Military Health System Coding Guidance:

Professional Services and Specialty Coding Guidelines

Version 3.6

Unified Biostatistical Utility

Effective date for this guide version: 1 March 2013 Effective date for audit use: 1 April 2013 1 CHAPTER 1 OVERVIEW ...... 1-1 2 1.1. PURPOSE ...... 1-1 3 1.2. DIAGNOSTIC CODING ...... 1-2 4 1.3. PROCEDURAL CODING ...... 1-2 5 1.4. EVALUATION AND MANAGEMENT (E&M) CODING ...... 1-3 6 1.5. CODING TABLE UPDATES ...... 1-3 7 1.6. LEGAL REFERENCE ...... 1-4 8 1.7. GETTING HELP ON CODING QUESTIONS ...... 1-4 9 1.8. USE OF THE TERM CAPER ...... 1-4 10 CHAPTER 2 DIAGNOSTIC CODING ...... 2-1 11 2.1. CODE TAXONOMY (STRUCTURE) ...... 2-1 12 2.2. SPECIFIC DIAGNOSTIC GUIDELINES ...... 2-2 13 CHAPTER 3 EVALUATION AND MANAGEMENT (E&M) CODING ...... 3-1 14 3.1. EVALUATION AND MANAGEMENT CODING – 99201-99499 ...... 3-1 15 3.2. OFFICE OUTPATIENT SERVICES, 99201–99215 ...... 3-6 16 3.3. HOSPITAL OBSERVATION SERVICES ...... 3-6 17 3.4. EMERGENCY DEPARTMENT ...... 3-6 18 3.5.CONSULTATION ...... ERROR! BOOKMARK NOT DEFINED. 19 3.6. MEDICAL EVALUATION BOARDS (MEB) ...... ERROR! BOOKMARK NOT DEFINED. 20 3.7. TOBACCO CESSATION COUNSELING ...... ERROR! BOOKMARK NOT DEFINED. 21 CHAPTER 4 PATIENT TO PROVIDER COMMUNICATION VIA TELEPHONE SERVICES AND 22 ELECTRONIC MEDIA ...... 4-1 23 4.1. TELEPHONE AND ONLINE (EMAIL) ENCOUNTERS ...... ERROR! BOOKMARK NOT DEFINED. 24 4.2. TELEHEALTH SERVICES ...... ERROR! BOOKMARK NOT DEFINED. 25 4.3. E&M CODING……………………………………………………………………………………………….…4-1 26 4.4. DIAGNOSIS CODING ...... ERROR! BOOKMARK NOT DEFINED. 27 4.5. PROCEDURAL CODING…………………………………………………………………………….…….4-2 28 4.6. MODIFIERS……………………………………………………………………………………………..….4-2 29 30 CHAPTER 5 PROCEDURAL CODING ...... 5-1 31 5.1. PROCEDURES ...... 5-1 32 5.2. MODIFIERS ...... 5-2 33 5.3. BUNDLED PROCEDURES AND GLOBAL PROCEDURES ...... ERROR! BOOKMARK NOT DEFINED. 34 5.4. CLINICAL PHARMACISTS ...... 5-4 35 5.5. CHAPLAINS AND PASTORAL COUNSELOR ...... 5-5 36 5.6. ELECTROCARDIOGRAM (ECG OR EKG) SERVICES 93000–93042 ...... 5-5 37 5.7. LASER TATTOO AND HAIR REMOVAL ...... 5-6 38 5.8. ON CALL ...... 5-6 39 5.9. RECORDS REVIEW ...... 5-6 40 5.10. INJECTIONS AND INFUSIONS ...... 5-6 41 5.11. CAST OR SPLINT APPLICATION ...... 5-7 42 CHAPTER 6 SPECIALTY CODING...... 6-1 43 6.1. ANESTHESIA ...... 6-1 44 6.2. AUDIOLOGY ...... 6-7 45 6.3. CHIROPRACTIC SERVICES ...... 6-12 46 6.4. DIALYSIS ...... 6-14 47 6.5. END STAGE RENAL DISEASE SERVICES (ESRD) (90951–90970) ...... 6-16 48 6.6. FLIGHT MEDICINE SERVICES ...... 6-19 49 6.7. GYNECOLOGY ...... 6-23 50 6.8. MENTAL HEALTH ...... 6-26 51 6.9. NUTRITIONAL MEDICINE ENCOUNTERS ...... 6-30 52 6.10. OBSTETRICS SERVICES ...... 6-37 53 6.11. OCCUPATIONAL THERAPY (OT) ...... 6-49 54 6.12. OPHTHALMOLOGY/OPTOMETRY ...... 6-53 55 6.13. PHYSICAL THERAPY (PT)—CODING FOR PHYSICAL THERAPIST OR TECHNICIAN ...... 6-62 56 6.14. PREVENTIVE MEDICINE SERVICES ...... 6-66 57 6.15. RADIATION ONCOLOGY SERVICES ...... 6-72 58 6.16. RADIOLOGY, INTERVENTIONAL ...... 6-76 59 6.17. HEALTH EXAMS OF DEFINED SUBPOPULATIONS, V 70.5_X ...... 6-78 60 6.18. RECONSTRUCTIVE AND COSMETIC SURGERY ...... 6-82 61 6.19. SOCIAL WORK AND FAMILY ADVOCACY SERVICES ...... 6-84 62 6.20. SUBSTANCE ABUSE PROGRAM SERVICES...... 6-88 63 CHAPTER 7 CODING AMBULATORY PROCEDURE VISIT (APV) ENCOUNTERS ...... 7-1 64 7.1. DEFINITIONS ...... 7-1 65 7.2. CODING PRE- AND POST-PROCEDURE APV ENCOUNTERS ...... 7-2 66 7.3. PATIENT ADMITTED FROM APV ...... 7-2 67 7.4. CONSULTATION FOR APV ...... 7-2 68 7.5. ASSISTANT AT SURGERY ...... 7-3 69 7.6. CODE 99199: INSTITUTIONAL COMPONENT OF AN APV ...... 7-3 70 7.7. CANCELLED APVS...... 7-3 71 7.8. PROCEDURES NOT PERFORMED IN THE APU ...... 7-4 72 CHAPTER 8 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL 73 SCENARIOS ...... 8-1 74 8.1. USE OF THE MAIL FUNCTION ...... 8-1 75 8.2. FOR CLINIC USE ONLY, AN ADM FUNCTION ...... 8-1 76 8.3. ADDITIONAL PROVIDERS ...... 8-1 77 8.4. TELEHEALTH SERVICES ...... ERROR! BOOKMARK NOT DEFINED. 78 8.5. REMOTE PROFESSIONAL SERVICES ...... ERROR! BOOKMARK NOT DEFINED. 79 8.6. RESIDENT/GME SERVICES ...... 8-1 80 CHAPTER 9 PROFESSIONAL CODING FOR INPATIENT PROFESSIONAL SERVICES ...... 9-1 81 9.1. BACKGROUND...... 9-1 82 9.2. DEFINITIONS ...... 9-1 83 9.3 INPATIENT PROFESSIONAL SERVICES DATA CAPTURE ...... 9-3 84 9.4. SURGICAL SERVICES ...... 9-7 85 9.5. INPATIENT CONSULTS ...... 9-9 86 9.6. SUBSEQUENT HOSPITAL CARE ...... 9-10 87 9.7. OBSERVATION STATUS ...... 9-10 88 9.8. NEWBORN EARLY HEARING DETECTION AND INTERVENTION (EHDI) ...... 9-10 89 90 Appendices: www.tricare.mil/ocfo/bea/ubu/coding_guidelines.cfm 91 A. Acronyms 92 B. Independent Duty Corpsmen/ Independent Duty Medical Technician (IDC/IDMT) 93 C. Modifiers 94 D. DoD Extender Codes 95 E. Case Management Services 96 F. Coding Audits 97 G. Traumatic Brain Injury (TBI) 98 H. Coding for Observation Please note the following

A thorough search of the document may be required to determine location of specific coding rules. Utilize the find feature (Ctrl+F) to expedite locating specific references. 99 100 101 COPYRIGHT 102 103 The American Medical Association (AMA) copyrights Current Procedural Technology (CPT). All 104 rights reserved. No fee schedules, basic units, relative values or related listings are included in CPT. 105 AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes 106 no liability for data contained or not contained herein. 107 108 U.S. Government Rights 109 This product includes CPT, which is commercial technical data, computer databases or commercial 110 computer software or computer software documentation, as applicable, developed exclusively at 111 private expense by the AMA, 515 North State Street, Chicago, IL, 60610. U.S. Government rights 112 to use, modify, reproduce, release, perform, display, or disclose these technical data and/or 113 computer databases and/or computer software and/or computer software documentation are subject 114 to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and to the restrictions of 115 DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable, for U.S. 116 Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 117 1987) and to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 118 (June 1987), as applicable, and any applicable agency FAR supplements, for non-Department of 119 Defense federal procurements.

OVERVIEW

120 Chapter 1 OVERVIEW 121 122 This document provides guidance for Department of Defense (DOD) coding for professional 123 services. MHS systems capture professional encounters in both outpatient and inpatient settings. 124 125 Updating Guidelines—MHS Coding Guidance is reviewed and updated annually, or more 126 frequently as needed, by the Unified Biostatistical Utility (UBU) Working Group. To suggest 127 updates, contact the Service point of contact listed in section 1.7. 128 129 Updates to coding guidance are on the UBU website, at the URL: 130 http://www.tricare.mil/ocfo/bea/ubu/coding_guidelines.cfm 131 132 Guidelines effective for MTF’s and External Audits, as indicated on title sheet of MHS Coding 133 Guidance: Professional Services and Specialty Coding Guidelines. 134 135 When delays to code table updates/system limitations occur, use applicable sections of the most 136 current version of MHS coding guidelines until limitations are resolved. 137 138 1.1. Purpose 139 In the simplest sense, coding is the numeric or alphanumeric representation of written descriptions. 140 It allows standardized, efficient data gathering for a variety of purposes. This document provides 141 MHS-specific guidance for coding ambulatory and professional service encounters. These 142 guidelines are derived from the following source documents, but take precedence over them: 143 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM); 144 Current Procedural Terminology (CPT), 4th Edition; 145 Centers for Medicare and Medicaid Services (CMS) Documentation Guidelines for 146 Evaluation and Management (E&M) Services; 147 Healthcare Common Procedure Coding System (HCPCS); 148 The American Hospital Association (AHA) Coding Clinic; 149 The American Medical Association (AMA) CPT Assistant; 150 The Coding Clinic for HCPCS. 151 152 This document is not intended to be an all-inclusive reference for MHS coding guidance. In the 153 absence of specific MHS coding guidance, refer to the appropriate industry standard coding 154 conventions. For specific workload issues not covered in this document, refer to service specific 155 workload guidance. 156 157 Coding serves a variety of purposes. While it can provide a detailed clinical picture of a patient 158 population, it can also be useful in overseeing population health, anticipating demand, assessing 159 quality outcomes and standards of care, managing business activities, and receiving reimbursements 160 for services. 161 162 When coding for DoD healthcare services, substitute the term privileged providers where the CPT 163 manual description uses the term physicians. Privileges are granted by individual military treatment 164 facilities (MTFs). Common examples of privileged providers are licensed physicians, advanced

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165 practice nurses, physician assistants, Independent Duty Corpsman (IDC), oral surgeons, 166 optometrists, residents (other than post-graduate year one [PGY-1]), and physical and occupational 167 therapists. 168 169 1.1.1 Other Qualified Healthcare Providers 170 An “other qualified healthcare professional,” as described in the Instructions for Use section of 171 the CPT® manual, “is an individual who is qualified by education, training, licensure/regulation 172 (when applicable), and faculty privileging (when applicable) who performs a professional service 173 within his/her scope of practice and independently reports that professional service. A clinical 174 staff member is a person who works under the supervision of a physician or other qualified 175 healthcare professional and who is allowed by law, regulation, and facility policy to perform or 176 assist in the performance of a specified professional service, but who does not individually report 177 that professional service.” When coding for DoD healthcare services, other qualified healthcare 178 professionals may report CPT codes, except as restricted by CPT descriptions or MHS Coding 179 Guidelines. For example, an MHS restriction can be found in 6.8.3.3. 180 181 1.2. Diagnostic Coding 182 Diagnostic coding began as a means of gathering statistical information to track mortality and 183 morbidity. Subsequent changes to add clinical information resulted in a coding structure that 184 describes the clinical picture of a patient, as well as non-medical reasons for seeking care and causes 185 of injury. Diagnosis codes are listed in the International Classification of Diseases, 9th revision, 186 Clinical Modifications or, ICD-9-CM. 187 188 1.3. Procedural Coding 189 Healthcare Common Procedure Coding System (HCPCS) codes are grouped in two levels: 190 191 Level I HCPCS are commonly referred to as Current Procedural Terminology (CPT). They 192 form the major portion of the HCPCS coding system, covering most services and procedures. 193 CPT codes supersede Level II codes when the verbiage is identical. 194 195 Level II codes supersede level I codes for similar encounters, when the verbiage of the level 196 II code is more specific as supported by the documentation. HCPCS includes evaluation and 197 management services, other procedures, supplies, materials, injectables, and dental codes. 198 Having a code number listed in a specific section of HCPCS does not usually restrict its use 199 to a specific profession or specialty. 200 201 Other Specifics Regarding HCPCS Level II Codes 202 Coding supplies/durable medical supplies/equipment. Code supplies/durable medical 203 supplies/equipment if specifically directed to do so in this document. Otherwise, do not code 204 clinic supplies or durable medical supplies/equipment funded by a different clinic or 205 organization. To code durable medical supply/equipment, it must meet all of the following. 206 207 a. Can withstand repeated use (e.g., not consumed in use such as a syringe, suction bulb or suture 208 removal kit); 209 b. Is primarily and customarily used to serve a medical purpose;

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210 c. Generally is not useful to a person in the absence of an illness or injury; 211 d. Is appropriate for use in the home; 212 e. There is a specific HCPCS code for the item (e.g., not otherwise specified [NOS] codes should 213 be used only when the value of the information collected exceeds the resources to 214 collect/process/store/analyze/use the data); and 215 f. There is no anticipation of the item being returned. For instance, a TENS unit loaned to a 216 patient to see if the TENS unit will work for that patient would not be coded as the TENS unit 217 will be returned. 218 219 Pharmaceuticals and Injectables HCPCS Level II codes will only be used when the 220 pharmaceutical or injectable is paid for directly from the clinic’s funds, and is not a routine 221 supply item. If a drug is issued by the pharmacy to the patient, and the patient brings the drug to 222 the clinic for administration, the drug will not be coded, as the pharmacy was the service issuing 223 the drug. Inpatient ward stock will not be coded, as it is part of the institutional component and 224 part of the diagnosis-related group (DRG). 225 226 C Codes These codes are commonly referred to as pass-through codes. They are usually only 227 available for a few years at which time the item is included in a procedure or no longer used. 228 These tend to be for high-cost items. The item must be coded if it is paid for out of clinic funds. 229 As with other drugs, do not code it if the pharmacy issued it to the patient. Frequently, coders 230 will need to query the provider or the clinic supply custodian on the method of acquisition. 231 232 1.3.1. Performance Quality Reporting System (PQRS) 233 Performance Quality Reporting System (PQRI) codes are not required to be reported within the 234 MHS unless otherwise required within this document. 235 236 1.4. Evaluation and Management (E&M) Coding 237 In the DoD, the term evaluation and management codes refers to the CPT codes inclusive of 238 99201–99499. These codes describe the non-procedural portion of services furnished during a 239 healthcare encounter. They classify services provided by a healthcare provider and indicate the 240 level of service. E&M codes are a subset of CPT codes (Level I HCPCS), yet are referred to as an 241 E&M instead of as a CPT code to distinguish between E&M services and procedural coding. See 242 Section 3 for details about E&M coding. 243 244 1.5. Coding Table Updates 245 ICD-9-CM diagnosis codes are updated annually in the Composite Health Care System (CHCS). 246 These updates, which usually affect a portion of the codes, should be effective on or about 1 247 October of each year. Implementation by DoD MTFs is tied to release and distribution of CHCS 248 file updates. Actual activation at a specific CHCS host and its client sites requires coordination 249 among coders and CHCS administrators at their facilities. Mechanisms should be in place to ensure 250 record completion by fiscal year end. Corrections may be needed to complete records once the new 251 codes are available. 252 253 CPT and HCPCS codes are updated annually about 1 January. Like the ICD-9-CM codes, 254 implementation in DoD MTFs depends on a release of CHCS file updates and may therefore be

