressure 4358Measurement of blood pressure is a vital sign and collected as a part of the constitutional 4359evaluation with other vital signs. It is inappropriate to use 93770 for arterial blood 4360pressure measurement obtained at patient intake. 4361 43626.14.1.3.4. Codes to Assist in Population Health Management 4363Consider using the category II codes for smoking if the MTF emphasizes smoking 4364cessation (i.e., S9075and S9453). 4365 43666.14.2. Counseling and Risk Factor Reduction Interventions 4367The second basic type of preventive medicine services is counseling or risk factor 4368reduction intervention. 4369 4370One of the more common coding errors in the DoD is using a preventive medicine, 4371individual, or group counseling code, when an education code should have been

791 68 792 MHS Coding Guidance 793 March 2008 794 795 SPECIALTY CODING 796 6.14 Preventive Medicine Services 797 4372used. Use a counseling or risk factor reduction intervention code when there is no 4373condition, symptom, or disease. 4374 4375For instance, a couple is considering having a child and the woman’s nephew has Tay- 4376Sachs. The couple does not have a child with Tay-Sachs, but there is a risk they could 4377since a nephew has it. This is therefore a counseling session. If the couple had already 4378had a child with Tay-Sachs and was seeing a provider to learn more about the disease and 4379how to manage their child, it would be education. 4380 4381Another example: Discussion about having a prophylactic mastectomy because a 4382woman’s mother and sister both had breast cancer is counseling. Discussion on treatment 4383options for a woman diagnosed with breast cancer is an office visit. Occupational 4384therapy to improve ADL after the mastectomy is occupational therapy. Classes 4385addressing post-mastectomy issues are education. Prenatal, obesity, and diabetes classes 4386are education. 4387 4388NOTE: When an applicable education class code is not available in HCPCS (many 4389are around S9436), use the 99078 CPT code, if applicable. These are procedure 4390codes and would be coded in the procedure field of the ADM. 4391 43926.14.2.1. E&M 4393The appropriate E&M codes should be assigned based on the documentation of the 4394services performed: Counseling or risk factor reduction E&M codes include 99401– 439599404 and 99411–99412. To determine if the counseling or risk factor reduction codes 4396are appropriate, ask: Was the encounter for an examination, education, or counseling? 4397 4398If the provider sees the patient for a problem, reviews the patient’s health assessment 4399form as part of the visit, and does risk factor reduction intervention (e.g., noticed on 4400health assessment form that the patient does not wear sunscreen and has been sunburned 4401a number of times), assign the office-outpatient codes 99201–99215. If the counseling 4402(e.g., about protection from the sun) takes more than 50 percent of the time of the 4403encounter, and it is documented, the encounter may be coded based on time instead of the 4404history, exam and decision making. Office visits not documented as a new visit should 4405be coded for established patients. 4406 4407Diagnosis coding is based on the provider’s assessment of problems or illnesses and any 4408counseling provided. It is also based on the type of exam or counseling performed and 4409any problems or illnesses assessed as part of the examination. 4410 4411If the provider is conducting preventive medicine counseling or risk factor reduction 4412counseling, (e.g., counseling on safe sex) the 99401–99404 codes should be assigned. 4413 4414NOTE: These codes are not to be used to report counseling and risk factor 4415reduction interventions provided to patients with symptoms or established illness. 4416The code selection is based on time. Documentation must support the reason for the 798 69 799 MHS Coding Guidance 800 March 2008 801 802 SPECIALTY CODING 803 6.14 Preventive Medicine Services 804 4417amount of time used. For instance: Counseled on safe sex, 30 minutes would not 4418adequately explain the amount of time involved. 4419 4420 Example: The 99411–99412 codes are appropriate for all students when the 4421 provider is teaching a healthy heart class for a general audience, even if one of 4422 the participants is diabetic, another is hypertensive, and a third is obese. 4423 44246.14.2.2. Diagnosis Coding for Preventive Encounters 4425Diagnosis coding is based on the type of counseling provided. When counseling is 4426provided, frequently used ICD-9-CM codes include: 4427 4428 V16.X Family history of malignant neoplasm 4429 V17.X Family history of certain chronic disabling diseases 4430 V25.09 Family planning (counseling for contraceptive mgt) 4431 V65.3 Dietary surveillance and counseling 4432 V65.40 Other counseling, no other symptoms 4433 V65.41 Exercise counseling 4434 V65.42 Counseling on substance use and abuse (this is a root code, use the 4435 appropriate DoD extender code) 4436 V65.43 Counseling on injury prevention 4437 V65.44 HIV counseling 4438 V65.45 Counseling on other sexually transmitted diseases 4439 V65.46 Encounter for insulin pump training 4440 V65.49_x Other specified counseling (this is a root code, use the appropriate 4441 DoD extender code) 4442 V69.0 Lack of physical exercise 4443 V69.1 Inappropriate diet and eating habits 4444 V69.2 High-risk sexual behavior 4445 V69.3 Gambling and betting 4446 V69.8 Other lifestyle-related problems 4447 V69.9 Problem related to lifestyle, unspecified 4448 44496.14.2.3. Procedures 4450Separate procedures for counseling or risk factor reduction are rarely done during an 4451encounter. 4452 44536.14.3. Modifiers 4454 -25 Append to any separate office visit E&M services provided. 4455 Reported in addition to the preventive medicine service codes. 4456 44576.14.4. Documentation 4458For counseling, the amount of time spent with the patient as well as the time counseling 4459the patient must be included in the documentation in addition to the date (e.g.. 12 Oct 04, 44600900–0930, counseling 20 minutes). Additional documentation guidelines are: 4461  Patient presents for annual physical when using preventive medicine codes. 805 70 806 MHS Coding Guidance 807 March 2008 808 809 SPECIALTY CODING 810 6.14 Preventive Medicine Services 811 4462  Patient presents for multiple concerns as well as health maintenance when using 4463 both a low-level office visit and a preventive medicine code. 4464  When reporting preventive medicine counseling codes, document the nature of 4465 the counseling and any education provided during the encounter. 4466  Do not document patient presents for yearly exam when using a problem- 4467 oriented visit code.

812 71 813 MHS Coding Guidance 814 March 2008 815 816 SPECIALTY CODING 817 6.15 Radiation Oncology Services 44686.15. Radiation Oncology Services 4469 44706.15.1. E&M Coding Rules 4471E&M codes are used in radiation oncology for services such as consultation, pre- 4472treatment evaluations, and non-routine follow-up visits. Select the appropriate code from 4473the documentation in the E & M section. For example, an inpatient might be evaluated 4474by the therapeutic radiologist to determine treatment options before a decision for 4475treatment is made. This visit would be coded as an initial inpatient consultation or 4476subsequent hospital care, as appropriate. 4477 44786.15.2. Diagnosis 4479Code the reason for the encounter. For instance, if the patient is being seen for radiation 4480therapy, the first code will be: 4481 4482V58.0 Radiotherapy. However, coding convention holds that this therapy is conducted if 4483the malignancy still exists. Therefore, the malignancy should also be coded. The 4484neoplasm table in the ICD-9-CM book is simple to use and codes may be taken directly 4485from it without referring to the tabular. 4486 44876.15.3. Procedural Treatment Planning Rules 4488 44896.15.3.1. Radiation Oncology 4490This treatment is used to destroy tumors and has professional and technical components. 4491Procedure codes are for initial consultation through patient management of the entire 4492course of treatment. 4493 44946.15.3.2. Treatment and Planning Codes 4495Privileged providers document treatment and planning using codes 77261, 77262 and 449677263. These codes include the initial consultation, so there is no separate E&M. 4497 44986.15.3.3. Clinical Treatment, Planning, and Tumor Mapping 4499This is used to identify the location, extent, volume of tumor(s) to be treated, and all 4500critical structures surrounding them. The privileged provider plans an individualized 4501course of radiation therapy that allows maximum benefit while protecting surrounding 4502tissues and structures. These codes include clinical treatment planning, which may 4503involve interpreting special tests. These professional services are usually provided once 4504during the course of treatment and include a follow-up period of up to three months 4505after treatment, unless a separate plan is implemented. 4506 45076.15.3.4. Simulation (77280–77295) 4508 45096.15.3.4.1. Simulation 4510The purpose of simulation is to determine treatment options and the placement of ports 4511for radiation treatment. It does not include the administration of radiation. The 4512complexity of a simulation is based on the number of ports, volumes of interest, inclusion 4513and type of treatment devices. 818 72 819 MHS Coding Guidance 820 March 2008 821 822 SPECIALTY CODING 823 6.15 Radiation Oncology Services 4514 45156.15.3.4.2. Simulations Not Reported Separately 4516Simulations that are not to be reported separately are: (1) portal changes based on 4517unsatisfactory initial simulations, (2) minor changes in port size without changes in beam 4518and simulation set up. The simulation set up is part of a period of treatment management, 4519usually in units of five. 4520 45216.15.3.4.3. Additional Simulations 4522These may be necessary during treatment to account for changes in port size, boost dose, 4523or tumor volume. Simulations need to be ordered by the privileged provider and 4524documentation should be completed and signed with the results. Documentation should 4525include the date, reason (initial, block check, subsequent, etc.), and a summary of the 4526procedure. 4527 45286.15.3.4.4. Teletherapy Isodose 4529If the documentation of the simulation supports CPT 77295, then teletherapy isodose 4530(77305–77315) plans are also reported. 4531 45326.15.3.4.5. Level of Complexity of Treatment Planning and Simulation Services 4533The levels of complexity for these services are clearly identified in the CPT code. All 4534criteria do not have to be met to establish the level of complexity. For example, three 4535or more separate treatment areas with simple blocking or no blocking would qualify as a 4536complex service. 4537 45386.15.4. Medical Radiation Physics 4539 45406.15.4.1. Basic Dosimetry 77300 4541The calculation of the radiation dose and placement is called dosimetry. The radiation 4542oncologist must order these services as part of the treatment plan. These are reported 4543once per port and may be repeated if documentation supports the reason for the new 4544calculation. 4545 45466.15.4.2. IMRT-Intensity Modulated Treatment Delivery 4547IMRT Planning—77301 4548 45496.15.4.3. Teletherapy Isodose Plans 77305–77315 4550Teletherapy Isodose plans are coded once for a specific treatment area. An additional 4551plan maybe coded if documentation supports that it was medically necessary to change 4552fields or equipment, or if clinical variations are made during the course of treatment. 45536.15.4.4. Special Therapy Port Plan 77321 4554This should be coded only once per treatment area (volume of interest) and not in 4555conjunction with 77300. 4556