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255 later than in the private sector. There may be table updates performed as needed in addition to the 256 annual releases. Even when a table update is required, records will need to be completed within the 257 normal 3 working days for clinic encounters and observation, and fifteen days for same-day surgery, 258 and 25 days after discharge for inpatient records. Failure to have all prior year professional services 259 CAPER coding complete before the tables update may result in situations where old codes are no 260 longer available. Health Insurance Portability and Accountability Act (HIPAA) compliant billing 261 requires use of the existing CPT or HCPCS code available at the time of the clinical service. 262 263 1.6. Legal Reference 264 The medical record is the legal record of care. When there is a difference between what is coded in 265 the Ambulatory Data Module (ADM) and what is documented in the medical record, a coder may 266 change a code to more accurately reflect the documentation. When this occurs, the coder must 267 notify the provider. The provider is ultimately responsible for coding and documentation. 268 269 While the data from the CHCS record can be used to create third-party claims, the medical record 270 must support the coding in the claim. 271 272 1.7. Getting Help on Coding Questions 273 For questions on coding issues, please contact the Service Representative, as follows: 274 275 Army http://pasba3.amedd.army.mil 276 Air Force AFMOA/[email protected] or 1-800-298-0230 277 Navy https://dataquality.med.navy.mil/codinghotline/forums/login_user2.asp 278 279 These Service sites can only be accessed from specific service domains (af.mil, navy.mil, 280 army.mil) and must be CAC card enabled. 281 282 System issues: For ADM functional software and technical support, contact the MHS Help Desk. 283 284 MHS HELP DESK 285 286 CONUS 1-800-600-9332 287 OCONUS 866-637-8725 288 289 This information is also available from www.mhs-helpdesk.com. 290 291 1.8. Use of the Term CAPER 292 The Comprehensive Ambulatory Professional Encounter Record or CAPER is a subset of 293 outpatient data collected in the ambulatory data module (ADM) in the CHCS. Data collected for 294 professional services in the MHS is referred to as coding a CAPER. 295 296 The CAPER provides two electronic file transmissions. One is exported daily from ADM and 297 sent to a central MHS database. A second file is transmitted to the Third-Party Outpatient 298 Collection System (TPOCS).

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299 Chapter 2 DIAGNOSTIC CODING 300 301 ALL CODING MUST BE SUPPORTED BY THE DOCUMENTATION IN THE MEDICAL 302 RECORD. 303 304 This section provides ICD-9-CM coding guidelines for data collection in the DoD. The following 305 guidelines pertain to professional services coding, which includes outpatient clinic, observation, 306 APVs (same-day surgeries), and inpatient. 307 308 2.1. Code Taxonomy (Structure) 309 ICD-9-CM codes are 3- to 5-digit numeric and alphanumeric codes. These codes are used to 310 describe diseases, conditions, symptoms, and other reasons for seeking healthcare services. Some 311 codes are modified for special use in the DoD. The first three digits usually represent a single 312 disease entity, or a group of similar or closely related conditions. The fourth digit subcategory 313 provides more specificity on the etiology, site, or manifestation. In some cases, fourth-digit 314 subcategories have been expanded to the fifth-digit level to provide even greater specificity. 315 316 2.1.1. Factors Influencing Health Status and Contact with Health Services 317 ICD-9-CM codes beginning with the letter V are used when the patient seeks healthcare for reasons 318 other than illness or injury. Examples include a well-baby exam or a physical. See section 2.2.8 in 319 this chapter for more guidance. 320 321 2.1.2. External Causes of Injury 322 ICD-9-CM codes beginning with the letter E describe external causes of injury, poisoning and 323 adverse reactions. They are used to describe where, why, and how an injury occurred. See section 324 2.2.9 in this chapter for more guidance. 325 326 2.1.3. Not Otherwise Specified (NOS) 327 Only use NOS codes when the documentation is insufficient to use a more specific code. 328 This is synonymous with unspecified. 329 330 Example: A provider note indicates the patient has otitis media. Code 382.9, unspecified 331 otitis media, is the appropriate code if the diagnostic statement or record lacks additional 332 information, such as purulent or serous. 333 334 2.1.4. Not Elsewhere Classifiable (NEC) 335 Use NEC codes when there is no specific code in the classification system for the condition, even 336 though the diagnosis may be very specific. 337 338 Example: 008.67 Enteritis due to Enterovirus NEC (Coxsackie virus, echovirus; excludes 339 poliovirus). In this example, this code would be reported even if a specific enterovirus, such 340 as echovirus, had been identified, because ICD-9-CM does not provide a specific code for 341 echovirus.

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342 343 2.2. Specific Diagnostic Guidelines 344 The following guidelines are to be followed when reporting diagnoses. The ICD-9-CM diagnostic 345 codes are used for professional services furnished in both the inpatient and ambulatory setting. 346 ICD-9-CM procedure codes are only used for inpatient institutional MHS coding and not 347 professional services MHS coding. 348 349 2.2.1. Prioritized Diagnoses 350 The primary diagnosis is the reason for the encounter, as determined by the documentation. When a 351 diagnosis has a manifestation, co-morbid condition, or etiology, the linked codes should be 352 sequenced together whenever possible (e.g., diabetic skin ulcer of the ankle, coded with 250.8x and 353 707.13). For some cases, ICD-9-CM conventions indicate that the underlying cause should be 354 coded first, before a manifestation. In these instances, manifestations cannot be coded as a primary 355 diagnosis. 356 357 The chief complaint does not have to match the primary diagnosis. 358 359 2.2.2. Pre-Existing Conditions 360 Conditions or diseases that exist at the time of the encounter, but do not affect the current 361 encounter are not coded. Documented conditions or diseases that affect the current encounter, 362 are considered in decision making, and are treated or assessed, are coded. This guidance 363 includes outpatient professional and rounds encounters. 364 365 2.2.3. Specificity in Coding Classification 366 Specificity in coding is assigning all the available digits for a code. Diagnostic codes should be 367 assigned at the highest level of specificity. If a code has five digits, all five digits must be used. 368 369  Assign three-digit codes only if there are no four-digit codes within that code category. 370  Assign four-digit codes only if there is no fifth-digit sub-classification for that category. 371  Assign the fifth-digit sub-classification code for those categories where it exists. 372  Assign a DoD extender code if one exists (refer to the DoD Diagnosis Extender section in 373 2.2.6). 374 375 Example: A patient is seen for abdominal pain in the upper right quadrant; no specific cause 376 has been determined. The appropriate diagnostic code would be the five-digit code 789.01— 377 other symptoms involving abdomen and pelvis, right upper quadrant—as opposed to the 378 four-digit code 789.0 (other symptoms involving abdomen and pelvis, unspecified site). 379 380 2.2.4. Selection of the Most Explicit Code 381 Coding should be as explicit as the documentation permits. For instance, when the provider 382 documents acute serous OM, code 381.01 acute serous otitis media, not 382.9 unspecified OM. 383 384 2.2.4.1. Renewal/Replacement Prescription Refills 2-2 MHS Professional Services Coding Guidelines March 2013

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385 Code V68.1 is the primary diagnosis when documentation only supports a prescription refill. In 386 most cases, this is an administrative encounter. 387 388 When a patient presents to a privileged provider and any assessment is made then the condition 389 for which the assessment is being performed is your primary diagnosis and not the V code for 390 prescription refill. The prescription refill V68.1 will not be used in this scenario. 391 392 2.2.5. Unconfirmed Diagnosis 393 When a provider is not certain of a diagnosis, capture the known manifestations, signs, symptoms, 394 or abnormal test results. 395 396 Example: The diagnosis documented “rule out malignant neoplasm of the pancreas” cannot be 397 coded, as the diagnosis is unconfirmed. The documentation indicates a mass on the pancreas. 398 The terms mass and neoplasm are not synonymous. Therefore, the most appropriate code 399 would be 577.9, unspecified disease of pancreas. 400 401 Although ADM permits designation of uncertain (unconfirmed) diagnoses with a U instead of a 402 number, unconfirmed diagnoses are not traditionally coded. If a U designator is used for a 403 diagnosis in ADM, those data are only available at the local server. The U-designated diagnosis 404 cannot be the only diagnosis captured; there must be a primary diagnosis other than the U diagnosis. 405 Currently, Air Force is the only Service that permits use of a U designator in ADM. 406 407 Example: A patient comes in with chest pain, and the provider wants to rule out myocardial 408 infarction. The provider documents the specific symptom of chest pain as the primary 409 diagnosis and documents the myocardial infarction code as an unconfirmed diagnosis. The 410 provider could document the myocardial infarction code as an unconfirmed U diagnosis if 411 that Service permits the designation. 412 413 NOTE: For inpatient professional services, see Chapter 9. 414 415 2.2.6. DoD Diagnosis Extender Codes 416 A number of ICD-9-CM codes have been modified to meet the needs of the Services. These codes 417 are referred to as DoD extender codes. The one-character extender is paired with a specific ICD-9- 418 CM code to acquire a unique meaning. The DoD established extender codes to address a number of 419 specific reporting requirements, including physicals, asthma, hepatitis, abortion, bacterial disease, 420 and Gulf War-related diagnoses. If an extender has been established in accordance with specificity 421 guidelines, the root code is no longer valid for use without an extender code. See Appendix D for a 422 complete list of DoD Extender codes. Many coders annotate the DoD extender codes in their ICD- 423 9-CM books so they do not overlook them when looking up codes to develop superbills. 424 425 2.2.6.1. Acquired Absence of Body Part(s) or Organ(s) 426 For population health purposes, use V45.71 to V45.79 with the appropriate extender code to capture 427 acquired absence of body part(s) or organ(s). The extender portion of these codes is not auditable;

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428 as the codes are used for population health to exclude patients from preventive exams, such as 429 mammograms. 430 431 432 2.2.6.2. Reaction to Vascular Devices 433 Codes for infection and inflammatory reactions to vascular devices and grafts, 996.62, are located in 434 Appendix D. 435 436 2.2.6.3. Traumatic Brain Injury (TBI) 437 TBI extender codes are located in Appendix D; specific DoD guidelines for TBI coding are located 438 in Appendix G. 439 440 2.2.7. Chronic Conditions 441 When a chronic disease is treated on an ongoing basis, it may be coded as often as treatment and 442 care are provided to the patient for that condition. 443 444 Example: A patient is treated monthly with an epidural block and steroid injection for 445 chronic low back pain (724.2). The code for low back pain would be reported each time the 446 patient presented for care for this problem. 447 448 A chronic condition not addressed during the encounter that does not affect the care provided during 449 the visit should not be coded with the encounter. Remind providers that medical decision making 450 can be supported for higher levels of service if providers properly document. 451 452 Example: The same patient listed above also has hyperlipidemia. The patient is coming in 453 for chronic low back pain, so unless hyperlipidemia is a factor in the care received for low 454 back pain, it does not get coded. 455 456 2.2.7.1. Tobacco Use 457 For tobacco cessation see section 3.8. 458

459 DoD Rule 460 461 When smoking is addressed (documentation of history of, or active tobacco 462 use and referral for, or initiation of treatment) in the A&P section of the note 463 by the privileged provider, assign “tobacco use” or “history of tobacco use” 464 codes (305.1 or V15.82).

465

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466 2.2.8. V Codes—Factors Influencing Health 467 DoD extender codes have been paired with selected V codes to further specify military unique 468 services. The addition of DoD extender codes to the root code enables differentiation of the types of 469 health assessments. The V codes are used to identify circumstances (diagnoses) other than disease, 470 symptom, or injury that are the reason for an encounter, or that explain why a service or procedure 471 was furnished. V codes are used to classify a patient in the following circumstances: 472 473 When a person is not currently or acutely ill, but requires healthcare services for some purpose, such 474 as preventive education and counseling or prophylactic vaccinations. 475 476 Examples: V04.2 would be used for the child receiving a measles vaccination in a pediatric 477 clinic; V65.3 would be used for the diabetic patient who receives dietary counseling. 478 479 V04.89 would be used for Human Papilloma virus (HPV) vaccination of girls and women 9- 480 26 years old. Use procedure codes 90649 (HPV vaccine) and 90471 (administration). 481 482 When a circumstance or problem influences the patient’s current illness or injury, but is not in itself 483 a current illness or injury. 484 485 Example: A patient visits a provider’s office with a complaint of chest pain with an 486 undetermined cause; patient status is post open-heart surgery for mitral valve replacement. 487 Code 786.50 would be used to identify the chest pain, unspecified, and code V43.3 would be 488 used to identify the heart valve replaced by other means. 489 490 When a person with a known disease or injury uses the healthcare system for specific treatment of 491 that disease or injury: 492 493 Example: Encounter for occupational therapy for patient with cognitive deficits secondary to 494 an old cerebral vascular accident (CVA) would be coded V57.21, 438.0. 495 496 2.2.8.1. DoD-Unique V-Code Guidance for Flyer Status 497 The annual flight physical or aviation exam is coded using V70.5_1. Flyers returning to active 498 flight status who have an appointment to evaluate their condition should be coded using V68.09 499 (medical certificate). 500 501 2.2.8.2. DoD-Unique V-Code Guidance for Assessments, Exams, Education, and Counseling 502 DoD extender codes have been paired with selected V codes to further specify military unique 503 services. The addition of DoD extender codes to the root code enables differentiation of the 504 types of health assessments. See section 6.17. for E&M coding guidance. 505 506 V70.5_0 Armed Forces medical exam: This is the initial general accession 507 exam. For pre-enlistment, this initial qualifying exam is a “yes” test

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508 that a person meets the requirements to join the military. Excludes 509 exams covered under V70.5_8 Special Program Accession Exam. 510 511 V70.5_1 Aviation Exam: Initial qualifying and any recurring aviation exam. 512 513 V70.5_2 Periodic Health Assessments (PHA) or Prevention Assessment: 514 Includes service member PHA documented on DD2766. Also use for a 515 complete military physical exam which is not an accession, 516 occupational, separation, termination or retirement exam. 517 V70.5_3 Occupational exam: Both initial qualifying and recurring exams 518 because the individual works in a specific occupation or in support of 519 occupational medicine programs (workers’ compensation). Examples 520 include: diving, firefighter, Personal Reliability Program (PRP), 521 protection of the president, crane operator and submariner. For return 522 to duty following a non-aviation occupation-related condition, use 523 V70.5_7. 524 525 V70.5_4 Pre-Deployment Related Encounter: Encounter related to a projected 526 deployment. Could include family members experiencing a 527 condition related to the projected deployment of the sponsor or other 528 family member. Excludes V70.5_D which codes the encounter 529 documented on the DD2795. 530 531 V70.5_5 Intra-Deployment encounter: Any deployment-related encounter 532 performed while individual (active duty [AD], contractor, etc.) is 533 deployed. Could include family members experiencing a condition 534 related to the deployment of the sponsor or other family member. 535 536 V70.5_6 Post-deployment related encounter: Specifically performed because 537 an individual was deployed. Could include family members 538 experiencing a condition related to a prior deployment of the sponsor 539 or other family member. Excludes V70.5_E and V70.5_F which 540 code the encounters documented on the DD2796 and DD2900. 541 542 V70.5_7 Duty Status Determination encounter: Used for service members 543 when the primary reason for being seen is to determine the ability to 544 perform their duties. Includes re-enlistment exams determination or 545 change in status of temporary or permanent duty limitations, 546 deployment limiting conditions, temporary and permanent duty 547 retirement list (TDRL/PDRL), medical evaluation board (MEB) 548 assessments, and return to duty following pregnancy or surgery and 549 treatment. See section 3.9.2.for MEB coding. Excludes return to 550 flight/dive status (e.g., upchit) which is V68.09.

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551 552 V70.5_8 Special Program Accession Encounter: A special medical 553 examination on individuals being considered for special programs 554 prior to Service entry. Exams are usually for officer candidates 555 (Reserve Officer Training Corps [ROTC] programs, college 556 graduates, professional schools, etc.) Other examples are DoD 557 Medical Review Board exams, Health Professional School Program 558 (HPSP) exams, and supplemental exams in support of Medical 559 Examination Processing Stations. 560 561 V70.5_9 Separation/Termination/Retirement Exam: Examination performed 562 at the end of employment and for retirement or separation. 563 564 V70.5_A Health Exam of defined subpopulations: Performed on a person in a 565 specified group (refugees, prisoners, preschool children, etc.) other 566 than exams identified above. Includes examinations related to the 567 Exceptional Family Member Program (EFMP) and Overseas 568 Screening. This is not the appropriate code for sport/school 569 physicals, for such guidance see 6.14.1.2.1. 570 V70.5_B Abbreviated Separation/Termination/Retirement Exam: This code 571 would be used when a partial examination is done within a defined 572 period after a complete examination as an update. Guidance for 573 abbreviated separation, termination or retirement exam will be 574 provided by each Service. 575 576 V70.5_C Physical Readiness Test (PRT) Evaluation: Evaluation of Active 577 duty/reserve/national guard member by a provider who is privileged to 578 determine participation in Physical Fitness Assessment program (PFA) or 579 physical conditioning. 580 581 V70.5_D Pre-Deployment Assessment: Documented on DD2795. 582 583 V70.5_E Initial Post-Deployment Assessment: Documented on DD2796. 584 585 V70.5_F Post Deployment Health Reassessment (PDHRA): Documented on 586 DD2900. 587 588 V70.5_G Global War on Terrorism (GWOT)/Wounded Warriors (WW). To be used 589 if the individual is designated a Wounded Warrior. For TBI coding, See 590 Appendix G. 591 592 V70.5_H Other Exam Defined Population 593

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594 2.2.8.3. Deployment Related Assessments 595 To proactively and reactively provide healthcare related to deployments, the DoD must be able to 596 identify healthcare needs caused by deployments. Codes V70.5 4/5/6 may be used in the second, 597 third, or fourth position to indicate some aspect or the encounter is deployment related. Codes 598 V70.5_4/5/6/D/E/F are to be used as a primary diagnosis for an exam, assessment, or screening 599 encounter when the purpose of the encounter is specifically deployment related. 600 601 Codes V70.5_4/5/6/D/E/F will be used in the subsequent diagnosis positions when the primary 602 purpose of the encounter was not specifically deployment related, but “deployment related” 603 concerns were found that should be coded as additional diagnoses. 604 605 Example: An AD member who recently returned from deployment presents to the clinic for an 606 evaluation of a rash. The provider evaluates the patient and diagnoses the patient with cutaneous 607 leishmaniasi related to his recent deployment to Iraq. The primary diagnosis in this scenario is 608 085.9 (unspecified cutaneous leishmaniasis) and the secondary code would be V70.5_6. If 609 during this encounter the provider discovers that the patient has not completed his DD2976 and 610 has the patient complete it, then V70.5_E should be added as an additional diagnosis. [Note: 611 The ambulatory coding systems may not allow the use of the same code on the same record 612 (V70.5_6 vs. V70.5_E), even as an extender code. Use the codes that best defines the services 613 being provided.] 614 615 2.2.8.4. Reporting Scenarios for V70.5 Extender Codes. 616 617 PRT (V70.5_C) 618 Prior to doing Physical Readiness Testing all service members must complete a PRT screening 619 questionnaire. If all answers are “no” the member is not referred for further follow up and 620 completes the PRT. There is no medical encounter or coding. If any answers are “yes” the 621 member comes in for a medical evaluation. 622 623 1. Service Member has a known medical problem, example post ACL repair. Provider 624 does not do an exam of the Service Member. Service Member is issued a waiver from PRT. Use 625 ICD-9 code V 70.5_C as the primary diagnosis and the medical problem(s) as secondary. 626 627 2. Service Member is referred for additional assessment face to face with privileged 628 provider based upon answers on the PRT questionnaire. Provider reviews assessment and 629 determines Service Member is cleared for PRT. Use E&M 99420 and ICD-9 code V70.5_C. For 630 example, the member is referred based solely on age, but is otherwise healthy with no 631 complaints, the provider finds the member fit to complete the PRT. 632 633 3. Service Member is referred for medical evaluation based upon answers on the PRT 634 questionnaire. Provider reviews the assessment and finds the patient requires further evaluation 635 and management. The encounter should be coded based on documentation and code V70.5_C as 636 primary and other diagnoses as secondary.

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637 Pre-deployment (DD Form 2795) (V70.5_D) 638 Collection of this information is for military readiness to ensure assessment is done prior to 639 deployment. 640 641 1. The DD Form 2795 is determined to be a negative assessment and is reviewed only by a 642 non-privileged provider, and the form is filed. Code the ICD-9 code V70.5_D under the 643 technician’s name. 644 645 2. The privileged provider reviews the form in a face to face encounter and makes a final 646 medical disposition. Code E&M 99420 and the ICD-9 code V70.5_D. 647 648 3. The provider identifies, addresses and documents a medical problem. The encounter 649 should be coded based on documentation and code V70.5_D as primary and other diagnoses as 650 additional. 651 652 Post Deployment Assessments (V70.5_E/F) 653 Exams will always be conducted by a face to face encounter with a privileged provider. 654 655 Initial Post Deployment (DD Form 2796) (V70.5_E) 656 657 1. If the purpose of the encounter is to complete the DD Form 2796 by the privileged 658 provider and no medical conditions are found, code V70.5_E first and use 99420 for the E&M. 659 660 2. If the purpose of the encounter is to complete the DD Form 2796 and assessment and 661 medical evaluation identifies medical conditions requiring treatment, code V70.5_E first and 662 then code appropriate ICD9 codes. Use 99420 for the E&M code and additional E&M based on 663 the documentation with modifier 25. 664 665 3. If during an encounter for other reasons, it is determined that a required DD Form 2796 666 has not been completed, code the appropriate ICD9 code for the principal reason for the visit and 667 use code V70.5_E in the first four diagnosis codes. Use appropriate office visit E&M code based 668 on the documentation. 669 670 Post Deployment Health Reassessment (PDHRA) (DD Form 2900) (V70.5_F) 671 672 Encounters involving completion of the DD Form 2900 should be coded in the same 673 manner as specified for DD Form 2796 Initial Post-Deployment Assessment, substituting 674 V70.5_F in place of V70.5_E. 675 676 Scenarios for coding primary complaints that are deployment related. 677 Type of Example Primary 2nd, 3rd or 4th Patient Diagnosis Dx Code

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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 799.89 (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 mission two years ago. Work- up to date is complete, but negative. 678 679 This guidance is subject to change. More detailed information on program management is at 680 http://www.pdhealth.mil/. 681 682 2.2.8.5. V68.09 Issue of Medical Certificates 683 Medical certificates are frequently completed as part of an examination or physical. Use code 684 V68.09 when there is no medical indication for the encounter, the patient’s reason for the encounter 685 was solely to obtain a medical certificate; there is not another more appropriate code to reflect the 686 primary reason for the encounter, and no symptoms, conditions, or diseases were evaluated or 687 treated. See Section 6.6 Flight Medicine Services for an example involving flight medicine ground 688 testing. The code V68.09 would not be used, for instance, when a student needs a sports physical, 689 as there is a more appropriate code to reflect the reason for the visit, V70.3—other medical exam for 690 administrative purpose. 691 2-10 MHS Professional Services Coding Guidelines March 2013

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692 2.2.8.6. Case Management Services 693 The Case Management coding and reporting framework can be found in Appendix E. 694 695 2.2.8.7. Body Mass Index (BMI) 696 Body Mass Index may be coded only when there has been a clinical correlation made by the 697 physician/nurse practitioner/physician’s assistant. A diagnosis related to overweight, obesity, 698 malnutrition, or other health (weight-related) problems must be documented. The BMI will then 699 be coded as a secondary diagnosis. (See Coding Clinic, 2nd Qtr. 2010 for further clarification.) 700 701 2.2.9. Injuries, Poisonings, Adverse Effects, and E Codes 702 703 2.2.9.1 Injuries 704 Injuries are coded separately to ensure accurate capture of all data related to the type and extent 705 of trauma. Use combination codes for multiple injuries when documentation in the record is 706 insufficient to completely identify each injury. When coding multiple injuries the most severe 707 injury is sequenced first. Where multiple sites of injury are specified in the titles, the word 708 “with” indicates involvement of both sites, and the word “and” indicates involvement of either or 709 both sites. 710 711 Do not code superficial injuries when they are associated with more severe injuries at the same 712 site. 713 714 For additional guidance and examples refer to ICD-9-CM Official Coding Guidelines 715 and MHS Inpatient Coding Guide Principle 10. 716 717 2.2.9.2 Poisoning 718 Poisoning due to drugs, medicinal substances, and biologicals is defined as conditions resulting 719 from overdose of these substances or from the wrong substance given or taken in error. 720 721 To code a poisoning, select a code from the poisoning column of the Table of Drugs and 722 Chemicals. If known, code the reaction/manifestation as an additional code. If a secondary code 723 is used, the code for the poisoning must be sequenced first. Unlike coding an adverse effect, 724 there is no code for an unknown reaction to a poisoning. 725 726 Physicians use various terms when describing poisoning such as: overdose, poisoning, toxic 727 effect, wrong dosage given or taken, and wrong drug given or taken. Interactions between any 728 drug and alcohol or between prescribed and over-the-counter drugs are classified as poisonings. 729 730 2.2.9.3. Adverse and Toxic Effects: 731 732 2.2.9.3.1. Adverse Effects of Drugs 733 An adverse drug reaction is defined as any response to a drug "which is noxious and unintended 734 and which occurs at doses used in man for prophylaxis, diagnosis, or therapy."

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735 Terms frequently used in diagnostic statements to identify adverse drug reaction to a correct 736 substance properly administered are: accumulative effect, allergic reaction, idiosyncratic 737 reaction, hypersensitivity, paradoxical reaction, side effects, synergistic reaction and antagonistic 738 drug interactions. 739 740 For additional guidance and examples refer to ICD-9CM Official Coding Guidelines and 741 MHS Inpatient Coding Guide Principle 13.2. 742 743 2.2.9.3.2. Adverse Effects of Surgery and Medical Care 744 For guidance and examples refer to ICD-9CM Official Coding Guidelines and MHS 745 Inpatient Coding Guide Principle 15. 746 747 2.2.9.3.3. Toxic Effects 748 In general, exposure to harmful substances – contact with or ingestion -- is referred to as a Toxic 749 Effect. These events are classified to categories 980-989, Toxic effects of substances chiefly non- 750 medicinal as to source. 751 752 A toxic effect code is sequenced first. It is followed by code(s) to identify the 753 conditions/symptoms present. External cause of injury code(s) are also used and selected from 754 the following categories: 755  E860-E869 for accidental exposure 756  E950.6 or E950.7 for intentional self-harm 757  E962 for assault 758  E980-E982 for undetermined intent 759 760 Example: 761 Fisherman presents to a clinic complaining of a non-productive cough. Patient spent the last 762 three weeks deploying booms to collect petroleum samples/reports. Provider attributes 763 symptoms due to the toxic exposure, and documents final diagnosis as cough due to toxic effect 764 of exposure to an oil spill. Code to: 765 766 First listed: 981 Toxic effect of petroleum product 767 Secondary: 786.2 Cough 768 Secondary: E862.1 Effect of petroleum fuel and cleaners 769 Secondary: Other relevant E-codes 770 771 2.2.9.4 E Codes 772 E codes should be used only for the first encounter at the MTF for treatment of an injury. 773 If the patient was treated at a local civilian emergency department and received follow up 774 or after care at the MTF, the first encounter at the MTF should have an E code. Providers 775 should be taught always to document when initial care is received elsewhere. For follow- 776 up care without documentation of the initial visit, assume the patient was initially treated 777 at the MTF and do not use an E code. 2-12 MHS Professional Services Coding Guidelines March 2013

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778 An E code should be used with any diagnosis that indicates an injury, poisoning, or 779 adverse effect with an external cause. In general, when the diagnosis code is in the range 780 of 800–999, and V71.3–V71.6, at least one E code should be entered on the ADM record 781 the first time the patient is seen for the condition. An example of when an E code would 782 not be used for the codes listed above would be in conjunction with 917.2, blister without 783 mention of infection, caused by walking in new shoes without wearing socks. 784 785 As many E codes should be assigned as necessary to fully explain each cause. All ICD- 786 9-CM codes describing the reason for treatment must precede the E codes. If only one E 787 code can be reported in ADM, assign the E code most related to the primary diagnosis or 788 injury. Use the full range of E codes to completely describe the cause, the intent, and the 789 place of occurrence, if applicable, for all injuries, poisoning, and adverse effects of drugs. 790 Owing to limited number of reporting fields (currently four diagnoses) in the CAPER 791 extract, the E codes may not be reported upward. The E codes should be assigned after 792 the more critical injuries are listed. Only use E codes for external causes of injury. There 793 is no additional code for most repetitive stress injuries and other injuries, such as knee 794 pain owing to obesity or back pain caused by pregnancy. 795 796 2.2.10. Child and Adult Abuse Guidelines 797 Child and adult abuse codes may only be documented in ADM when substantiated. 798 799 When the cause of an injury or neglect is intentional child or adult abuse, the first listed E code 800 should be assigned from categories E960–E968 (Homicide and Injury Purposely Inflicted by 801 Other Persons), except category E967. An E code from category E967 (Child and Adult 802 Battering and Other Maltreatment), should be added as an additional code to identify the 803 perpetrator, if known. 804 805 In cases of neglect, when the intent is determined to be accidental, E code E904.0 (Abandonment or 806 Neglect of Infant and Helpless Person) should be the first listed E code (not the primary diagnosis). 807 808 2.2.11. M Codes: Morphology of Neoplasms 809 The morphology of neoplasm is not collected in the ADM. 810 811 2.2.12. Abortions 812 The number of legal—elective or therapeutic—and illegal abortions performed in DoD MTFs must 813 be reported to Congress annually. Use of the 635, 636, and 637 codes should be carefully 814 scrutinized. Coding personnel will not use 635–638 without authorization from their supervisor. 815 Some of the basic rules that apply include the following: 816 817  Fifth-digit-1, incomplete, indicates that all of the products of conception have not been 818 expelled from the uterus prior to the episode of care. 819  Fifth-digit-2, complete, indicates that all of the products of conception have been 820 expelled from the uterus. 2-13 MHS Professional Services Coding Guidelines March 2013