824 73 825 MHS Coding Guidance 826 March 2008 827 828 SPECIALTY CODING 829 6.15 Radiation Oncology Services 45576.15.4.5. Special Dosimetry 77331 4558This service is the measurement of the actual amount of radiation a patient has received 4559at any given point. The radiation oncologist must order this service. This code may be 4560used more than once per day per treatment course. 4561 45626.15.4.6. Treatment Devices 77332–77334 4563Multiple devices may be coded if documentation substantiates. If two devices of separate 4564levels of complexity are documented, code only the one of the higher level. 4565 45666.15.5. Radiation Physics Consultations 4567 45686.15.5.1. Continuing Medical Physics Consultation 77336 4569CPT clearly identifies the documentation requirements. This code may be reported 4570weekly. 4571 45726.15.5.2. Special Medical Radiation Physics Consultation 77370 4573This code may only be reported once per course of treatment. This is used when a 4574problem or situation arises during treatment. It requires a written analysis or report of the 4575course of treatment, and is done at the direct request of the radiation oncologist. 4576 45776.15.6. Radiation Treatment Delivery Codes 77401–77416 4578Radiation treatment delivery codes are used for the actual delivery of the radiation and 4579consist of the technical component only. This code is chosen by level of service and 4580energy used. Multiple treatment sessions on the same day may be coded when there is a 4581break in sessions. The record should document a distinct break in therapy. 4582 45836.15.7. Radiation Treatment Management 77427–77499 4584 45856.15.7.1. Radiation treatment management codes consist of the professional component 4586only. CPT identifies documentation requirements for these services. This includes review 4587of port films and dosimetry, dose delivery, and treatment parameters, review of treatment 4588set up, and examination of patient for medical evaluation and management. The 4589documentation must clearly identify that the radiation oncologist examined the patient. 4590Nursing notes that the doctor adds, agree or patient doing well will not qualify as the 4591examination of the patient for this management. 4592 45936.15.7.2. 77427 Reporting 4594This is done every five treatments. For the first, second, third, and fourth treatment, use 4595diagnosis V58.0 and the code for the neoplasm. Do not code 77427 until the fifth 4596treatment. 77431 is reported if the course of treatment consists of one or two fractions. 4597 45986.15.8. Final Note 4599Some radiation oncology services may be bundled and may be modified under Correct 4600Coding Initiative, as discussed previously. 4601References: 4602CPT 2004 Professional Edition 830 74 831 MHS Coding Guidance 832 March 2008 833 834 SPECIALTY CODING 835 6.15 Radiation Oncology Services 4603”Cancer Care Network— 4604A User’s Guide For Radiation Oncology Management & Billing Procedures.” 4605Coding Strategies, Inc. 4606The Medical Management Institute—CUB All-In-One Coding Utility Book—Coding and 4607Medicare for Radiation Oncology 4608”AETC Radiation Oncology Training Modules,” by Patricia Bridges RHIT, CCS, CCS-P 4609and Victoria Flisk BHA, CPC

836 75 837 MHS Coding Guidance 838 March 2008 839 840 SPECIALTY CODING 841 6.16 Radiology, Intervention 842 46106.16. Radiology, Interventional 4611Interventional radiology is used to describe the use of cross-sectional imaging 4612techniques, such as ultrasound, CT and MRI, and digital processing of fluoroscopy. 4613These techniques are used not only for diagnostic but also therapeutic applications. 4614 46156.16.1. E&M Coding Rules 4616 46176.16.1.1. No Separate E&M Codes 4618Usually there is no separately identifiable E&M associated with an interventional 4619radiology encounter. 4620 46216.16.1.1.2. Coding E&M Separately 4622To code an E&M separately from a procedure, there must be a separately identifiable 4623reason. For instance, a provider determines the need for a procedure. At that encounter, 4624there would be a discussion of risks and benefits, informed consent would be obtained, 4625and there would be an evaluation to determine contraindications and other issues 4626affecting the procedure (such as allergies, previous adverse issue, or review of lab tests). 4627If it is a major procedure (usually with a global post-operative period of 90 days), there 4628would be a preoperative physical. In this case, there would be an E&M code. For minor 4629procedures (usually with a global postoperative period of 0–10 days), the pre-procedural 4630assessment is a component of the procedure. The postoperative encounter, usually for a 4631suture removal, does not have an E&M, but is coded with 99024 in the CPT field. 4632 46336.16.2. Diagnosis 4634 46356.16.2.1. First-Listed Diagnosis 4636The first-listed diagnosis is the reason the patient is having the procedure. If a definitive 4637diagnosis is not available by the end of the encounter and there will not be a pathology 4638report, code what is known. Do not code rule out. Code any additional diagnoses that 4639affect the encounter, such as diabetes, pregnancy, or a history of carcinoma. 4640 46416.16.2.2. Diagnosis Contingent on Pathology Report 4642When the diagnosis is contingent on a pathology report, wait to code the encounter until 4643the pathology report is available. For example, if the provider’s pre-procedure diagnosis 4644is mass and after the procedure, it is the provider’s assessment that the mass is benign, it 4645would be coded as a benign neoplasm. If after the procedure, the provider suspects the 4646mass may be malignant, the provider should wait to code the diagnosis and procedure 4647until the pathology results are available. For instance, if a patient presents for rule out 4648neoplasm of breast, but all that is known is that there is a mass in the breast, code a mass, 4649not a neoplasm. 4650 46516.16.3. Procedures 4652 46536.16.3.1. Interventional radiology usually involves two components: the imaging 4654procedural component and the therapeutic or diagnostic procedural component. In this 843 76 844 MHS Coding Guidance 845 March 2008 846 847 SPECIALTY CODING 848 6.16 Radiology, Intervention 849 4655section, the term imaging guidance usually indicates a procedure in the 7xxxx range of 4656CPT codes. The term procedural component usually indicates a procedure from the 465710000–69999 or 9xxxx CPT codes. 4658 46596.16.3.2. When performing the procedural component, (e.g., 19102, biopsy of breast; 4660percutaneous, needle core, using imaging guidance), collect the procedural component in 4661ADM. Collect the imaging guidance used in conjunction with the procedure (e.g., 76095, 4662stereotactic localization guidance for breast biopsy or needle placement, each lesion, 4663radiological supervision and interpretation) in the radiology module. 4664 46656.16.4. Modifiers 4666 46676.16.4.1. Modifier -26 4668Most procedures in the 10000–69999 and 9xxxx ranges do not have a professional and 4669technical component. Usually, the procedures are performed by a privileged provider in 4670one setting. Therefore, it is not necessary to use the modifier -26 for the professional 4671component. 4672 46736.16.4.2. Technical Component Modifier 4674Most procedures in the 10000–69999 range do not have a separate technical component. 4675There are a few in urology, but these would not usually be involved with interventional 4676radiology. In those cases when there is a technical component, the appropriate modifier 4677would be TC. The urology procedures may be performed by a urology technologist or 4678nurse but the data must be interpreted by the urologist. A radiology imaging exam 4679performed by a radiological technologist (imaging of the patient) must also have the data 4680interpreted by the radiologist. 4681 46826.16.4.3. MEPRS 4683Collect the procedural component of interventional radiology for procedures that do not 4684require medically supervised recovery (e.g., patient is able to respond to verbal stimulus 4685for the entire procedure and is able to depart upon termination of the procedure), in the 4686BBMA MERPS account. Collect the procedural component of interventional radiology, 4687for procedures requiring medically supervised recovery (e.g., patient needs to be 4688supervised in the post-anesthesia care unit), in the BBM5 MEPRS account when the 4689radiologist is AD or civil service.

850 77 851 MHS Coding Guidance 852 March 2008 853 854 SPECIALTY CODING 855 6.17 Readiness Assessment 856 46906.17. Health Exams of Defined Subpopulations, V 70.5_x 4691 46926.17.1. E&M Guidance 4693 ENCOUNTER TYPE E&M Encounter with exam, <1 years 99391 Encounter with exam, 1-4 years 99392 Encounter with exam, 5-11 99394 Encounter with exam, 12-17 99395 Encounter with exam, 18-39 99396 Encounter with exam, 40-64 years 99397 Encounter no exam, counseling provided to an individual, 15 minutes (with provider) 99401 Encounter no exam, counseling provided to an individual, 30 minutes (with provider) 99402 Encounter no exam, counseling provided to a group, 30 minutes (with provider) 99411 Encounter no exam, counseling provided to a group, 60 minutes (with provider) 99412 Encounter record review only (face to face), no exam, no Counseling, reviewed by 99420 provider (physicians, NPs, PAs or IDCs) Encounter record review, no exam, no Counseling, reviewed by provider (physicians, Do not code NPs, PAs or IDCs) Encounter Office Consultation 99241-99245 Encounter Tech Visit, face to face, no privileged provider contact 99211 4694 46956.17.1.1. Privileged Provider Performs Assessment 4696The appropriate E&M codes should be assigned based on the documentation. Was the 4697encounter for a DoD evaluation of the patient’s ability to perform his mission? Was the 4698encounter for counseling or an examination? The definition of counseling is a dialogue 4699with patient or family on one or more of the subsequent areas: 4700  diagnostic results, impressions, or recommended diagnostic studies 4701  prognosis 4702  risks and benefits of management (treatment) options 4703  instructions for management (treatment) or follow-up 4704  risk factor reduction 4705  patient and family education (CPT Assistant, January 1998, p. 6) 4706 47076.17.1.2. Assessing Ability to Perform Mission 4708If the provider is evaluating the patient’s ability to perform the mission, there is no 4709appropriate CPT code. If the provider is providing education (training about a symptom, 4710condition, or disease), there is no appropriate CPT code. 4711If the provider is conducting preventive medicine counseling or risk factor reduction 4712counseling, (e.g., counseling on safe sex so long as the patient is not doing anything that 4713could be considered unsafe sex) use codes 99401–99404. 4714 4715NOTE: These codes are not to be used to report counseling and risk factor 4716reduction interventions given to patients with symptoms or established illness. The 4717code selection is based on provider counseling time. Time spent on risk-factor 4718reduction must be documented. Time spent evaluating the patient for ability to

857 78 858 MHS Coding Guidance 859 March 2008 860 861 SPECIALTY CODING 862 6.17 Readiness Assessment 863 4719perform the mission or educating the patient is not included in the time used to 4720determine a preventive medical counseling or risk factor reduction. 4721 99401 Preventive medical counseling or risk factor reduction 4722 intervention(s) given to an individual (separate procedure): 15 4723 minutes 4724 99402 Preventive medical counseling or risk factor reduction 4725 intervention(s) given to an individual (separate procedure): 30 4726 minutes 4727 99403 Preventive medical counseling or risk factor reduction 4728 intervention(s) given to an individual (separate procedure): 45 4729 minutes 4730 99404 Preventive medical counseling or risk factor reduction 4731 intervention(s) given to an individual (separate procedure): 60 4732 minutes 4733 4734 Example: The privileged provider is rendering individual counseling on lifestyle 4735 modifications for risky behavior, preventive counseling based on family history and 4736 occupational exposure. The duration of this visit is 60 minutes with 15 for evaluation 4737 to perform the mission (do not include this time), 15 minutes discussing why the 4738 patient should stop smoking, exercise, and lose weight (education, do not include this 4739 time), and 30 minutes for counseling or risk-factor reduction. Code this as 99402 — 4740 counseling 4741 4742 If the provider is conducting a wellness or screening exam (e.g., pelvic examination 4743 for women or prostate examination for men) during the PHA, the preventive medicine 4744 codes are to be used. A pelvic exam or prostate examination by itself does not justify 4745 use of these codes. The appropriate comprehensive history, comprehensive exam and 4746 risk factor reduction must be completed. 4747 Patient Age (Years) New Patient Established Patient 18–39 99385 99395 40–64 99386 99396 4748 4749 If the provider sees the patient for a problem (e.g., patella femoral syndrome for 4750 physical fitness waiver or profile), and reviews the patient’s medical record (e.g. DD 4751 Form 2766) as part of the visit, assign the office or outpatient codes 99201–99215. 4752 4753NOTE: Code selection is based on documentation and new vs. established patient 4754status. 4755 47566.17.2. Non-privileged Provider Performs the Assessment 4757Code selection is based on what takes place during the encounter. 4758