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821  Code 635 requires additional code to identify the reason for the abortion. Codes from 822 categories 640–648 and 651–657 (with fifth digits 3) may be used as additional codes 823 with an abortion code to indicate the complication leading to the abortion. 824  Codes from the 660–669 series are not to be used for complication leading to the 825 abortion. 826  Retained products of conception following an abortion: Subsequent encounters with the 827 diagnosis of retained products of conception following a spontaneous or legally induced 828 abortion are assigned the appropriate code from category 634, spontaneous abortion, or 829 635, legally induced abortion, with a fifth digit of 1 (incomplete). This advice is 830 appropriate even when the patient was discharged previously with a diagnosis of 831 complete abortion. 832  A patient who has an abortion performed outside the MTF and presents for treatment 833 without complications is assigned code V58x. To treat a complication following an 834 abortion, code the complication using 639x codes. Category code 639 is to be used for 835 all complications following complete abortions. Code 639 cannot be assigned in the 836 presence of codes 634–638. 837  Illegally induced abortion (636): Not performed within prescribed statutes, performed 838 by an unqualified individual, or performed at an unauthorized location. Do not use in 839 DoD. 840  Unspecified abortion (637): No details about the abortion are available. Do not use in 841 DoD. 842  Failed abortion (638): The elective procedure failed to evacuate or expel the products of 843 conception (fetus) and the patient is still pregnant. 844  If a code from 636 or 637 must be used, supervisor approval must be obtained and 845 the supervisor must contact his/her Service coding representative prior to 846 assignment. 847 848 As with all coding, it is important to select the correct 3rd, 4th, and 5th digits, as applicable. Use 849 DoD-unique code extenders 0 (elective), 1 (therapeutic), 2 (elective, terminated elsewhere), or 9 850 (unspecified) with abortion codes 635 and 638. 851 852 Do not use unspecified abortion codes in DoD. 853 854 When using the code for abortions incomplete with other specified complications, an additional 855 code is required to describe the other specified complication. 856 857 If a patient has an abortion at the MTF or elsewhere and returns for care after the abortion, with no 858 problems present, the code is V58.49, after care, following surgery. 859 860 2.2.13. Abortion with Live-Born Fetus 861 When an attempted termination of pregnancy results in a live-born fetus, assign code 644.21, Early 862 Onset of Delivery, with an appropriate code from category V27, Outcome of Delivery. The 863 procedure code for the attempted termination of pregnancy should also be assigned. 2-14 MHS Professional Services Coding Guidelines March 2013

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864 865 2.2.14. Administrative Close Out of Encounters 866 If there is no indication of an encounter taking place in an outpatient clinic, cancel the appointment 867 in CHCS during end of day processing. 868 869 When there is an indicator that an encounter occurred (e.g., prior to ED triage, documented 870 technician screening, a prescription, or laboratory test or radiology study associated with the 871 encounter), but the provider’s documentation is not available, code as follows: 872 873 Dx: V68.89, Other specified administrative purpose 874 Disposition Type: Will vary depending on the circumstances and documentation available. 875 876 2.2.14.1. Patient Triaged in the Emergency Department 877 Patients who leave without being seen (LWBS) after being triaged by a nurse/technician will be 878 coded as follows: 879 Dx: None 880 E&M: None 881 Disposition Type: LWBS 882 883 2.2.14.2. Patient leaves AMA after being seen by the Emergency Department provider 884 Patients who leave AMA after being seen by a privileged provider but prior to being released 885 will be coded based upon the extent of the documentation contained within the record. When the 886 documentation does not support a minimum code of 99281 then append modifier 52 to support 887 services rendered by the provider. 888 889 Dx: Chief Complaint/diagnosis 890 E&M: 9928x-52 891 Disposition Type: Against Medical Advice (AMA) 892 893 2.2.15. HIV 894 Return visit for results of HIV serology test will be assigned to code V65.44, HIV counseling. 895 For inconclusive findings, an additional code of 795.71, Nonspecific serologic evidence of 896 human immunodeficiency virus (HIV) would be used. 897 898 2.2.16. Ordering Screening Exams 899

900 DoD Rule

901

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902 When ordering screening examinations in a clinical setting i.e. screening 903 mammograms, it is recommended to place the ICD-9-CM code supporting 904 the screening procedure in the last position. 905

906 907 2.2.17. Aftercare vs. Follow-up 908 Follow ICD-9-CM coding conventions.

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909 Chapter 3 EVALUATION AND MANAGEMENT (E&M) CODING 910 911 ALL CODING WILL BE SUPPORTED BY THE DOCUMENTATION IN THE MEDICAL 912 RECORD. 913

914 DoD Rule

915 916 AHLTA Documentation: Autocite information will not be considered when 917 determining the appropriate ICD-9-CM, E&M, and/or CPT code to be 918 assigned to the encounter, unless pertinent findings are acknowledged within 919 the body of the providers’ notes. 920

921 922 NOTE: This section refers to coding collected in the second data collection screen of the ADM. 923 Only E&M codes 99201–99499 may be entered in this screen. There are other E&M codes, most 924 frequently used in mental health, optometry or ophthalmology, physical therapy, and occupational 925 therapy. Refer to separate sections on E&M codes outside the 99201–99499 range. 926 927 Facilities must indicate in their Coding Compliance/Protocol Plan which set of CMS guidelines 928 each clinical service will follow. Encounters will be audited using the set of guidelines that the 929 facility selected for the clinical service. 930 931 NOTE: Chapter 3 is organized as follows: Section 3.1. gives general information on E&M coding 932 in the MHS. Sections 3.2. to 3.8. cover categories of E&M codes. The paragraphs follow the 933 numbering sequence in the CPT. For instance, paragraph 3.2. provides MHS information on codes 934 99201–99215; paragraph 3.3 gives MHS information on the next category in the CPT, codes 935 99217–99236. 936 937 3.1. Evaluation and Management Coding – 99201-99499 938 E&M codes, a subset of CPT codes, identify the location, type, and overall complexity of a 939 patient encounter. Modifiers clarify the E&M services provided, but their use is limited by MHS 940 systems. 941 942 3.1.1. Determination of Level of E&M Code 943 The three key elements in selecting the appropriate complexity of the E&M code are history, 944 examination, and medical decision making. These components must meet or exceed the minimum 945 requirements specified in the E&M guidance of CPT. Certain categories of encounters, such as new 946 patient office visits, hospital observation services, and emergency department services, require that 947 all three key E&M components are documented. From time to time, one of these categories of 948 services is provided, but all three components might not be rendered to the patient (example: 949 physical exam or history is deferred). In such instances, the lowest level E&M code of that category 3-1 MHS Professional Services Coding Guidelines March 2013

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950 (a level 1) is assigned, along with a -52 modifier to indicate that less than a full level 1 visit in that 951 category was provided. For established patients, privileged provider encounters with such limited 952 documentation as to only support a 99211 will be coded with a 99211. 953 954 3.1.1.1. Documentation of Key Components 955 The reason for the encounter, called the chief complaint, should always be noted in the encounter 956 documentation. This requirement can be met by printing out the reason entered by the 957 appointment clerk in the computer system. If the chief complaint is not what the appointment 958 clerk entered, (e.g., patient told clerk the appointment was for abdominal pain, but when the 959 patient met the provider, the patient expressed concerns about a sexually transmitted disease), the 960 correct chief complaint must be documented. All parts of the history (review of systems (ROS), 961 past-family-social history (PFSH) and the chief complaint may be documented by other staff 962 members, medical students or the patient. In the case of history of present illness (HPI), staff 963 documentation may only be counted towards E&M leveling if the provider’s 964 documentation demonstrates he reviewed and expanded on the staff documentation. This 965 could be accomplished in the electronic medical record by having the provider “edit” the 966 nurse’s S/O section and add additional information in the HPI. Only those parts of the 967 examination, and assessment/plan that are actually documented by the privileged provider may 968 be used in calculating the level of the encounter. Any documentation, from provider, staff 969 member, medical students or patient, may be used to calculate the level of the encounter for the 970 ROS and PFSH. 971 972 To certify that the provider reviewed the information documented by others, there must be an 973 expanded notation supplementing or confirming the review. Merely documenting “Reviewed 974 and agree” is not sufficient documentation to demonstrate that the physician truly took 975 ownership of the history. 976 977 3.1.1.2. Self-Limited/Minor Problems 978 A common error in E&M leveling is to assign a self-limited or minor problem in the “Number of 979 Diagnoses or Treatment Options” component of medical decision-making to the level of a new 980 problem, creating a tendency to overvalue the level of medical decision-making and increasing 981 the risk of over coding. In order to address this type of error, the CPT definition of a self-limited 982 or minor problem will be followed. 983 984 CPT defines a self-limited or minor problem as "a problem that runs a definite and prescribed 985 course, is transient in nature, and is not likely to permanently alter health status, OR has a good 986 prognosis with management/compliance." 987 988 In order to comply with this CPT definition, unless the provider documents risk factors specific 989 to the patient (e.g., co-morbidities or other extenuating circumstances) that indicate a specific 990 increased risk of altering the health status of the patient or of worsening his or her prognosis, any 991 self-limited or minor problems should be considered "self-limited or minor" in determining the 992 level for diagnoses/management options and level of risk in medical decision-making. Simply 993 stating potential risk factors or circumstances common to all patients with the problem will not 994 justify considering the problem beyond a self-limited/minor problem. 995 3-2 MHS Professional Services Coding Guidelines March 2013

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996 Example of self-limited/minor problem: 22 year old male (patient of Dr A, seen by Dr B) 997 presents for 2 day history of cough and congestion. Patient is otherwise healthy, without any 998 other positive findings noted in Review of Systems for ENT and Respiratory organ systems or 999 past medical, family, or social history. Provider performed exam and diagnosed patient with a 1000 URI, and prescribed a 10 day course of antibiotics. The appropriate code for this scenario is 1001 99212; the medical decision-making would be minimal since the problem would be self- 1002 limited/minor, even though the prescription of antibiotics would result in a moderate level of 1003 risk. 1004 1005 Example of problem beyond the “self-limited/minor problem”: 22 year old male (patient of Dr 1006 A, seen by Dr B presents for 2 day history of cough and congestion; positive family history of 1007 asthma documented; other positive findings noted in Review of Systems for ENT and 1008 Respiratory organ systems or past medical or social history. Provider performed exam and 1009 diagnosed patient with URI and prescribed a 10 day course of antibiotic, with instructions to 1010 follow-up and consider referral to Pulmonary to assess for asthma if no improvement. The 1011 appropriate code for this scenario is 99214; the medical decision-making would be moderate 1012 since the problem would be considered new to the provider and the prescription of antibiotics 1013 would result in a moderate level of risk. 1014 1015 3.1.2. Coding E&M 1016 Up to three E&M codes may be entered. Modifiers should be assigned where appropriate. 1017 1018 3.1.3. Privileged Providers 1019 A privileged provider may use any E&M code that accurately reflects the services rendered and 1020 documented. A privileged provider is an independent practitioner who is granted permission to 1021 provide medical, dental, and other patient care in the granting facility, within defined limits, 1022 based on the individual’s education, licensure, experience, competence, ability, health, and 1023 judgment. Resident physicians are not independent practitioners, although they are included in 1024 the scope of privileged providers for this document. Refer to MHS Guidelines 1.1.1 regarding 1025 the description of “other qualified healthcare professionals”. 1026 NOTE: Navy coding guidance for Independent Duty Corpsman 1027 (IDCs) and Air Force coding guidance for Independent Duty Medical Technician 1028 (IDMTs) are in Appendix B. 1029 1030 3.1.4. Non-Privileged Providers (Nurses and Technicians) 1031 Non-privileged providers are normally restricted to using E&M code 99211 to document face-to- 1032 face encounters in which no procedure is performed (e.g., education by a technician or offering a 1033 service or supply item that does not have a specific code). 1034 The following clinic services are not considered code-able events: 1035 1036  TB test reading 1037  Patient who presents for an order for pregnancy test only 1038  Blood pressure checks per patient request 1039  Patient who presents to pick up a prescription refill 1040  Pulse oximetry 3-3 MHS Professional Services Coding Guidelines March 2013

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1041 3.1.4.1. 5 Day BP Checks 1042 Nurses/technicians will use the vital signs module to collect the data for the 5 day blood pressure 1043 checks. 1044 1045 Create an encounter for each day. Enter the blood pressure into the vital signs module of 1046 AHLTA. Code 2000F to indicate the blood pressure check; do not enter an E&M code. 1047 1048 3.1.5. Encounter Duration 1049 1050 3.1.5.1. When Time Is Not a Dominant Factor 1051 Time is not a dominant factor for assigning the appropriate E&M code in most scenarios. The 1052 time frames identified in E&M code descriptions represent a general range of time that will vary 1053 depending on actual clinical circumstances. The severity of illness as documented by history, 1054 examination, and medical decision making should determine the choice of office visit or 1055 consultation E&M code. 1056 1057 3.1.5.2. Counseling and Coordination Exception 1058 Counseling and coordination are exceptions to the time factor in selecting the E&M code. Time is 1059 the determining factor when counseling or coordination of care consumes more than 50 percent of 1060 the time a provider spends face-to-face with the patient, the family, or both. 1061

1062 DoD Rule 1063 1064 AHLTA Documentation: When a provider selects greater than 50% of time 1065 spent “counseling and/or coordinating care” and also selects the appropriate

1066 amount of floor time (face to face) then time in and time out 1067 requirement has been met. 1068 1069 The AHLTA documentation area for documenting time-based E&M coding 1070 is NOT to be used to document time for non – E&M time-based CPT coding. 1071 1072 Detailed documentation must indicate specifics on the counseling or 1073 coordination of care, discussion of why the additional time was necessary, 1074 what occurred during the additional time, and how much time was spent. 1075 Note: “counseled on condition, diagnosis, or treatment alternatives” is not 1076 acceptable documentation in and of itself.