864 79 865 MHS Coding Guidance 866 March 2008 867 868 SPECIALTY CODING 869 6.17 Readiness Assessment 870 4759If a review of the medical record and DD Form 2766 results in preventive medicine or 4760risk factor reduction counseling, assign E&M code 99211. Diagnosis coding is based on 4761the type of counseling provided. (See the ICD-9-CM counseling code listing below.) 4762 4763If a review of the medical record and DD Form 2766 does not result in preventive 4764medicine or risk-factor reduction counseling, assign code V68.89 for the diagnosis. 4765 47666.17.3. Diagnosis Coding Rules 4767 47686.17.3.1. Use of V70.5 is located in Section 2.2.8. 4769 47706.17.3.2. Diagnosis coding is based on the type of counseling given. When counseling is 4771provided, refer to the following series of ICD-9-CM codes: 4772 4773 V25.09 Family planning (counseling for contraceptive management) 4774 V65.3 Dietary surveillance and counseling 4775 V65.40 Other counseling, no other symptoms (NOS) 4776 V65.41 Exercise counseling 4777 V65.42 Counseling on substance use and abuse (this is a root code; use the 4778 appropriate DoD extender code) 4779 V65.43 Counseling on injury prevention 4780 V65.44 HIV counseling 4781 V65.45 Counseling on other sexually transmitted diseases 4782 V65.49_x Other specified counseling (this is a root code, use the appropriate 4783 DoD extender code) 4784 V69.0 Lack of physical exercise 4785 V69.1 Inappropriate diet and eating habits 4786 V69.2 High-risk sexual behavior 4787 V69.3 Gambling and betting 4788 V69.8 Other problems related to lifestyle 4789 V69.9 Problem related to lifestyle, unspecified 4790 47916.17.3.3. Hearing Conservation and Hearing Loss 4792 4793DoD unique extender tracking codes: 4794 V41.2_1 Hearing Conservation (HC), PH-1 4795 V41.2_2 HC, PH-2 4796 V41.2_3 HC, PH-3 4797 V41.2_4 HC, PH-4 4798 V41.2_0 Other and Unspecified problems with hearing 4799 4800Hearing loss caused by injury: 4801 E923.8 Other Explosive Materials 4802 E928.1 Exposure to Noise 4803 871 80 872 MHS Coding Guidance 873 March 2008 874 875 SPECIALTY CODING 876 6.17 Readiness Assessment 877 48046.17.4. Documentation—What to Document 4805For counseling, the amount of time spent with a patient must be included in the 4806documentation, with the date (e.g., 12 Oct 04, 0900–0930). 4807 Patient presents for annual physical: use preventive medicine codes. 4808 Patient presents for multiple concerns as well as health maintenance: use both a low- 4809 level office visit and a preventive medicine code. 4810 When reporting preventive medicine counseling codes, document the nature of the 4811 counseling and any education provided during the encounter. 4812 48136.17.5. Procedural Coding 4814 48156.17.5.1. Education and Training for Patient Self-Management 4816Services prescribed by a physician and provided by a qualified nonphysician 4817healthcare professional designed to teach patients how to self-manage illness(es) or 4818disease(s) effectively. The following codes may be reported when a standardized 4819curriculum is used: 4820 98960 Face-to-face with patient each 30 minutes; individual patient 4821 98961 2–4 patient 4822 98962 5–8 patients 4823 48246.17.5.2. Procedures in Conjunction with Readiness Encounter 4825 Immunizations, 90465–90749 Prostate cancer screening, G0102 Venipuncture, 36415 Pap smear collection, Q0091 Audiometry: KOH, 87210–86220 Pure tone (threshold), 92252 Testing of groups, 92559 Tympanometry, 92567 Guaiac Test, 82270 Visual acuity and color vision, Dip Stick US, 81002 99172–99173 EKG, 9300093010 Pulmonary Function Test (PFT), 94010–60

878 81 879 MHS Coding Guidance 880 March 2008 881 882 SPECIALTY CODING 883 6.18 Reconstructive/Cosmetic Surgery 884 48266.18. Reconstructive and Cosmetic Surgery 4827Cosmetic procedures improve the patient’s appearance by plastic restoration, correction, 4828and removal of blemishes. Many cosmetic procedures are coded with the same procedure 4829codes as a reconstructive procedure. 4830 4831Reconstructive procedures are not cosmetic. Reconstructive procedures are performed on 4832abnormal structures, generally to improve function and to approximate normal 4833appearance. Reconstructive procedures are coded using codes in CPT. 4834 4835 DoD Rule. Regardless of training or skills maintenance for the provider, 4836 the patient must pay for all cosmetic procedures through the Medical 4837 Services Accounts (MSA) office and present a paid bill for the services 4838 prior to receiving services.

4839 48406.18.1. Diagnosis Coding Rules 4841 48426.18.1.1. Cosmetic Procedure 4843The provider determines if a procedure is reconstructive (e.g., to improve function) or 4844cosmetic (e.g., to improve the patient’s appearance or self-esteem). When a provider 4845documents that a procedure is cosmetic, use codes: 4846 4847 V50.0 Hair transplant 4848 V50.1 Other plastic surgery for unacceptable cosmetic appearance 4849 The term plastic surgery in this case includes cosmetic procedures such as laser tattoo 4850 removal and hair removal. 4851 V50.3 Ear piercing 4852 V50.8 Other. This includes piercing other than the ear. 4853 V50.9 Unspecified 4854 48556.18.1.2. Post-Procedure Services 4856For routine follow up for cosmetic procedures, use the appropriate V codes, such as 4857V58.3, attention to surgical dressings and sutures, V67.9, follow-up exam following other 4858surgery, and V67.59, follow-up exam following other treatment—other. 4859 48606.18.2. Procedural Coding Rules 4861 48626.18.2.1. Many procedures can be reconstructive or cosmetic, such as blepharoplasty. 4863Others are only cosmetic, such as hair transplant or lipectomy. When there is a CPT or 4864HCPCS code that accurately reflects the service provided, use the CPT or HCPCS code. 4865 48666.18.2.2. Post-Procedure Services 4867Routine post-procedure services are coded with 99024 for each visit within global period 4868in the CPT/HCPCS field. Complications are coded based on the documented 4869complication and procedures. 885 82 886 MHS Coding Guidance 887 March 2008 888 889 SPECIALTY CODING 890 6.18 Reconstructive/Cosmetic Surgery 891 4870NOTE: See section 5.3.2. for a detailed explanation of global period. 4871 48726.18.2.3. Botox for Cosmetic Surgery 4873Code J0585. The number of injections involved is not considered in coding. The 4874physician is required to document the number of units administered to the patient. The 4875number of units is entered in the unit’s field. Units feed to TPOCS and reside on the 4876local server. Units are not a field in the SADR and are not transmitted to a central 4877database injection codes are not used in coding Botox used for cosmetic reasons. There 4878is an injection code for therapeutic use of Botox.

892 83 893 MHS Coding Guidance 894 March 2008 895 896 SPECIALTY CODING 897 6. 19 Social Work and Family Advocacy Services 898 48796.19. Social Work and Family Advocacy Services 4880Social workers in the mental health and life skills clinic should refer to section 6.8, 4881Mental Health. 4882 48836.19.1. E&M Coding Rules 4884Social work providers do not use outpatient office E&M codes in addition to their 4885procedural services. When social work providers furnish diagnostic interviews, 4886psychotherapy, assessments, counseling, and other social work services, the services 4887should be coded as procedures. 4888 48896.19.2. Diagnosis Coding Rules 4890

4891 DoD Rule 4892 4893 Encounters for post-deployment related conditions will have V70.5_6 as 4894 the second code and the patient’s mental health condition listed first.

4895 48966.19.2.1. Diagnostic and Statistical Manual (DSM IV) 4897Mental health diagnoses are based on terminology and codes found in the Diagnostic and 4898Statistical Manual of Mental Disorders (DSM IV). Although the terminology in ICD-9- 4899CM or CHCS does not always match the terminology in DSM IV, the majority of the 4900codes are the same. 4901 49026.19.2.2. Coding for Clients Without Mental Disorder Diagnosis 4903Use V codes for encounters with patients or clients who do not have a mental disorder 4904diagnosis. For example: 4905 4906 V60.2 Financial problems 4907 V61.10 Counseling for marital and partner problems 4908 V61.49 Presence of sick or handicapped person in family or household 4909 V62.82 Bereavement 4910Any conditions that may contribute to the patient’s mental condition, affect treatment 4911(e.g., depression, anxiety) are coded as additional diagnoses. 4912 49136.19.2.3. Suspected Conditions 4914Encounters for suspected conditions, including abuse or neglect, that do not have any 4915reportable physical signs, symptoms, or conditions when the suspected condition is ruled 4916out are to be coded: 4917 V71 Observation and Evaluation for Suspected Conditions not found. 4918 49196.19.2.4. HIV-Related Conditions 4920Patients who have been diagnosed with HIV or AIDS may be evaluated to determine if 4921they are experiencing depression or anxiety that needs the services of a psychiatrist (e.g., 899 84 900 MHS Coding Guidance 901 March 2008 902 903 SPECIALTY CODING 904 6. 19 Social Work and Family Advocacy Services 905 4922pharmacological management of the mental problem). HIV will be reported as the reason 4923for the encounter, then the mental condition, because the mental condition being 4924evaluated is related to the HIV. 4925 49266.19.2.5. Family Advocacy Encounters 4927 4928NOTE: For Air Force, AD and Defense Health Program-funded civilians, report 4929family advocacy program (FAP) encounters. Refer to “Behavioral Health Coding 4930Handbook.” 4931 4932Initial domestic violence encounters for crisis intervention are reported with a code from 4933995.5 Child Maltreatment Syndrome or 995.8 Other Specified Adverse Effects, not 4934elsewhere classifiable (NEC). The code(s) for any physical injuries sustained, plus the 4935appropriate E codes for external cause of injury, will be additional codes. Subsequent 4936encounters for counseling will be reported with a V code such as: 4937 4938 V61.10 Counseling for marital and partner problems 4939 V61.12 Counseling of perpetrator of spousal and partner abuse 4940 V61.21 Counseling of victim or child abuse 4941 V61.22 Counseling for perpetrator of parent or child abuse 4942 V62.83 Counseling for perpetrator of physical or sexual abuse (used for a 4943 perpetrator who is not a parent, spouse, or partner of the victim) 4944 49456.19.3. Procedural Coding Rules 4946 49476.19.3.1. Social workers will use 90801, the CPT psychiatric diagnostic interview 4948examination codes for many initial encounters. 4949 Description ICD-9-CM E&M CPT Initial FAP assessment; no V71.9 N/A 90801 evidence or allegation Initial FAP assessment; evidence 995.80 N/A 90801 or allegation present; adult maltreatment Initial FAP assessment; evidence 995.50 N/A 90801 or allegation present; child maltreatment Individual follow-up for 995.80or 995.50 and N/A 90804 20—30 min maltreatment V61.10 90806 45—50 min 90808 75—80 min Group treatment 995.80 or 995.50 and N/A 90853 V61.20 or V61.22 Marital or family treatment 995.80 or 995.50 & N/A 90847 V61.20 or V61.22 4950 4951 906 85 907 MHS Coding Guidance 908 March 2008 909 910 SPECIALTY CODING 911 6. 19 Social Work and Family Advocacy Services 912 49526.19.3.2. Use of HCPS Level II Codes 4953Social workers will also use HCPCS Level II codes. For example, an initial encounter 4954for domestic violence is coded S9484, crisis intervention mental health services, per hour. 4955 49566.19.3.3. Health and Behavior Assessment/Intervention (96150–96155). 4957Health and behavior assessment or intervention codes are to be used by social workers 4958and other non-physicians. These codes are not intended for use by physicians. Non- 4959physician providers assess patients with acute or chronic medical illnesses who might 4960benefit from counseling. Patients have psychiatric issues that may affect their illness or 4961hinder treatment. Patients treated for psychiatric diagnoses are not coded using the 4962Health and Behavior Assessment/Intervention. 4963 49646.19.3.4. Modifiers 4965The following modifiers are used to identify the type of provider or to provide more 4966specificity about a service than is listed in the CPT or HCPCS Level II coding manuals. 4967 MODIFIER DESCRIPTION PROVIDER APPEND EXPLANATION TO 22 Unusual Mental/behavioral CPT & Indicates the service procedural service health provider HCPCS was more than is codes normally provided for the reported procedure (usually at least 25% more work involved). 32 Mandated services Mental/behavioral CPT & Services mandated by health provider HCPCS law, or regulation other codes than DoD regulations. AJ Clinical social Clinical social HCPCS Indicates type of worker worker codes provider. H9 Court-ordered Mental/behavioral HCPCS Indicates the service health provider codes was ordered by a court, a probation officer, or a parole officer. HE Mental health Mental/behavioral HCPCS Designates that a program health provider codes procedure is associated with a program specifically designed to provide mental health services.