1077 1078 1079 3.1.5.3. Other Specific Exceptions

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1080 Specific exceptions when time is always a factor are prolonged services, critical care, discharge 1081 services, and patient transport. Time plays a role in the extended duration of the encounter. 1082 Extended time may be identified with E&M codes 99354–99357 (Prolonged Services). 1083 1084 3.1.6. New and Established Patients 1085 To recognize the different levels of service between a patient who has not received care in a practice 1086 (and therefore needs more explanations about the operation of the practice) and an established 1087 patient (who is aware of the practice’s routines), there are different coding categories. 1088 1089 3.1.6.1. New Patient 1090 A new patient is one who has not received any professional services from the privileged provider 1091 or another privileged provider of the exact same specialty and subspecialty who belongs to the 1092 same group practice in the previous three years. The reason for the initial subspecialty encounter 1093 must be documented. 1094 1095 The following examples would NOT qualify as a new patient encounter: 1096  Privileged provider of any level filling in for another privileged provider (example: PA or 1097 NP covering for MD, or an IM provider covering for Peds provider) 1098 1099  Specialist embedded/assigned to the same group practice (example: BH specialist 1100 assigned to PCMH) 1101 1102  Patient sees same group of providers after group practice is reorganized (example: IM 1103 patient sees same providers after IM group changes to a PCMH) 1104 1105  Patient from child clinic seen in parent MTF within the installation (NOTE: 1106 Geographically separated child DMISs may be considered as separate facilities for the 1107 purpose of new vs. established) 1108 o Example: Patient seen in Ft. Benning, GA and then seen at Eglin AFB, FL. Eglin 1109 is a child clinic of Ft. Benning but would be new since out of the Geographic area. 1110 1111  Patient seen by same provider, regardless of location 1112 1113 A new patient may receive initial professional services as an inpatient or outpatient. 1114 Subsequent professional services would be coded as an established patient. The 1115 encounter that determines a new patient is the first encounter a patient has that meets the 1116 criteria above and meets the requirements of a visit. Occasions of service are not coded 1117 as a new patient encounter. A common error in the DoD is coding a newborn as a new 1118 patient at its first well-baby visit with the pediatrician involved with the delivery and 1119 initial hospitalization. The first well-baby visit would be as an established patient. 1120 1121 1122 3.1.6.2. Established Patient 1123 An established patient is one who has received professional services from the provider or another 1124 provider of the exact same specialty and subspecialty who belongs to the same group practice in 3-5 MHS Professional Services Coding Guidelines March 2013

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1125 the previous three years. A common error in DoD is an optometrist new to the facility coding all 1126 patients as new. The patients who had been seen in the clinic by the previous optometrists in the 1127 prior three years are all established patients to that optometry clinic. 1128

1129 DoD Rule 1130

1131 DoD requires the utilization of medical decision making as a 1132 mandatory component of an established patient E&M assignment. The 1133 provider may choose between History and Physical Exam for the second 1134 component to determine E&M code assignment for the encounter

1135 1136 3.1.6.3. Determining New versus Established based on Documentation 1137 New and established patients are determined based on documentation. If the documentation does 1138 not specifically indicate new or established and the record is not available to review for previous 1139 encounters, verify prior encounters in ADM. If, after research, the status of the patient cannot be 1140 determined, the encounter will be coded as an established patient. 1141 1142 3.2. Office Outpatient Services, 99201–99215 1143 These codes are used when a privileged provider collects a medically related history, performs an 1144 exam, and makes a medical decision in a DoD healthcare facility on a patient who is not admitted as 1145 an inpatient to a healthcare facility. 1146 1147 3.2.1. Shared Medical Appointments (SMA) 1148 SMAs are visits when multiple patients meet with the provider and a behaviorist at the same 1149 encounter. A list of chief complaints is compiled. All patients are present for those parts of the 1150 examination not requiring privacy. The provider examines each patient individually and addresses 1151 the patient’s issues. Immediately after completing the encounter with each patient, the provider 1152 documents the encounter while the behaviorist furnishes general education or counseling. When the 1153 provider completes the documentation, the provider starts the next patient’s exam. This continues 1154 until all patients are evaluated and treated. SMAs usually take 60–90 minutes to complete. SMAs 1155 are coded based on documentation. Only one encounter per patient will be completed. The 1156 appropriate E&M code will be assigned according to the documentation (i.e., prevention/office 1157 visit). The modifier TT, indicating individualized services with multiple patients present, is used 1158 when available in the ADM. 1159 1160 3.3. Hospital Observation Services 1161 See Appendix H for Coding for Observation 1162 3.4. Emergency Department 1163 Code procedures performed by the emergency department staff, such as infusions, injections and 1164 medications, EKG tracings, in addition to professional services. For consultation or referral 1165 within the ED, see Chapter 4. Not all services provided in the ED constitute use of an ED E&M

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1166 code (Office visit). For Level 1-5 hospital type B emergency visit (i.e., Fast Track or Urgent 1167 Care clinics in EDs), office visit E&M office visit codes should be used. 1168 1169 3.5. Consultations 1170 1171 THIS SECTION HAS CODING INFORMATION BASED ON THE SPECIALTY 1172 CLINIC THAT PROVIDES SERVICES. 1173 1174 3.5.1. Consultation Guidelines 1175 The MHS no longer recognizes consultation codes (99241-99245 and 99251-99255). Providers 1176 will use either a new patient or established patient E&M service, depending upon the setting 1177 (inpatient or outpatient) and if the patient has previously been seen by a privileged provider of 1178 the same specialty at the same facility. 1179 1180 3.5.2. Outpatient Guidance 1181 A privileged provider being consulted by another provider will use an established E&M code 1182 (99211-99215) for the initial encounter if the patient has been seen face-to-face by a privileged 1183 provider in the same specialty within 3 years of the date of service. A patient will be considered 1184 as a new patient if the patient has not received any face-to-face services by a privileged provider 1185 in the same specialty within 3 years of the date of service. Professional components of 1186 procedures previously performed, in the absence of a face-to-face service, are not to be used in 1187 designating a patient as established. A subspecialist may code a new patient visit (99201-99205) 1188 for the initial encounter if the patient has not been seen by a privileged provider of the same 1189 subspecialty within 3 years of the date of service, and the documentation of the encounter clearly 1190 demonstrates that the subspecialist is being consulted for a subspecialty issue. An example would 1191 be a cardiologist sending the patient to an EP or interventional cardiologist for evaluating a 1192 patient for a pacemaker/ICD implant. All follow-up face-to-face professional encounters after the 1193 initial encounter will be coded with the appropriate established E&M code (99211-99215). This 1194 guidance will also apply to observation services. 1195 1196 Example: A surgeon sees a patient in the office as a consultation for another provider at the 1197 MTF. The patient is either a new or established-depending on whether the patient had been seen 1198 at least once in the previous 36 months by that surgeon or by any other provider in that same 1199 clinic. If a new patient, the surgeon should report the consultation visit at the appropriate E&M 1200 level (1 through 5) using CPT codes 99201-99205. If the patient is an established patient, the 1201 surgeon should report the consultation visit as an established patient visit at the appropriate E&M 1202 level using CPT codes 99211-99215. 1203 1204 3.5.3 Consults in the Emergency Department 1205 The emergency department provider requests the specialist take over care or a portion of care. 1206 The emergency department does not intend for the patient to receive follow-up care in the 1207 emergency department. To code emergency department services with separate specialist 1208 services, two ADM records will be created. 1209

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1210 An appointment will be generated in the emergency department. The emergency department 1211 provider will document services provided. In the documented plan of care, the emergency 1212 department provider will indicate a portion or all of the care will be transferred to the specialist. 1213 The emergency department provider will generally use a code in the 99281–99285 series and 1214 collect the care in code BIAA of Medical Expense and Performance Reporting System 1215 (MEPRS). 1216 1217 The specialist will document services in a separate document. The specialist will have an 1218 appointment generated in the clinic, usually a walk-in. The appointment will be marked kept, 1219 which will generate a report to be completed in the ADM. This report will be separate from the 1220 ADM report generated in the emergency department. The specialist will usually code an office 1221 visit range of 99201–99215 in the specialist’s outpatient clinic MEPRS. 1222 1223 If the specialist admits the patient from the ED, there would not be a specialty clinic appointment 1224 generated. The specialist’s documentation would become part of the inpatient record and 1225 collected in the initial inpatient professional service rounds appointment. 1226 1227 3.5.4. Inpatient Guidance 1228 A privileged provider being consulted by the attending provider on an inpatient case will code 1229 their initial face-to-face service using inpatient codes 99221-99223. This service will be 1230 differentiated from the attending provider’s initial service by the attending provider appending 1231 modifier “AI” to their initial service code (99221-99223). All subsequent face-to-face encounters 1232 by the consulting provider will be coded with the subsequent inpatient codes (99231-99233). 1233 Refer to 9.2.4 of the MHS Guidelines for further information. 1234 1235 3.6 Medical Evaluation Boards (MEB) 1236 1237 3.6.1. Board Participation Not Code-able 1238 Participation on the board is an administrative service and is not code-able. Time spent 1239 participating on an MEB is not collected in the B*** MEPRS, but in the FED* MEPRS. 1240 1241 3.6.2. MEB Services (includes initial and follow-up) 1242 The MEB may originate from different sources; the privileged providers performing evaluations 1243 for a specific condition will be coded as an office visit, based on the documentation. The MEB 1244 initiating provider will assess the patient and request necessary consults. The consults (e.g., 1245 mental health evaluations, neurology, and orthopedics) will be coded based on the 1246 documentation. The package development by the MEB initiating provider, which incorporates all 1247 the consults and other documentation, will be coded with the 99455 or 99456 codes. The 1248 package development codes 99455 or 99456 documentation will include the following: 1249 completion of a medical history, commensurate with patient’s condition; performance of an 1250 examination commensurate with the patient’s condition; formulation of a diagnosis, assessment 1251 of capabilities and stability and calculation of impairment; development of future medical 1252 treatment plan; and completion of necessary documentation/certificates or reports. When the 1253 MEB meets, the primary provider presents the case, and the board makes a recommendation. 1254 MEB services do not include ongoing treatment for any disability-related condition. If the

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1255 package development takes more than 90 minutes, use the appropriate prolonged services code. 1256 Note: V70.5_7 will be used as the primary diagnosis when recording MEB package 1257 development. 1258 1259 3.7. Tobacco Cessation Counseling 1260 Use code 99406 for smoking and tobacco use cessation counseling visit, greater than 3 minutes up 1261 to 10 minutes: and 99407 for smoking and tobacco use cessation counseling when greater than 10 1262 minutes. These codes can be used by qualified MTF personnel as identified by MTF policy. For 1263 smoking cessation classes by non-privileged providers, use appropriate HCPCS level II code.

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1264 Chapter 4 Patient to Provider communication via telephone services and electronic media 1265 1266 All patient-to-provider communication will be documented within the patient’s medical record. 1267 For assessment, evaluation and management via electronic communications, such as emails, the 1268 patient’s consent is required. The telephone (T-con) module may be used to document both 1269 telephone and electronic communications. Each Service may have explicit policies concerning 1270 electronic communications. 1271 1272 Medical record documentation for telephone or electronic communication between patient and 1273 provider will follow medical record documentation standards. 1274 1275 Documentation guidelines for electronic communication between patient and provider include a 1276 physician's timely response to the patient's inquiry and must involve the permanent storage of 1277 this communication with either hard copy or electronic storage. It also encompasses the sum of 1278 communication including related telephone calls, prescription refills, or laboratory orders 1279 associated with the same on-line encounter. 1280 1281 4.1 Telephone and Online (Email) Encounters 1282 1283 4.1.1. Privileged Provider 1284 For privileged providers [to include IDC’s and residents beyond post-graduate year one (PGY1)] 1285 to use the following codes, communications via telephone or electronic media must be initiated 1286 by an established patient. Documentation must contain evidence of medical decision making by 1287 a licensed provider directly responsible for the management of the patient’s care. 1288 1289 99441 Telephone evaluation and management service provided by a privileged provider to an 1290 established patient, parent, or guardian not originating from a related E&M service provided 1291 within the previous 7 days nor leading to an E&M service or procedure within the next 24 hours 1292 or soonest available appointment; 5-10 minutes of medical discussion 1293 1294 99442 ; 11-20 minutes of medical discussion 1295 1296 99443 ; 21-30 minutes of medical discussion 1297 1298 99444 Online evaluation and management provided by a privileged provider to an established 1299 patient, guardian, or health care provider not originating from a related E&M service provided 1300 within the previous 7 days, using the internet or similar electronic communications network. 1301 1302 4.1.2. Non Privileged Provider 1303 For nurses and technicians (including IDMTs) to use the following codes, communications via 1304 telephone or electronic media must be initiated by an established patient. 1305 98966 Telephone assessment and management service provided by a non-privileged provider 1306 to an established patient, parent, or guardian not originating from a related assessment and 1307 management service provided within the previous seven days nor leading to an assessment 4-1 MHS Professional Services Coding Guidance March 2013

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1308 and management service or procedure within the next 24 hours or soonest available appointment; 1309 5-10 minutes of medical discussion 1310 1311 98967 ; 11-20 minutes of medical discussion 1312 1313 98968 ; 21-30 minutes of medical discussion 1314 1315 98969 Online assessment and management provided by a non-privileged provider to an 1316 established patient, guardian, or health care provider not originating from a related assessment 1317 and management services provided within the previous 7 days, using the internet or similar 1318 electronic communications network. 1319 1320 Patient initiated situations applicable for telephone and electronic communications 1321 1322 Examples include the following: 1323 1324  A patient describes new symptoms and requests intervention or advice from the 1325 privileged provider. 1326 1327  In response to a patient communication, a privileged provider makes a new diagnosis and 1328 prescribes new treatment. 1329 1330  A patient describes ongoing symptoms from a recent acute problem or chronic health 1331 problem and requests intervention or advice from the privileged provider to treat ongoing 1332 acute problem or chronic health problem. 1333 1334  In response to a patient communication, a privileged provider gives substantive medical 1335 advice, revises a treatment plan, prescribes or revises medication, recommending 1336 additional testing, or provides self-care or patient education information for new or 1337 chronic health problem. 1338 1339  A patient requests interpretation of lab or test results with evidence that the privileged 1340 provider is giving substantive explanation and possibly making recommendations to 1341 modify treatment plan, revise medications, etc. 1342 1343 1344  In response to a patient communication, a privileged provider gives extended personal 1345 patient counseling that changes the course of treatment and affects the potential health 1346 outcome. 1347

1348 DoD Rule 1349

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1350 There may be patient initiated communications that do not 1351 meet the criteria above and should be coded with a 99499. 1352 1353 Administrative telephone calls, or encounters/episode of care that would have 1354 not previously been captured or coded in MHS will now be captured as non- 1355 count and coded with 99499 in the E&M field and appropriate 1356 administrative V Code as a diagnosis.

1357 1358 4.1.3. Provider (privileged and non-privileged) Initiated Telephone Calls 1359 99499 is to be used for provider initiated telephone calls. Use 99499 as the E&M in the T-CON* 1360 module, and the diagnosis as the reason for the call. 1361 1362 The following list gives examples where you will not apply telephone and electronic 1363 communications codes (applies to privileged and non-privileged providers): 1364  Telephone services referring to an E&M service performed and reported by the same 1365 provider occurring within the past 7 days 1366  Telephone services ending with a decision to see the patient within 24 hours or next 1367 available urgent visit appointment 1368  Telephone services occurring within the post-operative period of the previously 1369 completed procedure 1370  New patient interaction 1371  Provider to provider interaction 1372  Provider to commander interaction 1373  Leaving messages on answering machines 1374  Scheduling/Billing/Administrative issues 1375  Communication of non-clinical information 1376  Telephone services completed by residents that are PGY-1’s 1377  Providing test results without any medical decision making 1378 1379 1380 4.2 Telehealth Services 1381 1382 A subset of e-Health, telehealth is the use of electronic information and 1383 telecommunications technologies to provide or support clinical healthcare, patient and 1384 professional health-related education, public health, and health administration when 1385 distance separates participants. It embraces several related areas, including electronic 1386 consultation and e-mail. Coding of telephone encounters is covered under the E&M

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1387 section. Coding for telehealth does not encompass provider-to-provider interaction (such 1388 as provider-to-provider e-mail).

1389 DoD Rule 1390 1391 Telehealth services are coded in the ambulatory care service appropriate 1392 MEPRS clinic, where workload performance is measured in visits. 1393

1394 NOTE: Provider-to-provider telephone calls, images transmitted via facsimile machines 1395 and text messages without visual images (e-mail) are not considered telehealth. 1396 1397 4.2.1. Providers must be privileged and credentialed per their Service’s requirements to 1398 perform Telehealth services.

1399 * clinical social workers cannot code for psychotherapy services that include medical E&M 1400 services. These practitioners may not use the following CPT codes: 90833, 90836 and 1401 90838. 1402 1403 4.2.2. Documentation of Telehealth 1404 Coders should look for telehealth encounters to be documented on an SF513 (Consultation 1405 Sheet), an approved substitute form or in AHLTA. For tele-radiology, the SF 519 (Radiographic 1406 Report) or AHLTA are used. Telehealth encounters must meet the same documentation 1407 requirements as face-to-face encounters. 1408 1409 4.2.3. How to Report 1410 1411 4.2.3.1. Real-time Communications 1412 Telehealth may be reported for interactive audio, video, or other electronic media 1413 telecommunications permitting real-time communication between the distant site provider and 1414 the patient. 1415 1416 4.2.3.2. Store and Forward Telecommunications 1417 Telehealth may also be reported for store-and-forward telecommunication that permits 1418 asynchronous transmission of medical information to be reviewed later by a provider at the 1419 distant site. The type of telehealth is identified by a modifier (see section 8.5.5 Modifiers). 1420 1421 4.2.3.3. Hospital Inpatients 1422 Telehealth encounters for hospital inpatients will be reported in ADM as outpatient encounters. 1423 1424 4.2.3.4. Photographs

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1425 Photographs, (e.g., of a skin lesion) must be specific to the patient’s condition and show enough 1426 detail for interpretation or confirmation of a diagnosis or treatment regimen. 1427 1428 4.2.4. Definitions 1429 1430 4.2.4.1. Originating Site 1431 The originating site is the location where the patient is at the time the service is furnished. The 1432 originating site will not use an E&M code for the telehealth encounter unless a separately 1433 identifiable E&M service is documented on the same day. For encounters involving patient- 1434 provider interaction, the visit will be entered as an office visit (e.g., 99201 or 99211) The 1435 originating site will report telehealth episodes with Q3014 Telehealth Originating Site Facility 1436 Fee. 1437 1438 4.2.4.2 Remote (Distant) Site 1439 The remote site is the location where the consultant is at the time the service is furnished. 1440 Services at the receiving facility are coded based on the documentation of the encounter. In 1441 general, the consultant will code the appropriate office visit E&M code for services. Mental 1442 health consultants will use mental health intake and therapy codes as appropriate. A provider at 1443 the originating site is not required to present the patient to a physician or practitioner at the 1444 remote site unless medically necessary. This decision will be made by the physician or 1445 practitioner located at the remote site. However, the provider must be in the facility and 1446 available to take part in the teleconference if needed. 1447 1448 4.2.4.3. Asynchronous Encounters: No communication between the distant-site physician or 1449 practitioner and the patient. Typically an interpretation of a diagnostic test by the distant-site 1450 physician. 1451 1452 Example: A 35 year old female presented to her primary care provider (PCP) with an 11 1453 year history of DM controlled with insulin. Her medical history includes known background 1454 diabetic retinopathy. The PCP sends her to the optometrist, who notes some potential retinal 1455 changes that are worrisome. Fundus photography is performed bilaterally, and the images are 1456 scanned and sent to the retinal specialist (remote) for interpretation. At the remote site, the retinal 1457 specialist documents that the interpretation is a telehealth encounter, reviews and interprets the 1458 images and provides a report to the referring provider. 1459 1460 Coding guidance for this scenario: 1461 1462 1. Originating Site codes: 1463 a. Diagnosis: The appropriate ICD-9-CM diagnosis code(s) 1464 b. E/M: 99499 1465 c. CPT: 92250-TC for the fundus photographs taken; and Q3014 (Telehealth 1466 Originating Site) 1467 1468 2. Remote Site codes:

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1469 a. Diagnosis: The appropriate ICD-9-CM diagnosis code(s) 1470 b. E/M: 99499 1471 c. 92250-26, GQ for review and interpretation of images 1472 1473 4.2.4.4. Real-Time Encounters: Real-time communication between the distant-site 1474 physician or practitioner and the patient. 1475 1476 Example: 25 year old AD service member was referred by PCP for evaluation regarding 1477 restless sleep, poor concentration, hyper vigilance, and irritability. A real-time telehealth 1478 encounter is conducted between the patient and a clinical psychologist. At the remote site, the 1479 clinical psychologist documents that the encounter is a telehealth encounter and conducts a 1480 review of PCP documentation; interviews patient, obtains a complete psychiatric history, 1481 including present illness, past history, and family history; and performs a complete mental status 1482 exam. The clinical psychologist provides their opinion and treatment recommendations to the 1483 PCP. 1484 1485 Coding guidance for this scenario: 1486 1487 1. Originating Site codes: 1488 a. Diagnosis: The appropriate ICD-9-CM diagnosis code(s) 1489 b. E/M: 99499 1490 c. CPT: Q3014 (Telehealth Originating Site) 1491 1492 2. Remote Site codes: 1493 a. Diagnosis: The appropriate ICD-9-CM diagnosis code(s) 1494 b. E/M: 99499 1495 c. CPT: 90791-GT 1496 1497 1498 4.2.5. Types of Remote Professional Services: Interpretations, Referrals, and Consults. 1499 1500 4.2.5.1 Interpretations 1501 An interpretation is made on limited clinical data and the finding(s) documented. The data could 1502 be transmitted electronically, via e-mail or facsimile, or by mail. If an EKG is done at one 1503 facility and transmitted to another for interpretation, the facility where the EKG was done would 1504 code 93005 and the facility where the EKG was interpreted would code 93010. Another 1505 common example would be radiology. For radiology, one facility would code the 7xxxx-TC 1506 (technical component) and the other would code the 7xxxx-26 (professional component). 1507 1508 4.2.5.2. Referrals 1509 When a provider at the remote site evaluates a patient for a specific problem or condition, this is 1510 called a referral. Please refer to 4.2.1.4 for an example of a referral. 1511 1512 4.2.5.3. Consulting Provider

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1513 When a provider at the remote site is asked for advice on a patient, this is called a consult. As 1514 with all consults, there must be a documented request and documented report. Documentation 1515 request can be from requesting or consulting provider. The request should specify the reason for 1516 the evaluation: the report should specify opinion and recommendations and any treatment 1517 initiated. The most common example is a family practice provider at the originating site e- 1518 mailing a request for consult along with EKG tracings and other documentation to the specialist 1519 at the remote MTF. The family practitioner then telephones or goes on line and discusses the 1520 patient with the specialist. The consulted provider (specialist at remote MTF) then evaluates the 1521 patient through a real-time telemedicine encounter, arrives at a diagnosis, develops a treatment 1522 plan, documents the encounter, and sends the requesting provider the consult report. This would 1523 be coded by the remote, consulted provider as a new or established office visit with the 1524 appropriate modifier. 1525 1526 Situations Applicable for Online Consultations (E-Mail) 1527  Patient describes new symptoms and requests intervention or advice from the privileged 1528 provider. 1529 1530  Patient describes ongoing symptoms from a recent acute problem or chronic health 1531 problem and requests intervention or advice from the privileged provider to treat ongoing 1532 acute problem or chronic health problem. 1533 1534  Physician is giving substantive medical advice, revising treatment plan, prescribing or 1535 revising medication, recommending additional testing, or providing self-care or patient 1536 education information for a new or chronic health problem. 1537 1538 1539  Physician makes a new diagnosis and prescribes new treatment. 1540 1541  Patient requests interpretation of lab or test results and privileged provider gives 1542 substantive explanation and possibly makes recommendations to modify treatment plan, 1543 revising medications, etc. 1544 1545  Clinical psychologist gives extended personal patient counseling, changing the course of 1546 treatment and affecting the potential health outcome. 1547 1548 4.3. E&M Coding 1549 1550 4.3.1. Documentation Needed 1551 When telemedicine is applied to conduct a professional office visit or consultation between provider 1552 and patient, the appropriate E&M codes for those services should be used. In general, the initial 1553 visit will be a consult and follow-up visits will be established office visits. Documentation must be 1554 filed in the patient’s permanent medical record and should include: 1555  Patient’s chief complaint 1556  Additional information from the patient to clarify his or her condition 4-7 MHS Professional Services Coding Guidance March 2013

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1557  Any medications (over the counter, herbal, or prescription) being taken 1558  Date and time a prescription was ordered (may be available in CHCS) 1559  Date and time the patient is to return for care 1560  Electronic signature of the individual who performed the service when the online 1561 consultation is placed into AHLTA 1562 1563 4.4. Diagnosis Coding 1564 Official outpatient coding guidelines will be followed for reporting diagnoses for telehealth 1565 encounters. 1566 1567 4.5. Procedural Coding 1568 1569 4.5.1 Originating Site 1570 The originating site will report telehealth episodes with Q3014 Telehealth Originating Site 1571 Facility Fee. 1572 1573 4.5.2 Distant Site 1574 The distant site may report telehealth for many store-and-forward applications including but not 1575 limited to the interpretation of: 1576 1577  Colposcopy 1578  Obstetric ultrasound 1579  Electrocardiography, fetal 1580  Echocardiography 1581  ESRD-related services 1582  Cardiography interpretation and report 1583  MRI 1584  Laboratory results 1585  Video clips 1586 1587 4.6. Modifiers 1588 1589 4.6.1. Asynchronous vs. Real-Time Encounters 1590 Telehealth encounters will be identified with one of the following modifiers: 1591 * GQ for asynchronous encounters, or 1592 * GT for real-time interactive encounters. 1593 1594 Professional telehealth services are coded with the appropriate E/M level code and telehealth 1595 modifier appended. 1596 1597 4.6.1.1. GT Modifiers 1598 This signifies real-time communication between the distant-site physician or practitioner has 1599 taken place with the patient present and participating in the telehealth visit. 1600 4-8 MHS Professional Services Coding Guidance March 2013

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1601 4.6.1.2. GQ Modifiers 1602 This signifies the distant site physician or practitioner certifies that the asynchronous medical file 1603 was collected and transmitted to him/her at his or her distant site from an eligible originating site 1604 when the telehealth service was furnished. 1605 1606 4.6.2. Modifier -26 1607 When a provider at a distant site provides an interpretation and report of a diagnostic study (e.g. 1608 laboratory or radiology test), the service is reported with the -26 modifier for the professional 1609 component of the procedure. The originating site would report the procedure with the –TC 1610 modifier if no interpretation and report are rendered

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1611 1612 Chapter 5 PROCEDURAL CODING 1613 1614 ALL CODING WILL BE SUPPORTED BY THE DOCUMENTATION IN THE MEDICAL 1615 RECORD. Specific uses of procedural coding are listed under specialty chapters in Section 7. 1616 1617 5.1. Procedures 1618 The term procedures include E&Ms not in the 99201–99499 range, such as mental health, physical 1619 therapy, occupational therapy and optometry or ophthalmology evaluations. Procedures also 1620 include supplies and durable equipment. Procedure codes are entered in the CPT/HCPCS 1621 Description position on the ADM screen. CPT procedure codes (00100–99199 and 99500+, 1622 Category II and Category III) and all of the HCPCS Level II codes are entered in the CPT/HCPCS 1623 Description position. All procedure codes will be entered before the anesthesia code for APVs. 1624 The last code listed for the institutional component of the APV will always be 99199. 1625 1626 ICD-9-CM procedure codes are not used when coding professional services. The ICD-9-CM 1627 diagnosis that shows the medical necessity for a procedure must be linked to the procedure. The 1628 codes for diagnostic radiology and laboratory procedures (other than those done and interpreted in 1629 the clinic such as obstetric ultrasounds and KOH tests) should only be added to the encounter when 1630 performed in the clinical setting. 1631 1632 Example: A child presents with ear pain. Because the tympanic membrane cannot be 1633 seen because cerumen is impacted, cerumen is removed with magnification and 1634 instrumentation. The primary diagnosis is otitis media (1). The secondary diagnosis is 1635 impacted cerumen (2). The procedure for removal of impacted cerumen, one or both 1636 ears, is coded with the CPT code 69210 and matched to impacted cerumen secondary 1637 diagnosis. 1638 1639 5.1.1. Minimize Use of Unlisted Procedure Codes 1640 Efforts should be made to minimize use of unlisted procedure codes. In CPT, unlisted codes 1641 usually end in 99. In HCPCS, unlisted codes are less consistent in their numbering and may 1642 have any numbering convention (e.g., Q4050 Unlisted Cast Supplies), though the terminal digit 1643 is frequently a 9. 1644 1645 5.1.2. Non-Privileged Provider Procedures 1646 When a non-privileged provider is granted permission by the MTF to do a procedure, the procedure 1647 code may be used to reflect nurse or technician services. Common examples are physical therapy 1648 technicians performing physical therapy procedures and technicians removing warts. In these cases, 1649 the technicians may only furnish the service if working under the written orders of a privileged 1650 provider. 1651 1652 5.1.3. Documentation Requirements for All Procedural Interpretation and Report 1653 The documentation of the procedure and its interpretation does not have to be a separate page. 1654 The summary of the findings must contain sufficient detail that a conclusion can be made. 1655 Simply clicking the procedure in AHLTA is not adequate documentation to support coding of a

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1656 procedure. 1657 1658 5.2. Modifiers 1659 Modifiers are used to indicate a service or procedure has been performed, but was altered by some 1660 specific circumstance. Modifiers are two-character codes added to the E&M or CPT/HCPCS 1661 procedures. They are alpha, numeric, or alphanumeric codes. Modifiers and their associated 1662 nomenclature are derived from two sources—CPT and HCPCS. Common modifiers can be located 1663 in Appendix C of the MHS Coding Guidelines. Not all modifiers are currently available at this time 1664 in ADM and AHLTA. 1665 1666 5.2.1. CPT Modifiers Approved for Ambulatory Surgery Hospital Outpatient Use 1667 The MHS does not utilize the modifiers associated with the institutional component of an 1668 ambulatory surgery center (modifiers 27, 73, and 74). Utilize modifier 52 or 53 for procedures 1669 which have been reduced or cancelled. 1670 1671 5.2.2. Modifier -32 Mandated Services 1672 The intent of this modifier is to define when another entity has a mandate, not when an entity is 1673 following its own regulations. Therefore, it is inappropriate to use this code for encounters such 1674 as flight physicals, hearing conservation screenings or newborn hearing screenings and 1675 premarital laboratory testing. 1676 1677 5.3. Bundled Procedures and Global Procedures 1678 1679 5.3.1. Bundled Procedure 1680 Bundled procedure codes should be used whenever possible. Bundled services are a set of medical 1681 or surgical services wrapped in a group package. The components listed in a particular service are 1682 considered integral to the procedure and should not be billed separately. An example of this is a 1683 sigmoidoscopy with removal of foreign body. The code 45332 captures both procedures. 1684 1685 5.3.2. Global Procedures 1686 Global procedures are similar to bundled procedures. Global surgical packages have one code 1687 for all three parts: preoperative services, the procedure, and uncomplicated postoperative care--a 1688 package deal. The global package includes low-level patient monitoring and topical anesthesia. 1689 1690 The encounter when a decision for surgery is made is coded as an E&M. If the decision for 1691 surgery is made within 24 hours of a procedure with a 90-day postoperative period, the E&M is 1692 appended with the -57 modifier. If the decision for surgery is made at the same encounter as a 1693 procedure with a 0-or 10-day postoperative period, the E&M is appended with a -25 modifier in 1694 accordance with guidance in 5.3.2.1. 1695 1696 When one provider performs the surgery, and postoperative care will be provided at a different 1697 MTF, the surgeon will code the procedure followed by modifier -54 to indicate only performance 1698 of intraoperative care. The provider at a different MTF performing the first episode of 1699 postoperative care codes the encounter using modifier -55, postoperative. Additional