HO Master’s degree Mental/behavioral HCPCS Provider’s education is level health provider codes master’s degree level

HP Doctoral level Mental/behavioral HCPCS Provider’s education is health provider codes doctoral level

913 86 914 MHS Coding Guidance 915 March 2008 916 917 SPECIALTY CODING 918 6. 19 Social Work and Family Advocacy Services 919 MODIFIER DESCRIPTION PROVIDER APPEND EXPLANATION TO HQ Group setting Mental/behavioral HCPCS Reported services are health provider codes provided to two or more clients who have no definite relationship during a single treatment encounter.

HR Family/couple Mental/behavioral HCPCS Reported services are with client present health provider codes provided to two or more clients who have a familial or significant other relationship, during a single tx encounter

HS Family/couple Mental/behavioral HCPCS Reported services are without client health provider Codes provided to two or present more clients who have a familial or significant other relationship, during a single treatment encounter 4968* HCPCS II modifiers are not available in AHLTA. 4969 49706.19.4. Documentation of Time-Based Encounters 4971The actual start and stop time or the total amount of time spent with a patient must be 4972documented to support coding for encounters based on time. 4973 49746.19.5. Case Management Services 4975The Case Management coding and reporting framework can be found in Appendix E. 4976 4977 4978 4979 4980 4981 4982 4983 4984 4985 4986 4987

920 87 921 MHS Coding Guidance 922 March 2008 923 924 SPECIALTY CODING 925 6. 20 Substance Abuse Program Services 926 49886.20. Substance Abuse Program Services 4989How to Report 4990

4991 Workload performed by Non-Defense Health Program-funded personnel 4992 is NOT captured in ADM. 4993 4994 Air Force Rule 4995 4996 Air Force substance abuse rehabilitation services provided by AD and 4997 Defense Health program-funded civilians will begin coding for ambulatory 4998 services provided. See “Behavioral Health Coding Handbook.” 4999 5000 Navy and Army Rule 5001 5002 Navy Substance Abuse and Rehabilitation Program (SARP) and Army 5003 Substance Abuse Program (SAP) encounters will be reported in an 5004 ambulatory service B MEPRS clinic in the ADM. Workload performance 5005 is measured in visits for this service. 5006 5007 *Army, contact the Service representative for specific guidance on use of 5008 HCPCS II and CPT codes.

5009 50106.20.1. E&M Coding Rules 5011Behavioral health evaluation services related to substance abuse programs should not be 5012reported with E&M codes. HCPCS Level II codes will be used to report these 5013encounters. However, an encounter solely for the purpose of reviewing laboratory results 5014will be reported with an E&M code. 5015 5016 99408 Alcohol and/or substance (other than tobacco) abuse structured 5017 abuse structured screening (eg, AUDIT, DAST), and brief 5018 intervention (SBI) services; 15-30 minutes 5019 99409 ; greater than 30 minutes 5020 50216.20.2. Diagnosis Coding Rules 5022 50236.20.2.1. Reporting Substance Abuse Disorders 5024Substance abuse disorders are never to be reported as dependence without specific 5025documentation of the dependence. Licensed chemical dependency counselors (LCDC) or 5026certified alcohol drug abuse counselors (CADAC) can diagnose a substance abuse 5027problem, but a privileged provider must evaluate the patient for a diagnosis of 5028dependence to be established. 5029 5030 5031

927 88 928 MHS Coding Guidance 929 March 2008 930 931 SPECIALTY CODING 932 6. 20 Substance Abuse Program Services 933 50326.20.2.2. Coding for Patients Without Substance Abuse Diagnosis 5033Patients who present to the clinic seeking program information or advice without a 5034diagnosed substance abuse problem are coded V65.42—a root code—with the 5035appropriate DoD extender). Encounters with a person seeking information or advice for 5036someone else (e.g., for a family member) are coded V65.19, person consulting on behalf 5037of another. 5038 5039 5040

5041 DoD Rule 5042 5043 Encounters for post-deployment related conditions have V70.5_6 as the 5044 first listed code and the patient’s mental health or physical condition listed 5045 second.

5046 50476.20.2.3. Medical Treatment for Physical Condition 5048Medical treatment for an acute physical condition caused by substance abuse or 5049dependence is coded and sequenced as a poisoning, with the E code for the substance and 5050circumstance. The abuse will be an additional diagnosis. 5051 50526.20.3. Procedural Coding Rules 5053Most encounters by CADAC, including evaluation for eligibility for a SAP, will be 5054reported using H codes from the HCPCS Level II coding manual. 5055 H CODES- *H0001 Alcohol, drug assessment (initial screening) *H0002 Behavioral health screening to determine eligibility for admission to treatment program H0004 Behavioral health counseling and therapy, per 15 minutes H0005 Alcohol, drug services; group counseling by clinician or counselor H0006 Alcohol, drug services; case management (documenting any indirect services rendered on behalf of patient, i.e. referral, follow-up, continuum of care) H0007 Alcohol, drug services; crisis intervention (outpatient) H0012 Alcohol, drug services; sub-acute detoxification (residential addiction program outpatient) (level II) H0013 Alcohol, drug services; acute detoxification (residential addiction program outpatient) H0015 Alcohol, drug services; intensive outpatient (treatment program that operates at least 3 hours/day at least 3 days/week, based on individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education (level I) 934 89 935 MHS Coding Guidance 936 March 2008 937 938 SPECIALTY CODING 939 6. 20 Substance Abuse Program Services 940 H0017 Behavioral health; residential (hospital residential treatment program), without room and board, per diem H0018 Behavioral health; short-term residential (non-hospital residential treatment program), without room and board, per diem *H0021 Alcohol, drug training service (for staff and personnel) not used by providers) H0022 Alcohol, drug intervention service—planned facilitation (family intervention) *H0023 Behavioral health outreach service (planned approach to reach a target population) *H0024 Behavioral health prevention information dissemination service (one-way direct or non-direct *H0025 Behavioral health prevention education service (delivery of services with target population to affect knowledge, attitude, or behavior) *H0026 Alcohol, drug prevention process services, community-based (delivery of services to develop skills of impactors) *H0028 Alcohol, drug prevention problem identification and referral (e.g., student and employee assistance programs), does not include assessment *H0029 Alcohol, drug prevention alternatives services (for populations that exclude alcohol and other drug use, e.g., alcohol-free social events) *H0047 Alcohol, drug abuse services, not otherwise specified H0048 Alcohol, other drug testing: collection and handling only, specimens other than blood 5056 CPT Codes 82075 Breath analyzer 99082 Transportation 90885 Psychiatric evaluation of records, tests, etc. 90887 Fitness for evaluation 90889 Prepare reports for agencies 5057 50586.20.4. Modifiers Used in Substance Abuse Programs 5059The following modifiers are used to identify the type of provider or to provide more 5060specificity to a service than is listed in the CPT or HCPCS Level II coding manuals. 5061 5062 Modifiers Used in Substance Abuse Programs MODIFIER DESCRIPTION PROVIDER APPEND EXPLANATION TO 22 Unusual procedural Mental/behavioral CPT & Indicates service was more service health provider HCPCS than is normally provided codes for the reported procedure (usually at least 25% more work involved). 32 Mandated service Mental/behavioral CPT & Services mandated by law or health provider HCPCS regulation other than DoD. 941 90 942 MHS Coding Guidance 943 March 2008 944 945 SPECIALTY CODING 946 6. 20 Substance Abuse Program Services 947 MODIFIER DESCRIPTION PROVIDER APPEND EXPLANATION TO codes AH Clinical Clinical HCPCS Indicates type of provider. psychologist psychologist codes AJ Clinical social Clinical social HCPCS Indicates type of provider. worker Worker codes H9 Court ordered Mental/behavioral HCPCS Indicates the service was health provider codes ordered by a court, probation officer, or parole officer. HE Mental health Mental/behavioral HCPCS Designates a procedure is program health provider codes associated with a program specifically designed to provide mental health services. HF Substance abuse Mental/behavioral HCPCS Designates a procedure is program health provider codes associated with a program specifically designed to provide substance abuse services. HG Opioid addiction Mental/behavioral HCPCS Designate a procedure is treatment program health provider codes associated with a program specifically designed to provide opioid treatment services, including but not limited to the provision of methadone and levo-alpha-acetylmethadol (LAAM). HO Master’s degree Mental/behavioral HCPCS Provider’s education level is level health provider codes a master’s degree HP Doctoral level Mental/behavioral HCPCS Provider’s education level is health provider codes a doctorate HQ Group setting Mental/behavioral HCPCS Reported services are health provider codes provided to two or more clients who have no definite relationship during a single treatment encounter. HR Family/couple with Mental/behavioral HCPCS Reported services are client present health provider codes provided to two or more clients who have a familial or significant other relationships during a single treatment encounter HS Family/couple Mental/behavioral HCPCS Reported services are without client health provider codes provided to two or more present clients who have a familial or significant other

948 91 949 MHS Coding Guidance 950 March 2008 951 952 SPECIALTY CODING 953 6. 20 Substance Abuse Program Services 954 MODIFIER DESCRIPTION PROVIDER APPEND EXPLANATION TO relationships during a single treatment encounter 5063 5064 Examples: A master’s level LCDC conducts substance abuse counseling with 5065 an AD patient and his wife as part of the soldier’s treatment program. 5066 5067 A patient in the SAP who is being treated by a psychiatrist with Antabuse is 5068 seen for management of the medication. 90862 Pharmacological management 5069 modifier HF indicates this is being done for a patient in an SAP. 5070 50716.20.5. Documentation of SAP Treatment 5072Documentation of SARP treatment is governed by Navy regulations. Referral of patients 5073to the SARP or SAP through medical channels is documented on an SF 513. Military 5074health records (HREC) and outpatient treatment records (OTR) will only contain the 5075following notation for outpatient mental health treatment: “Patient seen, refer to file 5076number 40-216k1” for adults or “Patient seen, refer to file number 40-216k2” for minors. 5077The referenced file will contain the actual documentation of any mental health treatment. 5078 50796.20.6. Documentation of Time-Based Encounters 5080The actual start and stop time or the total amount of time spent with a patient must be 5081documented to support coding for encounters based on time. 5082