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1700 uncomplicated follow-up care for this service is coded with 99024, indicating subsequent visits 1701 within the 90-day global period. 1702 1703 The provider may be entitled to code additional services performed in the evaluation of a new 1704 patient in accordance with procedural coding rules. When providing postoperative care, the date 1705 of procedure is included in the documentation. 1706 1707 5.3.2.1. E&M Services Bundled Into Procedures. 1708 1709 Preoperative and postoperative care protocols associated with a procedure are included in the 1710 CPT code for a minor procedure (0-10 day global period); an E&M code would not be reported 1711 in addition to the procedure. In some instances, the physician may need to indicate that on the 1712 day a procedure is identified with a CPT code as being performed, the patient’s condition 1713 required a significant, separately identifiable evaluation and management service above and 1714 beyond the usual preoperative and postoperative care associated with the procedure. For these 1715 instances, an E&M code with a 25 modifier would be reported in addition to the CPT code; the 1716 provider’s documentation must demonstrate an important, notable, distinct correlation with signs 1717 and symptoms to make a diagnostic classification or demonstrate a distinct problem causing the 1718 provider to work beyond the usual preoperative and postoperative work included in the 1719 procedure. A common error is using an E&M to code uncomplicated postoperative services 1720 already included in a global procedure. Also, an E&M code is typically not utilized on an 1721 encounter when a decision is made to perform a minor procedure (0 – 10 day global period) 1722 immediately prior to performing the procedure. 1723 1724 Example of E&M service bundled into the CPT code: 1725 1726 69 year old black female presents with complaint of soreness in her knee. The provider 1727 evaluates the knee and determines it would be beneficial for the patient to undergo an 1728 arthrocentesis. The physician performed the arthrocentesis and instructed the patient to schedule 1729 a follow up visit in two weeks. The encounter is coded 20610 for the arthrocentesis. The 1730 provider does not code an evaluation and management code since the focus of the encounter is 1731 related only to the knee pain, which resulted in the performance of the arthrocentesis. 1732 1733 5.3.2.1.2. MHS specific RVUs have been developed to support utilization of code 99024. 1734 Exceptions to the global surgical package are as follows: 1735 1736 A. The initial consultation or evaluation of the problem by the surgeon to determine the need 1737 for surgery. This encounter would be coded with the appropriate E&M office code (99201-99215) or 1738 initial inpatient code (99221-99223) for consultation encounters. Please note that this policy only 1739 applies to major surgical procedures. The initial evaluation is always included in the allowance for a 1740 minor surgical procedure. 1741 1742 B. Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the 1743 visits occur due to complications of the surgery. 1744

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1745 C. Treatment for the underlying condition or an added course of treatment which is not part 1746 of normal recovery from surgery. 1747 1748 D. Diagnostic tests and procedures, including diagnostic radiological procedures. 1749 1750 E. Clearly distinct surgical procedures during the postoperative period which are not re- 1751 operations or treatment for complications. (A new postoperative period begins with the subsequent 1752 procedure.) This includes procedures done in two or more parts for which the decision to stage the 1753 procedure is made prospectively or at the time of the first procedure. Examples of this are procedures 1754 to diagnose and treat epilepsy (codes 61533, 61534-61536, 61539, 61541, and 61543) which may be 1755 performed in succession within 90 days of each other. 1756 1757 F. Treatment for postoperative complications which requires a return trip to the operating 1758 room (OR). An OR for this purpose is defined as a place of service specifically equipped and staffed 1759 for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a 1760 laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a 1761 recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be 1762 insufficient time for transportation to an OR). 1763 1764 G. If a less extensive procedure fails, and a more extensive procedure is required, the second 1765 procedure is coded separately. 1766 1767 H. Immunosuppressive therapy for organ transplants. 1768 1769 I. Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously 1770 injured or burned patient is critically ill and requires constant attendance of the physician. 1771 1772 5.3.2.2. Services of other physicians (except where the surgeon and the other physician(s) agree on 1773 the transfer of care) are not covered under the global surgical package and thus may be coded 1774 separately. The transfer of care agreement may be in the form of a letter or an annotation in the 1775 discharge summary, hospital record, or Ambulatory Surgical Center (ASC) record. 1776 1777 5.3.2.3. When a patient has surgery at one clinical service/facility, the first follow-up at a 1778 different clinical service/facility will be coded with the surgical procedure code and modifier -55 1779 (postoperative care only). Code 99024 is for all subsequent uncomplicated encounters until 1780 resolution. 1781 1782 5.3.2.4. Obstetrical Coding. 1783 See section 6.10 1784 1785 5.4. Clinical Pharmacists 1786

1787 DoD Rule 1788

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1789 Anticoagulation INR lab tests review may be reported with appropriate 1790 diagnosis code. E&M codes are reported only once at the end of the 90 day time 1791 frame. Pharmacists will code 99363 or 99364 once the 90 day time frame has 1792 elapsed. If the services performed occur for less than 60 days each encounter must 1793 be coded using 99211. 1794 INR lab test will be reported on each encounter if performed in the B MEPRS clinic. 1795 1796 Clinical pharmacists are privileged to provide patient care independently outside the pharmacy 1797 environment. These providers are usually doctors of pharmacy or pharmacists with extensive 1798 training that covers a particular range of disease processes for which they are credentialed to 1799 manage pharmacologically in a clinical setting. See Service-specific guidance for privileging 1800 procedures. Pharmacists will use Medication Therapy Management CPT codes (99605–99607) for 1801 patient treatment other than coagulation therapy. These are face-to-face timed codes that must 1802 include the following documented elements: review of the pertinent patient history; medication 1803 profile; recommendations for improving health outcomes and treatment compliance. 1804 1805 5.5. Chaplains and Pastoral Counselor 1806 Chaplain and pastoral counselor services will always be non-count. On occasion, chaplains 1807 document in the hard copy medical record to communicate with medical providers. In this case, it is 1808 inappropriate to code in ADM as only Defense Health Program (DHP) funded visits should be 1809 collected in CHCS or AHLTA. To document in AHLTA as a communication tool, the documenter 1810 must be able to enter the provider (usually with nurse or technician permission). Use the provider 1811 specialty code 530 Pastoral Counselor. No workload will be credited for pastoral care. The usual 1812 diagnosis would be V62.89, Other, religious or spiritual problem or V62.6, Refusal of treatment for 1813 reasons of religion or conscience. 1814 1815 5.6. Electrocardiogram (ECG or EKG) Services 93000–93042 1816 ECG/EKG has a global code (93000, 93040) when the tracing, interpretation, and report are 1817 completed in the same clinic. When the tracing (technical component) is performed in the 1818 cardiopulmonary lab or other clinic, code 93005 or 93041 for the tracing only. The provider 1819 privileged to interpret and report the ECG/EKG uses 93010 or 93042 after a report is completed to 1820 code the professional component. Interpretation only without a report is not a code-able event. An 1821 example of an interpretation would be an emergency department physician interpreting, but not 1822 creating a report for ECG tracing performed in the ED. This should be included in the medical 1823 decision-making portion of the E&M code. 1824 1825 NOTE: Although the interpretation does not have to be on a separate page, the summary of findings 1826 must contain sufficient detail that a conclusion of the significance of the findings can be made 1827 without the tracing itself being available. Documentation must include descriptive or tabular 1828 summary including information such as PR, QRS, QT intervals, rate, rhythm, axis, ST segment 1829 changes, along with an interpretation of these findings. Simple notations in the E&M visit notes, 1830 such as "EKG-neg" or "EKG-acute MI," are not adequate documentation. 5-5 MHS Professional Services Coding Guidance March 2013

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1831 Example: ECG/EKG ordered and read by the same provider in conjunction with a visit. 1832 The provider would capture the tracing, as well as the interpretation and report for the ECG 1833 along with the visit and code 93000 or 93040, as appropriate. The technician performing the 1834 test could be included as an additional provider in ADM. 1835 1836 Example: ECG/EKG performed in a central cardiopulmonary lab and interpreted by a 1837 provider. Currently there is no module to capture and code these procedures. NOTE: For 1838 ADM reporting, the MTF may establish a non-count clinic, non-count appointment 1839 type in CHCS using DDA and capture the CPT tracing only code. The interpretation 1840 and report will be captured by the provider doing the initial interpretation in their B 1841 MEPRS clinic. 1842 1843 5.7. Laser Tattoo and Hair Removal 1844 For laser removal of tattoos code to ICD-9-CM 709.09, use procedure code 17999. For laser hair 1845 removal of pseudofolliculitis barbae (shaving bumps) code to ICD-9-CM 704.8 and procedure code 1846 96999. 1847 1848 5.8. On Call 1849 On call codes will not be used. To enter an encounter in the ADM, a patient must be associated 1850 with the procedure code. On call is not for a specific patient. 1851 1852 5.9. Records Review 1853 Records review for peer review and the Medical Record Review Committee are administrative 1854 activities. There are no CPT/HCPCS codes for administrative records review. 1855 1856 5.10. Injections and Infusions 1857 To capture the immunization administration for vaccines or toxoids, for individuals younger than 1858 19, report 90460-90461 in cases where the physician provides face-to-face counseling of the 1859 patient or family during administration of the vaccine. These two codes are not like the other 1860 administration codes as 90460 is for the first vaccine/toxoid component and 90461 is for each 1861 additional vaccine/toxoid component. For instance, if 90710 Measles, mumps, rubella, and 1862 varicella vaccine (MMRV) is administrated, 90460 quantity 1 and 90461 quantity 3 would be 1863 coded. 1864 For services provided by technicians or nurses, and services provided by providers without 1865 counseling for patients of any age, use the code range 90471 –90474 and the immunization 1866 product code 90476–90749. 1867 If a significantly identifiable E&M service is performed with a vaccine or toxoid procedure, the 1868 appropriate E&M service code should be reported in addition to the vaccine or toxoid 1869 administration. 1870 1871 For injections/immunization administration, documentation must include at a minimum, method of 1872 administration, unit(s), and substance. 1873

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1874 For infusions, documentation must include at a minimum, start and stop times, method of 1875 administration, unit(s) and substance. 1876 1877 It is insufficient to simply select corresponding CPT codes in AP section of AHLTA note. Although 1878 this information may be reported in a different system, documentation must be contained in the 1879 AHLTA note. 1880 1881 5.11. Cast or Splint Application 1882 All casts, casting supplies, and splints applied will be coded when not bundled with another 1883 procedure on the ordering privileged provider’s CAPER, with the technician listed as a secondary 1884 provider. When applying other than the initial cast or splint, also use the casting and splint supply 1885 codes Q4001–Q4051. 1886 1887 5.12. Dry Needling 1888 Dry needling (also known as Intramuscular Manual Therapy (IMT)) pertains to the insertion of 1889 small, fine, solid needles into specific muscle locations or trigger points for the purpose of relieving 1890 pain caused by muscle contraction and spasm. This procedure differs from traditional acupuncture 1891 techniques. Dry needling may be performed by privileged providers within their scope of practice as 1892 defined by their service. HCPCS code S8990 will be used to code the dry needling procedure. 1893

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SPECIALTY CODING 6.1. Anesthesia

1894 Chapter 6 SPECIALTY CODING 1895 1896 THIS SECTION HAS CODING INFORMATION BASED ON THE SPECIALTY CLINIC 1897 THAT PROVIDES SERVICES. 1898 1899 6.1. Anesthesia 1900 1901 6.1.1. Basic Tenets of Professional Services Anesthesia Coding 1902 Anesthesia procedures are coded when local anesthesia is supplemented, or when regional, 1903 monitored anesthesia care or general anesthesia is performed by a person other than the provider 1904 performing the surgical procedure. 1905 1906  Regional anesthesia is the use of anesthetic agents with or without sedation to provide 1907 pain relief or the loss of sensation to a specific area of the body, such as epidural 1908 anesthesia or a brachial plexus block. 1909  General anesthesia is the total loss of consciousness and reflexes caused by the 1910 administration of drugs and inhalation agents. 1911  Monitored anesthesia care (MAC) is intra-operative monitoring by an anesthesiologist or 1912 CRNA of the patient’s vital signs, in anticipation of possible need to transition to general 1913 anesthesia. The patient maintains an airway and responds to verbal stimuli, except 1914 possibly for brief periods of time (e.g., fewer than 60 seconds). 1915 1916 6.1.2. Reporting B MEPRS for Anesthesia Services 1917 The professional component of anesthesia services will be captured on the lead surgeon’s ADM 1918 encounter. The anesthesia code will be sequenced after all procedures performed by any 1919 surgeons and before the 99199 code for the institutional component of the APV. Procedures 1920 performed by the surgeon should be linked to the surgeon. Procedures performed by the 1921 anesthesia provider should be linked to the anesthesia provider. 1922

1923 DoD Rule 1924 1925 Anesthesia services will be reported in MTFs when performed by a provider 1926 other than the surgeon using anesthesia procedure CPT codes: 00100–01999.

1927 1928 1929 MTFs will list anesthesiologists or CRNAs as additional providers on the 1930 surgeon’s record in the ADM.

1931 1932 6.1.3. Providers 1933

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1934 6.1.3.1. Anesthesia Performed by a Provider Other than the Surgeon 1935 When the provider administering and monitoring the anesthesia is a provider other than the 1936 surgeon (e.g., another physician, anesthesiologist, or CRNA), the anesthesia services will be 1937 reported using anesthesia procedure CPT codes: 00100–01999. 1938 1939 6.1.3.2. Anesthesia Performed by Provider Also Performing Surgical Procedure 1940 When the provider performing the surgical procedure also administers and monitors the 1941 anesthesia, a surgical CPT procedure(s) code and not an anesthesia code is applied. Append 1942 modifier -47 to the surgical procedure code. 1943 1944 6.1.4. Gathering Documentation 1945 Medical records will be reviewed for the anesthesia provider’s documentation supporting 1946 the use of regional, MAC, or general anesthesia. Generally, these anesthesia services can 1947 be found on DA Form 7389 for the Army or OF 517 for the Navy and Air Force. 1948 1949 6.1.4.1. When Not to Code for Anesthesia Services 1950 1951 6.1.4.1.1. Types 1952 Anesthesia services are NOT coded when the procedure is performed using the following types 1953 of anesthesia: 1954 1955  topical; 1956  local infiltration of anesthetic agents to a limited area, such as those used for minor 1957 procedures like biopsies, and the excision of skin tumors and lesions; or 1958  metacarpal, metatarsal, or digital block. 1959 1960 6.1.4.1.2. Procedures 1961 Anesthesia guidelines in the CPT coding manual and the National Correct Coding Initiatives 1962 (NCCI) provide guidance on the services that are inclusive to the provision of anesthesia, and 1963 therefore are not coded separately. They are: 1964 1965  normal pre- and post-anesthesia visits; 1966  provision of fluids or blood; 1967  normal monitoring of vital signs, EKG, pulse oximetry, capnography (blood carbon 1968 dioxide concentration), and mass spectrometry; 1969  laryngoscopy for placement of airway and placement; and 1970  nerve stimulation to determine level of consciousness. 1971 1972 6.1.4.1.3. Moderate Sedation (Previously Termed Conscious Sedation) 1973 Clinicians use moderate sedation to achieve a medically controlled state of depressed 1974 consciousness while maintaining the patient’s airway, protective reflexes, and ability to respond 1975 to stimulation or verbal commands. Review CPT code descriptions to avoid unbundling as some 1976 procedures (e.g., some endoscopies) include moderate sedation. Moderate sedation is reported 1977 when the physician performing the surgical procedure also provides the moderate sedation. 6-2 MHS Professional Services Coding Guidelines March 2013

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1978 Moderate sedation requires an independent observer be present to assist the physician in 1979 monitoring the patient’s level of consciousness and physiologic status. Report moderate sedation 1980 on the surgeon’s ADM entry in the appropriate MEPRS code. 1981 1982 6.1.5. Additional Anesthesia Procedures 1983 Other forms of monitoring by anesthesia personnel will be coded on the surgeon’s ADM 1984 encounter when they are done by an anesthesia provider. These codes should be linked to the 1985 anesthesia provider. For example: 1986 1987  Central venous puncture (CVP) line insertion, 1988  Intra-arterial lines, 1989  Swan–Ganz catheters, 1990  Emergency intubation, 1991  Critical care visits and 1992  Transesophageal echocardiography. 1993 1994 6.1.6. Coding Anesthesia 1995 1996 6.1.6.1. Coding with a Crosswalk 1997 Anesthesia can be coded in a number of ways. A crosswalk between surgical procedures and 1998 anesthesia is available from a variety of sources, including the American Society of 1999 Anesthesiologists (www.asahq.org) or the Coding Compliance Editor (CCE). When a crosswalk 2000 is not available, follow the steps below. 2001 2002 6.1.6.2. Coding without Crosswalk: 2003 1. Identify all surgical procedures performed. 2004 2. Refer to the main term, anesthesia, in the CPT index. 2005 3. Search for a sub-term to indicate the anatomic site of the procedure or the actual 2006 procedure performed. 2007 4. Reference the code or codes noted in the index’s tabular portion of the CPT 2008 codebook. 2009 5. Read and apply any notes in the index or in the tabular portion of the CPT 2010 codebook. 2011 6. If multiple anesthesia services are performed in the same session, the anesthesia 2012 procedure with the highest base unit will be determined (see the “Relative Value 2013 Guide,” published by the American Society of Anesthesiologists). 2014 7. To calculate the base units for multiple anesthesia services, see section 6.1.8 2015 Base Unit in this document. 2016 8. At this time the MHS cannot accommodate modifiers for anesthesia. Therefore, 2017 the MHS does not report medical direction or supervision. 2018 9. Assign codes for any qualifying circumstances, if applicable. See section 6.1.14. 2019 Reporting Qualifying Circumstances in this document.