955 92 956 MHS Coding Guidance 957 March 2008 958 959 SPECIALTY CODING 960 6. 20 Substance Abuse Program Services 961 5083Chapter 7 CODING AMBULATORY PROCEDUREVISIT (APV) ENCOUNTERS 5084 5085Coding audits indicate that the DoD needs to improve coding of APV procedures in five 5086areas: procedure or service not coded, code(s) not supported by documentation, 5087appropriate use of modifiers, appropriate use of quantity, and future focus on coding 5088improvement (codes not matched to correct diagnosis, sequencing, and application of 5089ancillary services). APV procedures can occur in the ambulatory procedure unit, 5090emergency department, clinic, or outpatient activities on a ward. Diagnostic radiology 5091and laboratory procedure codes should not be coded in the ADM, since that workload is 5092reported in other MHS systems. Administration of local anesthesia is not reported 5093separately because it is considered part of the procedure. 5094 50957.1. Definitions 5096The definition of APV per Department of Defense Instruction (DoDI) 6025.8, Subject: 5097APV, dated September 23, 1996, was modified by the UBU effective 01 Oct 2004. The 5098complete list of CMS-approved ambulatory surgical center (ASC) procedures is at 5099http://www.cms.hhs.gov/ASCPayment/04f_CMS-1392-FC(ASC).asp#TopOfPage 5100 51017.1.1. Ambulatory Procedure Visit 5102APVs are defined as procedures or surgical interventions that require pre-procedure care, 5103a procedure, and immediate post-procedure care, directed by a qualified healthcare 5104provider. Minor procedures performed in an outpatient clinic that do not require post- 5105procedure care by a medical professional are not considered APVs. The nature of the 5106procedure and the medical status of the patient combine to require short-term, but not 5107inpatient care. These procedures are appropriate for all types of patients (obstetrical, 5108surgical, and non surgical) who, by virtue of the procedure or anesthesia, require post- 5109procedure care or monitoring by medical personnel. Requiring an individual to remain in 5110the area for a period of time, such as 20 minutes after an injection, is not post-procedure 5111care. 5112 51137.1.2. Ambulatory Surgery Program 5114A facility program for the performance of elective surgical procedures is defined as an 5115APV in DODI 6025.8. APV care is not to exceed 23 hours and 59 minutes, measured 5116from the time patient care begins in the MTF to the time the patient no longer requires 5117medical supervision. Being checked in CHCS does not begin patient care. Frequently, 5118care begins a significant amount of time after the nurse activates the encounter in CHCS. 5119An APV patient who stays beyond 24 hours past actual patient care start time must be 5120admitted to a hospital as an inpatient, if medically necessary. APV patients staying 5121beyond 24 hours after start of care are not automatically admitted. As with any 5122admission, there must be a written order from a provider to change an APV to an 5123admission. 5124Observation is not an APV. 5125 5126 5127 962 1 963 MHS Coding Guidance 964 March 2008 965 966 SPECIALTY CODING 967 6. 20 Substance Abuse Program Services 968 51287.1.3. Ambulatory Procedure Units (APUs) 5129APUs are designated MTF-approved locations or areas that are specially equipped and 5130staffed to perform the level of care associated with APV services. APUs provide a 5131coordinated program of care for patients usually requiring care that lasts less than 24 hours. 5132 51337.2. Coding Pre- and Post-Procedure APV Encounters 5134 51357.2.1. Global Surgery Coding 5136Global surgery coding for DoD does not necessarily follow civilian guidelines. In the 5137DoD, each privileged provider-patient encounter that involves medical decision making 5138and is documented, is collected in the ADM. The encounter when a decision for surgery 5139is made is coded as an E&M. If the decision for surgery is made within 24 hours of a 5140procedure with a 90-day postoperative period, the E&M is appended with the -57 5141modifier. If the decision for surgery is made at the same encounter as a procedure with a 51420-or 10-day postoperative period, the E&M is appended with a -25 modifier. 5143 51447.2.2. Uncomplicated Post-Operative Encounters 5145Code these with a 99024 procedure code 5146 51477.2.3. History and Physical 5148Usually a preoperative history and physical is done a few days prior to the scheduled 5149surgery to ensure the patient is a candidate for surgery. The history and physical is coded 5150based on documentation. It becomes part of the APV record. If a pre-op is done within 24 5151hours of a major operation (having a 90-day global postoperative period), it is not coded 5152unless the decision for surgery was made at that time. In that case, use modifier –57 to 5153indicate the decision for surgery was made during that E&M. Preoperative encounters to 5154check that there have been no significant changes in the patient’s condition are not coded. If 5155there is a significant change that requires medical intervention or a completely different 5156issue is addressed, the encounter should be coded. 5157 51587.2.4. Complications 5159Unlike some civilian coding guidance, all complications (conditions not expected at that 5160time after the surgery) must be documented and coded with an E&M based on the 5161complication documentation. 5162 51637.2.5. Postoperative Visits 5164Visits during the postoperative period that are unrelated to the surgery should be coded and 5165appended with the modifier -24. 5166 51677.2.6. Preoperative Appointments 5168If visits the day before major surgery involve a nurse, but no independent medical judgment 5169(although perhaps following medical staff-approved decision tables), they are usually 5170performed outside the clinic visit and are not collected in the ADM. 5171

969 2 970 MHS Coding Guidance 971 March 2008 972 973 SPECIALTY CODING 974 6. 20 Substance Abuse Program Services 975 51727.3. Patient Admitted from APV 5173If a patient is admitted from an APV, the ADM record should be coded and closed out with 5174disposition type admitted. The procedure codes associated with the APV will not be 5175included in the inpatient stay. 5176 51777.4. Consultation for APV 5178When an APV patient requires a consultation, the consulted provider will code the 5179consultation services in his or her specialty clinic. 5180 51817.5. Assistant at Surgery 5182When coding an APV, capture the additional providers (assistant surgeons) in the Provider 5183field of the ADM screen. The assistant surgeon should be linked to the same CPT code as 5184the operating physician. Code the anesthesia provider on the same ambulatory data record as 5185the surgeon. For anesthesia coding, see section 6.1. 5186 51877.5.1. Co-Surgeon 5188The individual operative report submitted by each surgeon should indicate the distinct 5189service each surgeon provided. 5190 51917.6. Code 99199: Institutional Component of an APV 5192 51937.6.1. Coding APV’s Institutional Component 5194There is no CPT or HCPCS code for the institutional component of an APV. To bill, the 5195MHS will use the CPT code 99199 to indicate the institutional component of an APV. 5196 51977.6.2. Discontinuance of Code 99199 5198All MTFs discontinued using the CPT code 99199 as an unlisted code by 30 September 51992004. CPT defines 99199 as “unlisted special service, procedure or report.” Most MTFs do 5200not use the CPT code 99199. A few have used it to track unlisted services that currently do 5201not have a code, such as a pediatrician sedating a patient so a radiologist can do a diagnostic 5202imaging procedure. 5203 52047.6.3. No RVU with Code 99199 5205As of 1 October 2004, to ensure correct billing, the MHS only uses the CPT code 99199 for 5206APV data collection and billing. As the code is only for billing, no RVU is associated with 5207it. Using the CPT code 99199 in the MHS now means Institutional Component, APV. Code 520899199 will be reported as the last procedure on the lead surgeon’s SADR. 5209 52107.7. Cancelled APVs 5211 52127.7.1. Coding Cancelled APVs 5213A patient may present for an APV, but the procedure is cancelled because: 5214  Patient develops a condition that contra-indicates surgery (V64.1). For example, 5215 patient experiences arrhythmia that causes the procedure to be terminated. 5216  Patient decides not to have the planned surgery (V64.2). 976 3 977 MHS Coding Guidance 978 March 2008 979 980 SPECIALTY CODING 981 6. 20 Substance Abuse Program Services 982 5217  The provider is unavailable to perform the APV, or 5218  Supplies or necessary resources are not available to support the APV (V64.3). 5219 52207.7.1.2. Additional Coding 5221Mark the appointment or encounter as kept. Code 2000F (blood pressure, measure) as a 5222placeholder. 5223 52247.7.1.3. Coding Presenting Medical Conditions 5225It may also be necessary to code presenting medical conditions (e.g., fever, elevated 5226hypertension) that prevented the procedure from being carried out. The first diagnosis 5227coded should be the preoperative diagnosis, secondary diagnosis should be the conditions 5228that prevented the procedure to be performed, then the appropriate V64*. 5229 52307.7.1.4. Incomplete Procedures 5231If a scheduled procedure was started but not completed, use the appropriate surgical CPT 5232code with appropriate modifier; 5233 -52 Reduced Services: Service or procedure partially reduced or eliminated at 5234 provider’s discretion. 5235 -53 Discontinued Procedure: Anesthesia has been started or the patient has been 5236 prepped in the operating room suite. 5237 52387.7.1.5. Anesthesia Cancellations 5239See Anesthesia section 6.1.13 for coding anesthesia procedures that are cancelled. 5240 52417.8. Procedures Not Performed in the APU 5242Since DoD only reports four procedures in the SADR, the highest risk or most resource- 5243intensive procedure needs to be listed first. Examples of procedures that are not APVs 5244are services associated with a magnetic resonance imaging (MRI), suturing a laceration, 5245wart removal, removal of wisdom teeth, or unlisted dental procedures. The list of office 5246procedures excludes the DoD ambulatory surgical procedures.

983 4 984 MHS Coding Guidance 985 March 2008 986 987 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 988 SCENARIOS 989 990 5247

5248Chapter 8 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR 5249CLINICAL SCENARIOS 5250 5251This section provides coding guidance for specific functions and situations. 5252 52538.1. Use of the MAIL Function 5254In the menu across the bottom of the ADM entry screen, mail permits providers with coding 5255questions to forward them to the MTF. The coder who receives this mail determines the 5256most appropriate code for the condition or encounter and replies in a timely manner. This 5257relieves providers from spending excessive amounts of time determining appropriate codes. 5258The provider may also elect to have the coder complete the ADM encounter documentation, 5259according to the policies of the clinic or facility. 5260 52618.2. For Clinic Use Only, an ADM function 5262This function permits each clinic to collect data unique to that clinic. These data are not part 5263of the SADR and remain at the facility level. 5264 52658.3. Additional Providers 5266This function permits data collection of names and categories of personnel who assist with 5267an encounter. It is especially useful to indicate when a second provider assists in performing 5268a procedure. The second privileged provider may bill a percentage of the procedure in 5269which he/she assists. For nurses and paraprofessional personnel, this function should be 5270used when the data collected justify the time and effort involved in data collection. The 5271categories for additional providers are: 5272  Attending 5273  Assisting 5274  Supervising 5275  Nurse 5276  Paraprofessional 5277  Operating provider #1 (will only appear if APV field is YES) 5278  Surgeon 5279  Anesthesia 5280  GME (resident) 5281 52828.4. Telehealth Services 5283A subset of e-Health, telehealth is the use of electronic information and telecommunications 5284technologies to provide or support clinical healthcare, patient and professional health-related 5285education, public health, and health administration when distance separates participants. It 5286embraces several related areas, including electronic consultation and e-mail. Coding of 5287telephone encounters is covered under the E&M section. Coding for telehealth does not 5288encompass provider-to-provider interaction (such as provider-to-provider e-mail). 991 1 992 MHS Coding Guidance 993 March 2008 994 995 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 996 SCENARIOS 997 998 5289

5290 DoD Rule 5291 5292 Telehealth services are coded in the ambulatory care service B MEPRS 5293 clinic, where workload performance is measured in visits. 5294

5295 5296NOTE: Provider-to-provider telephone calls, images transmitted via facsimile 5297machines and text messages without visual images (e-mail) are not considered 5298telehealth. 5299 53008.4.1. The following types of providers may code for telehealth encounters: 5301  Physician 5302  Nurse practitioner 5303  Physician assistant 5304  Nurse midwife 5305  Clinical nurse specialist 5306  Clinical psychologist* 5307  Clinical social worker*

5308 *Clinical psychologists and clinical social workers cannot code for psychotherapy 5309 services that include medical E&M services. These practitioners may not use the 5310 following CPT codes: 90805, 90807, and 90809.

53118.4.2. Documentation of Telehealth 5312Coders should look for telehealth encounters to be documented on an SF513 5313(Consultation Sheet), an approved substitute form or in AHLTA. For tele-radiology, the 5314SF 519 (Radiographic Report) or AHLTA are used. Telehealth encounters must meet the 5315same documentation requirements as face-to-face encounters. 5316 53178.4.3. How to Report 5318 53198.4.3.1. Real-time Communications 5320Telehealth may be reported for interactive audio, video, or other electronic media 5321telecommunications permitting real-time communication between the distant site 5322provider and the patient. 5323 53248.4.3.2. Store and Forward Telecommunications 5325Telehealth may also be reported for store-and-forward telecommunication that permits 5326asynchronous transmission of medical information to be reviewed later by a provider at

999 2 1000 MHS Coding Guidance 1001 March 2008 1002 1003 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 1004 SCENARIOS 1005 1006 5327the distant site. The type of telehealth is identified by a modifier (see section 8.5.5 5328Modifiers ). 5329 53308.4.3.3. Hospital Inpatients 5331Telehealth encounters for hospital inpatients will be reported in ADM as outpatient 5332encounters. 5333 53348.4.3.4. Photographs 5335Photographs, (e.g., of a skin lesion) must be specific to the patient’s condition and show 5336enough detail for interpretation or confirmation of a diagnosis or treatment regimen. 5337 53388.4.4. Site (MTF) Definitions 5339 53408.4.4.1. Originating Site 5341The originating site is the location where the patient is at the time the service is furnished. 5342The originating site will not use an E&M code for the telehealth encounter unless a 5343separately identifiable E&M service is documented on the same day. For encounters 5344involving patient-provider interaction, the visit will be entered as an office visit (e.g., 534599201 or 99211). 5346 53478.4.4.2. Remote (Distant) Site 5348The remote site is the location where the consultant is at the time the service is furnished. 5349Services at the receiving facility are coded based on the documentation of the encounter. 5350Consultation services (e.g., 99241 or 99242) for the receiving facility are coded in 5351ADM/AHLTA under the provider’s outpatient clinic (B MEPRS). Mental health, CPTs 535290804–90809 and 90862 (medication management) are available for telemedicine. A 5353provider at the originating site is not required to present the patient to a physician or 5354practitioner at the remote site unless medically necessary. This decision will be made by 5355the physician or practitioner located at the remote site. However, the provider must be in 5356the facility and available to take part in the teleconference if needed. 5357 53588.5. Remote Professional Services 5359A provider at one facility performing an interpretation of results, consultation or referral 5360(office visit code with modifier) for another facility is an example of remote professional 5361services. Interpretation would be coded using the appropriate code, such as 59051. 5362Consultations should be coded with a consultation code, such as 99241–99245 or 88321– 536388325. Referrals should be coded with an office visit code, such as 99201–99215 with 5364modifier (GQ or GT). Other types of encounters include mental health, in the code 5365ranges 90801 and 90804–90809, and nutritional counseling, with codes 97802, 97803, 5366and 97804. 5367 53688.5.1. Types of Remote Professional Services: Interpretations, Referrals, Consults, 5369and E-Mails. 53708.5.1.1. Interpretations 1007 3 1008 MHS Coding Guidance 1009 March 2008 1010 1011 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 1012 SCENARIOS 1013 1014 5371An interpretation is made on limited clinical data and the finding(s) documented. The 5372data could be transmitted electronically, via e-mail or facsimile, or by mail. If an EKG is 5373done at one facility and transmitted to another for interpretation, the facility where the 5374EKG was done would code 93005 and the facility where the EKG was interpreted would 5375code 93010. Another common example would be radiology. For radiology, one facility 5376would code the 7xxxx-TC (technical component) and the other would code the 7xxxx-26 5377(professional component). 5378 53798.5.1.2. Referrals 5380When a provider at the remote site evaluates a patient for a specific problem or condition, 5381this is called a referral. The most common example is a family practice physician at the 5382originating MTF who refers the patient to a remote MTF for care. The referral includes 5383history, vital signs, and photographs of the involved tissue and the contra-lateral tissue. 5384The dermatologist at the remote site reviews the collected data, makes a diagnosis, 5385develops a patient care plan, writes a prescription if necessary, and communicates the 5386plan to the patient and patient’s physician, usually through the technician. The technician 5387at the originating site would code a 99211 for each episode of care. The remote provider 5388would code a referral (office visit) and any applicable procedure codes, such as 5389interpretations. 5390 53918.5.1.3. Consult 5392When a provider at the remote site is asked for advice on a patient, this is called a 5393consult. As with all consults, there must be a written request and written report. The 5394most common example is a family practice provider at the originating site e-mailing a 5395request for consult along with EKG tracings and other documentation to the specialist at 5396the remote MTF. The family practitioner then telephones and discusses the patient with 5397the specialist. The consulted provider (specialist at remote MTF) arrives at a diagnosis, 5398develops a treatment plan, documents the encounter, and sends the requesting provider 5399the consult report. This would be coded by the remote, consulted provider as a consult 5400with the appropriate modifier. 5401 54028.5.1.4. Provider–Patient E-Mail 5403A reportable service would encompass the sum of communication and be documented in 5404the patient’s medical record. The entire e-mail thread must become part of the patient’s 5405medical record, including the acknowledgment of informed consent for e-mails, all e- 5406mails in the thread. 5407 5408Documentation guidelines for e-mail consultations between patient and provider should 5409include date and time of e-mail (this should be automatically imbedded in the body of the 5410e-mail). 5411 5412 54138.5.1.5. Situations Applicable for Online Consultations (E-Mail)

1015 4 1016 MHS Coding Guidance 1017 March 2008 1018 1019 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 1020 SCENARIOS 1021 1022 5414  Patient describes new symptoms and requests intervention or advice from the 5415 privileged provider. 5416  Patient describes ongoing symptoms from a recent acute problem or chronic 5417 health problem and requests intervention or advice from the privileged provider to 5418 treat ongoing acute problem or chronic health problem. 5419  Physician is giving substantive medical advice, revising treatment plan, 5420 prescribing or revising medication, recommending additional testing, or providing 5421 self care or patient education information for a new or chronic health problem. 5422  Physician makes a new diagnosis and prescribes new treatment. 5423  Patient requests interpretation of lab or test results and privileged provider gives 5424 substantive explanation and possibly makes recommendations to modify 5425 treatment plan, revising medications, etc. 5426  Clinical psychologist gives extended personal patient counseling, changing the 5427 course of treatment and affecting the potential health outcome. 5428 54298.5.2. E&M Coding 5430 54318.5.2.1. Documentation Needed 5432When telemedicine is applied to conduct a professional office visit or consultation between 5433provider and patient, the appropriate E&M codes for those services should be used. In 5434general, the initial visit will be a consult and follow-up visits will be established office visits. 5435Documentation must be filed in the patient’s permanent medical record and should include: 5436  Patient’s chief complaint 5437  Additional information from the patient to clarify his or her condition 5438  Any medications (over the counter, herbal, or prescription) being taken 5439  Date and time a prescription was ordered (may be available in CHCS) 5440  Date and time the patient is to return for care 5441  Electronic signature of the individual who performed the service when the online 5442 consultation is placed into AHLTA 5443 54448.5.3. Diagnosis Coding 5445Official outpatient coding guidelines will be followed for reporting diagnoses for 5446telehealth encounters. 5447 54488.5.4. Procedural Coding 5449 54508.5.4.1. Originating Site 5451The originating site will report telehealth episodes with Q3014 Telehealth Originating 5452Site Facility Fee. 5453 5454 54558.5.4.2. Distant Site

1023 5 1024 MHS Coding Guidance 1025 March 2008 1026 1027 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 1028 SCENARIOS 1029 1030 5456The distant site may report telehealth for many store-and-forward applications including 5457but not limited to the interpretation of: 5458  Colposcopy 5459  Obstetric ultrasound 5460  Electrocardiography, fetal 5461  Echocardiography 5462  ESRD-related services 5463  Cardiography interpretation and report 5464  MRI 5465  Laboratory results 5466  Video clips 5467 54688.5.5. Modifiers 5469 54708.5.5.1. Asynchronous vs. Real-Time Encounters 5471Professional telehealth services are coded with the appropriate modifier, for example, 547299245 GT. Telehealth encounters will be identified with 5473  GQ for asynchronous encounters, or 5474  GT for real-time interactive encounters. 5475 54768.5.5.2. GT Modifiers 5477This signifies real-time communication between the distant-site physician or practitioner 5478has taken place with the patient present and participating in the telehealth visit. 5479 54808.5.5.3. GQ Modifiers 5481This signifies the distant site physician or practitioner certifies that the asynchronous 5482medical file was collected and transmitted to him/her at his or her distant site from an 5483eligible originating site when the telehealth service was furnished. 5484 54858.5.5.4. Modifier -26 5486When a provider at a distant site provides an interpretation and report of a diagnostic 5487study (e.g. laboratory or radiology test), the service is reported with the -26 modifier for 5488the professional component of the procedure. The originating site would report the 5489procedure with the –TC modifier if no interpretation and report are rendered. 5490 54918.5.6. E-mail Encounters 5492 54938.5.6.1. Telephone Module 5494The telephone (T-con) module documents e-mail. Each facility or Service (i.e. Army, Navy, 5495Air Force) needs to determine its security risk and the Service must endorse in writing the 5496use of e-mail in its facility or Service. 549799444 Online evaluation and management service provided by a physician to an 5498 established patient, guardian, or health care provider not originating from a 1031 6 1032 MHS Coding Guidance 1033 March 2008 1034 1035 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 1036 SCENARIOS 1037 1038 5499 related E/M service provided within the previous 7 days, using the internet 5500 or similar electronic communications network 5501 55028.5.6.2. Multiple E-Mails 5503Beginning with an acknowledgment of informed consent, an episode of care can 5504accommodate multiple e-mails for the same problem. If additional correspondence is 5505expected on the same medical issue, the encounter should be left open until the e-mail 5506thread is complete. Additionally, if acknowledgment is requested from the patient, the 5507encounter should remain open until the acknowledgment is received. This is for an 5508established patient only and not provider-to-provider e-mail. The appointment belongs to 5509the B MEPRS clinic of the provider and would not be used for inpatient care or ancillary 5510services. The E&M code is limited to 99371 at this time owing to DoD system 5511limitations. There is no modifier. 5512 55138.5.6.3. Situations Applicable for Online Consultations (E-mail) 5514Examples include the following: 5515  A patient describes new symptoms and requests intervention or advice from the 5516 privileged provider. 5517  A patient describes ongoing symptoms from a recent acute problem or chronic 5518 health problem and requests intervention or advice from the privileged provider to 5519 treat ongoing acute problem or chronic health problem. 5520  A privileged provider gives substantive medical advice, revises a treatment plan, 5521 prescribes or revises medication, recommending additional testing, or provides self 5522 care or patient education information for new or chronic health problem. 5523  A privileged provider makes a new diagnosis and prescribes new treatment. 5524  A patient requests interpretation of lab or test results with evidence that the 5525 privileged provider is giving substantive explanation and possibly making 5526 recommendations to modify treatment plan, revise medications, etc. 5527  A privileged provider gives extended personal patient counseling that changes the 5528 course of treatment and affects the potential health outcome. 5529 55308.5.6.4. E-Mail Consultation 5531Following are documentation guidelines for e-mail consultations between patient and 5532provider. Documentation must be filed in the patient’s permanent medical record. 5533 5534  Date and time of e-mail (should be automatically imbedded in the body of the e- 5535 mail) 5536  Patient’s chief complaint 5537  Additional information received from the patient to clarify his/her condition 5538  Medications (over-the-counter, herbal, or prescription) being taken 5539  Date and time a prescription was ordered (may be available in CHCS) 5540  Date and time the patient is to return for care

1039 7 1040 MHS Coding Guidance 1041 March 2008 1042 1043 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 1044 SCENARIOS 1045 1046 5541  Electronic signature of the individual who performed the service when the online 5542 consultation is placed into AHLTA 5543 55448.6. Resident/GME Services 5545 55468.6.1. Definitions for Staff and Providers 5547For DoD purposes, the following definitions are applicable for staff or providers in a 5548GME program. 5549 5550Chief Resident. An individual who has completed an accredited residency program, then 5551engaged in an additional year of training and responsibility. Chief residents are board- 5552eligible or board-certified and are able to be privileged in the discipline of their 5553completed specialty training program. Chief residents are frequently licensed independent 5554practitioners. This model is common in internal medicine programs. 5555 5556Fellow. A physician or dentist, who has enrolled in a special fellowship program for 5557additional training, primarily in research. 5558 5559Resident. An individual engaged in a graduate training program in medicine (including 5560all specialties, e.g., internal medicine, surgery, psychiatry, radiology, nuclear medicine, 5561dentistry, podiatry or optometry), who participates in patient care under the direction of 5562supervising practitioners. Such programs must be accredited or certified as appropriate. 5563 5564NOTE: The term resident includes individuals in a recognized ACGME 5565(Accreditation Council for Graduate Medical Education) program and individuals 5566in approved subspecialty graduate medical education programs who historically 5567have also been referred to as fellows by some sponsoring institutions. 5568 5569Intern. A physician typically in the first year of training after medical school, often 5570described as PGY1. Interns typically do not have a license. 5571 55728.6.2. GME Documentation Requirements 5573

5574 DoD Rule 5575 5576 Physicians at Teaching Hospitals (PATH)/Primary Care Exception. 5577 PATH, which includes the Primary Care exception, does not apply to the 5578 MHS, because the MHS funds its own GME programs. GME participants, 5579 except for PGY1, are permitted to use any code based on the 5580 documentation.

5581 5582

1047 8 1048 MHS Coding Guidance 1049 March 2008 1050 1051 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 1052 SCENARIOS 1053 1054 5583

5584 DoD Rule 5585 Providers who participate in a residency program for GME usually do so 5586 with the oversight of an attending or teaching provider. Licensed 5587 physicians have the full range of E&M and procedure codes available. For 5588 unlicensed physicians (typically interns or PGY1), coding is limited to 5589 lower or mid-range E&M codes and office visit procedure codes. 5590 5591 When an attending and resident are both involved in a procedure, the 5592 primary provider must be identified in the documentation. The record is 5593 coded under the primary and the other individual is assigned the role of 5594 either supervising (staff) or GME (resident). The primary provider is the 5595 individual who performs critical and key portions of the procedure.

5596 55978.6.2.1. Documentation 5598All students, including medical students, may document in the medical record; however, 5599coding cannot occur for these encounters. 5600 56018.6.2.2. Supervision Documentation 5602Documentation of supervision must be entered into the medical record by the supervising 5603practitioner or reflected in the resident progress notes or other appropriate entries in the 5604medical record (e.g., procedure reports, consultations, discharge summaries). Pathology 5605and radiology reports must be verified by a supervising practitioner. 5606 5607NOTE: Co-signatures for coding purposes are required unless the notes meets the 5608documentation standards outlined in 1 (d). 5609 5610 (1) Allowable documentation: 5611 (a) SF 600/Progress note or other entry into the medical record by the 5612 supervising practitioner, or 5613 (b) Addendum to the resident SF 600 or progress note by the supervising 5614 practitioner, or 5615 (c) Co-signature of the SF 600 or progress note or other medical record 5616 entry by the supervising practitioner, or 5617 5618 (d) Resident SF 600 or progress note or other medical record entry 5619 documenting the name of the supervising practitioner with whom the 5620 case was discussed, a summary of the discussion, and a statement of 5621 the supervising practitioner’s oversight responsibility for the 5622 assessment, diagnosis, plan for evaluation, or treatment. 5623 5624NOTE: Statements such as the following are acceptable to demonstrate the 5625supervising practitioner’s oversight responsibility. “I have seen and discussed the 1055 9 1056 MHS Coding Guidance 1057 March 2008 1058 1059 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 1060 SCENARIOS 1061 1062 5626patient with my supervising practitioner, Dr. X, and Dr. X agrees with my 5627assessment and plan.” “I have discussed the patient with my supervising 5628practitioner, Dr. X, and Dr. X agrees with my assessment and plan.” The 5629supervising practitioner of record for this patient care encounter is Dr. X. 5630 5631 (2) Allowable documentation varies by clinical setting and kind of patient 5632 encounter. In all cases, the responsible supervising practitioner must be 5633 clearly identifiable in the documentation of the patient encounter or report of 5634 reviews of patient material.

1063 10 1064 MHS Coding Guidance 1065 March 2008 1066 1067 INPATIENT PROFESSIONAL SERVICES 1068 1069 5635INPATIENT PROFESSIONAL SERVICES 5636 56379.1. Background 5638The MHS captures inpatient workload with professional and institutional data. All 5639SADRs generated have a flag that indicates if the patient is inpatient or outpatient. The 5640flag can be used to identify all inpatient professional services. 5641 56429.2. Definitions 5643 56449.2.1. Attending Service 5645Is the medical or surgical service to which the patient is officially admitted via admission 5646or transfer orders. 5647 56489.2.2. House Staff 5649Medical students, interns (PGY1), and residents working under approved GME program 5650guidelines. 5651 56529.2.3. Diagnosis 5653The documentation records the progression of the workup and treatments leading to the 5654final (principal) diagnosis. The coding will reflect what is addressed each day; except for 5655the discharge day when non-surgical admissions coding reflects the discharge diagnoses. 5656Post-operative inpatient professional services will be coded with the appropriate aftercare 5657code with the 99024 CPT. 5658 56599.2.4. Inpatient Consult 5660A consult resulting from a request by the attending physician or provider to a physician 5661or provider from another service to evaluate or give advice and initiate diagnostic or 5662therapeutic services to an inpatient remaining under the care of the attending physician or 5663provider. There is only one inpatient consult code per service per admission. Follow-up 5664inpatient consults from that service are coded with subsequent E&M hospital day codes. 5665 56669.2.5. Institutional Services 5667Healthcare services provided by interns, residents, fellows, technicians, and some physician 5668extenders and non-privileged providers. It includes resources used or consumed during a 5669patient’s encounter with the healthcare system (e.g., equipment, facilities, utilities, and sup- 5670plies) including cardiac care units and intensive care units. 5671 56729.2.6. Interservice Transfers 5673If an inpatient is transferred from one clinical service to another for care and the transfer is 5674noted in CHCS, an inpatient SADR may be generated for both the losing and gaining clini- 5675cal services for that day. 5676 56779.2.7. Professional Services 5678Healthcare services provided directly to the patient by a privileged provider or GME person- 5679nel with appropriate documentation. This excludes ancillary services. 1070 9-1 1071 MHS Coding Guidance 1072 March 2008 1073 1074 INPATIENT PROFESSIONAL SERVICES 1075 1076 5680 56819.2.8. Rounds (RNDS) 5682An appointment type in DoD information systems (CHCS/AHLTA) is designed to capture 5683professional services delivered in the inpatient environment by the service of the attending 5684provider of record. 5685 56869.2.9. Business Rules 5687 56889.2.9.1. Institutional Service or Cost 5689Inpatient services provided by technicians, allied health providers, some physician 5690extenders, and non-privileged providers are counted as a part of institutional service/cost 5691and will not produce an inpatient professional service round in CHCS. 5692 5693Professional Services Scenarios for Inpatient Encounters 5694 GYN Example: Patient with menorrhagia is admitted to GYN for planned hysterectomy. Hysterectomy was performed the day of admission. It was determined that uterine fibroids were the cause of menorrhagia. 5695 ICD-9 E/M CPT Responsible Planned Clinic admission Day 1 Uterine fibroids N/A Hysterectomy GYN w/out Day 2 Aftercare N/A 99024 GYN complicatio Day 3 Aftercare N/A 99024 GYN n Discharge Aftercare N/A 99024 GYN 5696 Family Practice Transfer of Care to General Surgery Example: Patient was admitted to family practice with abdominal pain. General surgery consulted on day 3 of admission and determined a diagnosis of appendicitis. Care was transferred to general surgery. On day 3, an appendectomy was performed. General surgery consulted prior to transfer of care so the consult with -57 modifier is entered in the B MEPRS for general surgery since it was not the attending practice at the time. 5697 Medical ICD-9 E&M CPT Responsible condition Clinic w/global Day 1 Abdominal 99221–99223 ~~ Family Practice event Pain Day 2 Abdominal 99231–99233 ~~ Family Practice Pain Day 3 Appendicitis 99251–99255- Appendectomy General Surgery 57 Discharge Aftercare N/A 99024 General Surgery 5698 5699 1077 9-2 1078 MHS Coding Guidance 1079 March 2008 1080 1081 INPATIENT PROFESSIONAL SERVICES 1082 1083 5700OB Care Example: 5701Patient admitted for planned c-section. There were no complications during delivery or 5702admission. 5703 ICD-9 E&M CPT Responsible Clinic OB with DAY 1 Delivery codes N/A 5XXXX OB planned DAY 2 Post partum aftercare N/A 99024 OB C- DAY 3 Post partum aftercare N/A 99024 OB section N/A Discharge Post partum aftercare 99024 OB 5704 5705OB Care Example: 5706Patient admitted in labor. Baby was delivered the following day. There were no 5707complications during delivery or during admission. 5708 Responsible ICD-9 E&M CPT Clinic OB with DAY 1 Pregnancy N/A 0502F OB normal Delivery N/A delivery DAY 2 codes 59XXX OB Post partum N/A DAY 3 aftercare 99024 OB Post partum N/A Discharge aftercare 99024 OB 5709 5710Surgery Example: 5711Orthopedist consulted in emergency room on patient and decided there that surgery 5712should be performed. Patient was then admitted to Ortho for reduction of fracture. 5713 Responsible ICD-9 E&M CPT Clinic Fracture code w/ 99241- Reduction of Traumati Day 1 E code 99245–57 Fracture Ortho c Day 2 Aftercare N/A 99024 Ortho Fracture Day 3 Aftercare N/A 99024 Ortho Discharge Aftercare N/A 99024 Ortho 5714 5715Illness With No Complication Example: 5716Patient admitted from clinic with a diagnosis of gastritis. No surgical procedure was 5717performed during this stay. 5718 ICD-9 E&M CPT Responsible Clinic Admission Gastritis 99221–99223 ~~ Gastro Gastritis DAY 2 Gastritis 99231–99233 ~~ Gastro DAY 3 Gastritis 99231–99233 ~~ Gastro Discharge Gastritis 99238–99239 ~~ Gastro 5719 1084 9-3 1085 MHS Coding Guidance 1086 March 2008 1087 1088 INPATIENT PROFESSIONAL SERVICES 1089 1090 57209.2.9.2. Ambulatory Data Module (ADM/AHLTA/P-GUI). 5721Inpatient professional services rely on accurately capturing inpatient professional services 5722(diagnosis, procedures, etc.). 5723 57249.2.9.3. ADT Module 5725Inpatient professional services rely on appropriate use of the ADT Module. The correct 5726specialty service is designated by the MEPRS code. The attending physician’s name and 5727MEPRS code must be associated with the patient to accurately identify and allocate both 5728professional and institutional services and costs. This is especially important when 5729patients are transferred from one service to another. 5730 57319.2.9.4. MTFs with GME Program 5732MTFs that operate a GME program are particularly affected by this effort. For example, 5733MTF medical staff bylaws typically permit the attending (teaching) physician to place 5734documentation in the inpatient record once every three days. If the house staff or 5735attending work is to be captured using the rounds (RNDS) process, the attending provider 5736is required to provide more frequent and detailed documentation. Residents will 5737document the involvement of the staff attending provider’s management of the patient. 5738The documentation requirements will mirror those outlined in section 8.6. Residents may 5739be included as secondary provider on the rounds encounter. 5740 57419.2.9.5. Inpatient Professional Services 5742These will capture surgical services (see surgical services guidelines 9.4). 5743 57449.2.9.6 Ancillary Services 5745For the purposes of the MHS and these guidelines, ancillary services include radiology, lab- 5746oratory, pharmacy, and anesthesiology. These are not coded in rounds. 5747 57489.3 Inpatient Professional Services Data Capture 5749There are two methods for capturing this workload in ADM/AHLTA/P-GUI. 5750 57519.3.1 Auto Generation 5752The RNDS appointment type will automatically be generated upon admission and each 5753night at the census hour in the A MEPRS code of the inpatient service to which the 5754patient is admitted. (Example: A nephrologist admits a patient to internal medicine. The 5755MEPRS code will be AAA based on the service to which the patient is admitted; ADT 5756determines both the attending provider and the service. 5757 5758 Example: When a surgical consult is performed on an internal medicine patient 5759 who is subsequently transferred to the surgical service on the same day, the 5760 surgeon cannot get credit for the consultation and the RNDS on the same patient 5761 on the same day. 5762 5763 5764 1091 9-4 1092 MHS Coding Guidance 1093 March 2008 1094 1095 INPATIENT PROFESSIONAL SERVICES 1096 1097 57659.3.1.1 Default to Admitting Provider 5766If the attending provider field is not filled in, the default will be the admitting provider. 5767In a GME program, this is extremely important since the ambulatory data record- 5768generated IBWA round will default to the house staff, if the house staff is listed as 5769admitting provider. Per MHS policy, house staff do not have admitting privileges. If a 5770house staff officer receives an inpatient RNDS, the record needs to be redirected to the 5771attending provider and the ADT module must be updated appropriately. 57729.3.1.2. Appointment Status Default to Kept 5773CHCS automatically sets the appointment status to kept. This will generate an encounter 5774to be completed by the physician/provider. 5775 57769.3.2. Manual Creation 5777Use the RNDS Appointment Processing option to create new RNDS appointments. There 5778are two common reasons for creating a RNDS manually. 5779 5780 1. Interservice transfers at the same facility: When a transfer is not precipitated by a 5781 consult, or the consult was done on a day preceding the transfer, a RNDS 5782 encounter will be initiated using the manual creation feature in DoD systems. 5783 2. Transfer precipitated by the consult module on the same day. Instead of collecting 5784 the inpatient consult in the B MEPRS, use the Data Entry Menu/Rounds 5785 Appointment Processing to generate a RNDS visit in the A MEPRS. 5786 5787NOTE: The inpatient admission E&M is collected by the admitting clinical 5788service; an E&M is not collected in the clinic (or B MEPRS). The workload 5789for an inpatient consult that results in the transfer to a new service is 5790collected in the RNDS E&M for the new service for that day. 5791 57929.3.2.1. Inter-service Transfer at Same Facility Without Referral Initiated in the 5793Consult Module. 5794When an inpatient is transferred from one clinical service to another for care and the 5795transfer is noted in CHCS, an inpatient E&M may be generated for both the losing and 5796the gaining clinical service for that day. 5797 5798NOTE: The gaining clinical service will have to manually generate a new 5799encounter. The E&M will be based on the rounds documentation for that service 5800for that day. 5801 5802 Example: A patient changes services (e.g., a surgical patient with a post- 5803 surgical embolism is transferred to internal medicine). One E&M may be 5804 coded in the initial service (surgery) and one E&M may be coded in the new 5805 service for that day (internal medicine). 5806 5807 Example: When a patient is transferred from service A to service B and the 5808 attending on service B sees the patient and had completed an inpatient consult

1098 9-5 1099 MHS Coding Guidance 1100 March 2008 1101 1102 INPATIENT PROFESSIONAL SERVICES 1103 1104 5809 earlier that day, an RNDS record for the attending on service B will need to be 5810 manually generated and completed. 5811 58129.3.2.2. Recording a Procedure by Another Provider at the Same Clinical Service 5813 5814 Example: Dr. A makes rounds on patient X in the morning. Dr. A documents 5815 sufficiently for E&M code 99232 for the rounds with appropriate diagnoses.. 5816 Dr. B (same clinic service, covering for Dr. A) is called to see patient X that 5817 same calendar day. Dr. B documents patient’s fever, headache, and stiff neck 5818 and wants to rule out meningitis. Dr. B performs a lumbar puncture. Additional 5819 diagnosis codes would be added to Dr A’s ADM RNDS encounter. Enter Dr. B 5820 as an additional provider on Dr. A’s ADM record for the total E&M services. 5821 58229.3.2.3. A separate RNDS encounter would be created for Dr B with diagnosis codes for 5823fever, headache and stiff neck. These diagnosis codes support the medical necessity for 5824the procedure (lumbar puncture). The lumbar puncture code (62270) would be coded on 5825Dr B’s ambulatory data record. Dr B’s E&M was included in Dr A’s SADR. 58269.3.3. RNDS Record Completion 5827Complete the RNDS encounter based on the patient interaction and the documentation in 5828the inpatient record. The physician or provider is responsible for documenting all patient 5829encounters in the medical record in accordance with hospital and Service policies. Codes 5830will be assigned based on documentation. 5831 58329.3.3.1. Dates for RNDS Documentation 5833RNDS encounters will be completed for the dates the attending physician sees and 5834documents the encounter with the patient. If house staff sees the patient and the attending 5835provider is not physically present during the portion of the service that determines the 5836level of service and the attending does not document the key components of those 5837services, no RNDS encounter will be completed. The RNDS appointment for that date 5838should be cancelled by the physician or provider (or by the coder upon completion of the 5839inpatient stay), although it will automatically disappear after 30 days. Once cancelled or 5840after 30 days, the RNDS appointment cannot be re-created. 5841 5842NOTE: Even though the rounds appointment is canceled, patients may appear on 5843other reports as “kept” appointments. 5844 58459.3.4. E&M Coding 5846 58479.3.4.1. Services Recorded Once Daily 5848E&M services may only be recorded once per patient per clinical specialty day. The 5849correct codes are based on the sum of the documentation of all E&M services. 5850 5851NOTE: If the admission E&M is not documented within 24 hours by the 5852attending, then only the E&M code for a subsequent day of care can be used. 5853Once the initial hospital care visit is completed and fully documented, only 1105 9-6 1106 MHS Coding Guidance 1107 March 2008 1108 1109 INPATIENT PROFESSIONAL SERVICES 1110 1111 5854two of the three components for an E&M are required to be documented on 5855subsequent visits. Multiple E&M codes can be reported in a cost center but 5856they must all be recorded on one RNDS encounter. Generally, one E&M 5857code is sufficient. 5858 58599.3.4.2. Coding for Multiple Providers 5860When multiple providers from the same clinical specialty cover for the attending 5861provider, and the attending provider does not see the patient at all that day, the E&M 5862services will be coded under the name of the last provider who documents services on 5863that calendar day. This will require the default provider on the ADM to be changed to the 5864last provider of the day. All other providers may be listed as additional providers on the 5865encounter record. 5866 58679.3.4.3. Providers Covering for Attendings 5868Providers covering for the attending are considered to be in the same specialty as the 5869attending, even if the provider is from a different specialty. For example, if it is an 5870internal medicine patient, then it is internal medicine work, even if the provider covering 5871is a family practice provider. 5872 58739.3.4.4. Inter-Service Transfer. 5874When an inpatient is transferred from one clinical specialty to another for care, and the 5875transfer is noted in CHCS, an inpatient ambulatory data record may be generated for both 5876the losing and gaining clinical specialty for that day. NOTE: The gaining clinical 5877specialty will have to manually generate a new RNDS encounter if the patient is not 5878transferred through a consult. 5879 5880 Example: A patient who has taken an overdose as a suicide attempt is admitted 5881 to the internal medicine service. The internist requests a psychiatry consult. 5882 The psychiatrist sees the patient and recommends the patient be transferred to 5883 the psychiatry service when medically stable. The next day, the patient is 5884 deemed medically stable and the transfer occurs. 5885 58869.3.4.5. Transfer on Day of Consult 5887If the patient is transferred to a new specialty on the day of the consult, no RNDS 5888appointment is completed. Professional services are recorded through the inpatient 5889consult process and in this example would be accrued to the Psychiatry B MEPRS code. 5890 58919.4. Surgical Services 5892 58939.4.1. Elective Surgery 5894When elective/non-elective surgery is determined to be necessary, assign appropriate 5895E&M code with modifier -57 in addition to any surgical procedure codes performed by 5896the same provider. 5897 5898 1112 9-7 1113 MHS Coding Guidance 1114 March 2008 1115 1116 INPATIENT PROFESSIONAL SERVICES 1117 1118 58999.4.2. Surgery More Than Two Days After Admission 5900If surgery is not the day of or the day after admission, use inpatient hospital care E&M 5901codes. Review rules for modifiers if care involves a separately identifiable E&M service 5902on the day of procedure (-25) or an unrelated E&M service during the post-op period (- 590324). 5904 59059.4.3. Assigning CPT Codes 5906Assign CPT codes for any operating room or bedside procedures. 5907 59089.4.4. Post-Surgical Codes 5909Assign code 99024 for routine postoperative follow-up visits. 5910 59119.4.5. Surgical Specialty 5912Following are scenarios that surgical specialists may encounter. The following codes are 5913reported by surgical specialists: 5914 5915 SCENARIO E&M PROCEDURE 1. Elective surgical admission: Scheduled N/A 27447 total knee replacement 2. Non-elective surgical admission: 9922_-57 44950 Patient presents to ER with abdominal pain; admitted for appendectomy 3. Medical admission for pneumonia; If applicable, E&M code with 33910 patient develops pulmonary embolism and modifier -57 if decision for requires embolectomy with surgery is made that day or cardiopulmonary bypass within 24 hours of surgery 5916 59179.5. Inpatient Consults 5918 59199.5.1. Outpatient Appointment Type 5920Follow current procedures for capturing consults to inpatients, using the outpatient 5921appointment type walk-in. When prompted, “Is this clinic visit related to the inpatient 5922stay?” answer No. This will ensure credit is given to the appropriate B MEPRS code for 5923services rendered. 5924 5925Inpatient consults are collected using the appropriate E&M code along with the 5926appropriate diagnoses and procedure codes. Example: Dr Orthopedics, an orthopedic 5927surgeon, requests a pulmonary consult on a high-risk surgical patient. In this case, Dr. 5928Pulmonary did not recommend the patient be transferred to his service. The inpatient 5929consult performed by Dr. Pulmonary, the consulting physician, will be entered in CHCS 5930under the B MEPRS code along with the appropriate diagnosis and procedures. 5931 59329.5.2. Non-Attending Inpatient Professional Service 5933Use codes 99251–99255 when a physician provides an initial opinion or gives advice on 5934the evaluation or management of a specific problem at the request of another physician. 5935The consultant may start diagnostic or therapeutic services. A written report must be sent 1119 9-8 1120 MHS Coding Guidance 1121 March 2008 1122 1123 INPATIENT PROFESSIONAL SERVICES 1124 1125 5936to the requesting physician to be placed in the inpatient medical record. The 5937documentation required for the consultation is the request for a consult, the need for the 5938consultation, the consultant’s opinion, and any services ordered or performed. A code 5939from the initial inpatient consult code series (99251–99255) may only be used once by a 5940consultant during a hospitalization. 5941 59429.6. Subsequent Hospital Care 5943Use the 99231–99233, 99294, 99296, 99298–99299 codes when an initial consult is 5944completed and the consultant assumes some (both attending and consultant responsible 5945for different aspects of care) or all (patient transferred to consultant) inpatient care. 5946 5947 59489.6.1. Same Specialty: Additional Provider 5949A request for a consult from a physician or provider in the same specialty would be listed 5950as an additional provider on the attending’s inpatient E&M encounter. 5951 5952 Example: An internist seeing another internist’s patient would be listed as the 5953 additional provider. 5954 5955 Example: A cardiologist seeing an internal medicine patient will generate a 5956 separate inpatient consultation (B MEPRS). The document will be maintained 5957 in the inpatient record and not the clinic. 5958 59599.7. Observation Status 5960This is an outpatient status. Patients may not be discharged from inpatient status to 5961observation status. Patients may be admitted directly from observation. Once admitted, 5962all E&M services, both the observation and inpatient, for a specific condition provided 5963that calendar day (for clinic or observation status) shall be collected in the E&M code for 5964inpatient services. 5965 59669.7.1. Inpatient Record 5967All professional services given to the patient are documented in the inpatient record. 5968Ambulatory clinic services for the inpatient are also recorded in the inpatient record. 5969 59709.8. Newborn Early Hearing Detection and Intervention (EHDI) 5971 59729.8.1. EHDI while the newborn is in the hospital should be documented in the RNDS if 5973done by the attending provider. 5974 5975 5976 5977 5978 5979 5980 NEWBORN EARLY HEARING DETECTION AND INTERVENTION 1126 9-9 1127 MHS Coding Guidance 1128 March 2008 1129 1130 INPATIENT PROFESSIONAL SERVICES 1131 1132 Encounter Type ICD-9-CM CPT CPT Diagnosis E&M Procedure Codes Codes Codes Newborn hearing screening with no V72.1** If applicable, 92586 or abnormalities performed in newborn 992XX* 92587 nursery or neonatal ICU (Inpatient rounds SADR) 5981 5982If a newborn hearing test is performed by the pediatrician, then the service is reported as 5983a "Rounds" encounters. 5984 5985If a newborn hearing test is performed by the audiologist (a consult), then report to the 5986appropriate "B" MEPRS. 5987

1133 9-10 1134 MHS Coding Guidance 1135 March 2008