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SPECIALTY CODING 6.1. Anesthesia

2020 6.1.7. Base Unit 2021 A base unit reflects the difficulty (or level of acuity) of the anesthesia service. The base unit 2022 includes the initial anesthesia assessment to determine if the patient is an anesthesia candidate. It 2023 also includes the following services, usually provided on the day of surgery: 2024 2025  preoperative visit, 2026  postoperative visit, and 2027  administration of fluids or blood products incident to the anesthesia care and 2028 interpretation of non-invasive monitoring. 2029 2030 Each anesthesiology CPT code is assigned a base unit value in the Medicare Relative Value 2031 Guide. It is available at the CMS Website: (http://www.cms.hhs.gov/center/anesth.asp) in 2032 Appendix A, Chapter 8, Medicare Carriers Manual, Part 3. 2033 2034 6.1.8. Single Code Exceptions for Anesthesia 2035 There are exceptions to the inclusion of all anesthesia procedures performed during the same 2036 surgical session under one code. The exceptions are the anesthesia add-on codes for the excision 2037 or debridement of burns (that accommodates percentage of body surface) and obstetrical 2038 anesthesia (that allows for time). The anesthesia add-on codes have separate base units. All add- 2039 on codes are reported in addition to the principal procedure code(s). They are never used as the 2040 first-reported or solo code. 2041 2042 6.1.9. Identifying Type of Provider 2043 When available in the MHS systems, an HCPCS level II modifier identifies the provider as an 2044 anesthesiologist or CRNA. The modifier indicates whether the CRNA provider is or is not under 2045 the medical direction or supervision of an anesthesiologist. Additionally the modifier indicates 2046 the number of cases directed or supervised by a provider. The physician or anesthesiologist and 2047 the anesthetist both report their services with the appropriate modifier. 2048 2049 6.1.10. Coding Anesthesia for Cancelled Procedure 2050 If the procedure is cancelled or terminated prior to the induction of anesthesia or the 2051 administration of drugs or medication, but there has been a pre-surgical anesthesia assessment, 2052 then code the anesthesia with the appropriate low level E&M. 2053 2054 If the surgical procedure is cancelled or terminated after preparation of the patient for anesthesia, 2055 assign the anesthesia code for the anticipated surgical procedure, along with the appropriate 2056 modifier -53 for discontinued procedure. 2057 2058 6.1.11. Aborted Procedure 2059 If the surgical procedure is cancelled or terminated (not patient elective) after the surgical 2060 procedure has started, assign the appropriate anesthesia code for the procedure in the routine 2061 manner, based on the actual procedure performed. Do not use modifier -53 on anesthesia codes. 2062 Modifier -53 would be used on the surgical procedure code. 2063

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SPECIALTY CODING 6.1. Anesthesia

2064 6.1.12. Monitored Anesthesia Care (MAC) 2065 MAC entails intra-operative monitoring of the patient’s vital physiological signs in anticipation 2066 of the need for administration of general anesthesia or in the event the patient develops physical 2067 complications from the surgical procedure. To report MAC, the anesthesia provider must: 2068 2069  provide a pre-anesthesia evaluation and examination; 2070  prescribe the anesthesia plan; 2071  dispense any oral or parenteral anesthesia drugs to the patient; 2072  provide intra-procedural monitoring of patient’s vital signs, maintenance of the patient’s 2073 airway, and continual evaluation of vital functions; 2074  conduct any postoperative care needed; and 2075  maintain adequate medication and ensure pharmacological equipment is readily available 2076 at all times. 2077 2078 Because MAC requires at least the same level of monitoring as that of general anesthesia, it is 2079 treated the same as general anesthesia except that the appropriate modifiers should be coded 2080 when they become available in the DoD system. Medical necessity must be documented to 2081 support the need for MAC. 2082 2083 6.1.13. Reporting Qualifying Circumstances 2084 Additional codes are needed to report unusually difficult circumstances for anesthesia 2085 administration. The qualifying circumstances codes are in the Medicine Section of the CPT. 2086 They are also listed in the beginning of the Anesthesia Section of the CPT coding manual. These 2087 codes are not stand-alone codes. More than one qualifying circumstance code can be used if 2088 applicable. 2089 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). 2090 2091 6.1.14. Postoperative Pain Management 2092 2093 6.1.14.1. Overview 2094 The most common techniques for postoperative pain control are patient-controlled analgesia 2095 (PCA), epidural analgesia, and nerve blocks. Postoperative pain management is only reported 6-5 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.1. Anesthesia

2096 when the attending surgeon requests, in writing, that the anesthesia provider performs 2097 significant, separately identifiable services, such as ongoing critical care services, postoperative 2098 pain management services, or extensive unrelated ventilator management. 2099 2100 6.1.14.2. Patient Controlled Analgesia 2101 PCA therapy is a technique for pain management that involves self-administration of intravenous 2102 drugs through an infusion device. When PCA is initiated in the recovery room by an 2103 anesthesiologist as part of the anesthesia time, the initial set-up time for PCA may be 2104 incorporated into the total number of anesthesia time units reported. 2105 2106 6.1.14.3. Epidural 2107 Epidural analgesia involves the administration of a narcotics drug through an epidural catheter. 2108 Insertion of an epidural catheter should be reported as a separate procedure code. Management 2109 of epidural or subarachnoid drug administration (CPT code 01996) is reported on dates of service 2110 after the date of the surgery. Management of epidural or subarachnoid drug administration is 2111 limited to one unit of service per postoperative day, regardless of the number of visits necessary 2112 to control the catheter per postoperative day. Postoperative pain management services are 2113 generally provided by the surgeon, who is reimbursed under a global payment policy related to 2114 the procedure and is reported by the anesthesia provider only when separate, medically necessary 2115 services are required that cannot be rendered by the surgeon. The surgeon is responsible for 2116 documenting in the medical record the reason care is being referred to the anesthesia provider. 2117 2118 6.1.14.4. Nerve Block 2119 A nerve block injection involves injection of an anesthetic agent into or around a given nerve. 2120 When an injection or block is administered postoperatively by an anesthesia provider in the 2121 recovery room as part of the anesthesia time, any additional time required for the injection may 2122 be included in the total number of anesthesia minutes reported. 2123 2124 6.1.15. Physical status modifiers are used in the civilian sector but not currently used in DoD. 2125 2126 6.1.16. Anesthetic Agents 2127 Anesthetic agents, as well as other medications (e.g., anti-emetics, antibiotics) are part of the 2128 institutional component of the surgery. They are not coded separately. 2129

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SPECIALTY CODING 6.2. Audiology

2130 6.2. Audiology 2131 2132 6.2.1. Evaluation & Management (E&M) Rules 2133 E&M codes are not appropriate for routine audiology encounters for procedures. The medical 2134 E&M components of an outpatient office visit are already included in the special procedures 2135 codes listed in the Special Otorhinolaryngologic Services subsection. 2136 2137 Encounters with patients for whom no procedure is done are reported with an E&M code 2138 (99201–99205 or 99211–99215) based on the chief complaint, history, exam, and decision 2139 making documented in the medical record. 2140 2141 6.2.2. Diagnosis Coding Rules 2142

2143 DoD Rule

2144 2145 Deployment-related encounters will code one of the following: V70.5_4 for pre- 2146 deployment, V70.5_5 during deployment, or V70.5_6 for post-deployment related 2147 conditions. See section 2.2.8.2. 2148 2149 6.2.2.1. Extender Codes 2150 2151 See Appendix D for a complete list of all extender codes. 2152 2153 V72.1 Examination of Ears and Hearing 2154  V72.11* 0 Encounter for Hearing Examination Following Failed Hearing 2155 Screening. 2156  V72.11* 1 Encounter for Hearing Examination Following Failed Hearing 2157 Screening, Otoscopic Exam Done 2158  V72.11* 2 Encounter for Hearing Examination Following Failed Hearing 2159 Screening, Otoscopic Exam Not Performed 2160  V72.19* 0 Other Examination of Ears and Hearing 2161  V72.19* 1 Other Examination of Ears and Hearing, Otoscopic Exam Done 2162  V72.19* 2 Other Examination of Ears and Hearing, Otoscopic Exam Not Performed 2163 2164 6.2.2.2. Hearing Conservation Program (HCP) 2165 HCP guidelines in DA Pam 40–501 or other Service guidelines require all military and civilian 2166 personnel who routinely work in noise-hazardous areas to have reference (base line), annual, and 2167 terminal audiograms. 2168 2169 6-7 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.2. Audiology

2170 DoD Rule 2171 2172 Hearing Conservation Program services are coded in a Special Program service in 2173 an F MEPRS clinic (FBN*). Please refer to your Service MEPRS Office for work 2174 load reporting. 2175

2176 2177 Hearing tests performed in other than an audiology clinic or for HCP are reported in the clinic 2178 where the test or procedure is performed. These examination encounters are coded according to 2179 the table below. The table includes only codes for HCP encounters leading to referral to an 2180 audiology clinic. 2181

2182 DoD Rule 2183

2184 Official ICD-9-CM coding guidelines state that both V70.5 and V72 codes 2185 are only listed first. Code V72 excludes V70.5. However, for the DoD to identify the 2186 specific type of HCP exam, particularly those with an identified significant 2187 threshold shift (STS), or permanent threshold shift (PTS), both codes are reported 2188 in the order shown for HCP exams. 2189 2190 HEARING CONSERVATION PROGRAM (HCP) TABLE

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SPECIALTY CODING 6.2. Audiology

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)

2191 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 2192 * Indicates there are various 4th and 5th digits or extender codes that may be assigned to indicate a specific 2193 condition or encounter 2194 ** For patients tested using Defense Occupational and Environmental Health Readiness System-Hearing 2195 Conservation (DOEHRS-HC). 2196 *** Code to be used by non-professionals (e.g., technicians, nurses, volunteers). Only physicians or 2197 audiologists may diagnose noise-induced hearing loss. 2198 2199 NOTE: 99078 may be used as an additional code if physician education services are 2200 provided in a group setting. 2201 2202 6.2.2.3. Hearing Loss Caused by Injury 2203 Initial encounters for hearing loss acquired from performance of duties, but not associated with 2204 physical trauma to the head will be identified with the appropriate E code as a secondary 2205 diagnosis. E codes are only used for the first encounter for the condition that was caused by the

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SPECIALTY CODING 6.2. Audiology

2206 situation described by the E code. There is an injury or accident field in the ADM that should be 2207 answered yes each time the patient is seen for a condition caused by an accident or injury. 2208 2209 E923.8 Other Explosive Material—explosions not a result of war operations 2210 E928.1 Exposure to Noise 2211 E993 Injury Caused by War Operations by Other Explosion—including 2212 accidental explosion of own weapon 2213 E995 Injury Caused by War Operations by Other and Unspecified Forms 2214 of Conventional Warfare—for hearing losses caused by exposure to 2215 other noises during war operations 2216 2217 6.2.2.4. Early Hearing Detection and Intervention (EHDI) 2218 EHDI will not be coded on the SIDR. EHDI screening exams and interventions are coded 2219 according to the table below. The table includes only codes for EHDI encounters. 2220 2221 NEWBORN EARLY HEARING DETECTION AND INTERVENTION 2222 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 2223 * Code to be used by non-professionals (e.g., technicians, nurses, volunteers). 2224 ** Indicates there are various 4th and 5th digits that may be assigned to indicate a specific condition or 2225 encounter 2226 *** Initial screening exam for patients not tested in the hospital prior to discharge from birth episode. 2227 2228 6.2.3. Procedural Coding Rules 2229 2230 6.2.3.1. CPT procedure Codes for Audiology 2231 These services are in the Special Otorhinolaryngologic Services subsection of the Medicine 2232 section (92502–92700). Codes in the 92500 series do not require the supervision of a physician. 2233 Tests in this series can be performed by a qualified audiologist, but diagnostic procedures must 2234 be ordered by a physician. 6-10 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.2. Audiology

2235 6.2.3.2. Cerumen Removal 2236 Removal of cerumen is considered integral to audiology services. Instillation of drops, minor 2237 scraping, or simple irrigation is bundled into the evaluation portion of audiology service. If a 2238 physician removes impacted cerumen before audiology testing, the physician should use code 2239 G0268. In all other circumstances, use 69210 for removal of impacted cerumen. Removal of 2240 cerumen to see the tympanic membrane is included in the E&M component. The physician or 2241 audiologist may report separate E&M service with modifier -25. 2242 2243 6.2.3.3. Tinnitus 2244 Audiologists are qualified to evaluate, diagnose, develop management strategies, and provide 2245 treatment and rehabilitation for tinnitus patients. Diagnostic audiologic testing for tinnitus is 2246 reported with CPT code 92625. 2247 2248 6.2.3.4. Hearing Equipment Services 2249 Services related to fitting, providing or repairing hearing supplies and equipment, excluding 2250 implantable bone conduction devices, are reported with HCPCS Level II codes V5008–V5299. 2251 2252 6.2.4. Other Audiology Guidance 2253 2254 6.2.4.1. Documentation of Hearing Conservation 2255 The results of administering all aspects of monitoring audiometry with the DOEHRS HC 2256 equipment is documented by completion of the following: 2257 2258 DD Form 2215 Reference Audiogram 2259 DD Form 2216 Hearing Conservation Data 2260 2261 6.2.4.2. Dispositions or Referrals 2262 DOEHRS HC software will automatically determine if an Occupational Safety and Health 2263 Administration (OSHA)-reportable hearing loss (RHL) is present and will provide disposition 2264 instructions. 2265 2266 6.2.5. Modifiers 2267 TC Technical Component is used by technicians who perform tests in a different 2268 clinic than the one used by the audiologist who interprets the test and 2269 renders a report. 2270 26 Professional Component is used by the audiologist who only interprets tests 2271 performed elsewhere and provides a report. 2272 52 Reduced Service is used when audiologic function tests (except 92559) are 2273 performed on one ear only. 2274

6-11 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.3. Chiropractic Service

2275 6.3. Chiropractic Services 2276 2277 6.3.1. E&M Rules 2278 2279 6.3.1.2. Initial Encounter for a Problem 2280 If chiropractic manipulative treatment (CMT) was furnished during the initial encounter, 2281 indicating the chiropractor accepted the patient for treatment of the problem, and a separately 2282 identifiable chiropractic evaluation was conducted, use an E&M code, usually in the new or 2283 established office visit codes (9920x/9921x) with a modifier -25, along with the CMT procedure 2284 code (98940–98943). 2285 2286 6.3.1.3. Referrals 2287 If there is a request for the chiropractor to evaluate and treat the patient, this is a referral. CMT 2288 covers pre- and post-services, including an assessment specific to CMT. The documentation 2289 must reflect a history, exam or decision of something not related to the CMT to use a separate 2290 E&M code. 2291 2292 6.3.1.4. Consult When CMT Not Appropriate 2293 If there is a request for evaluation and advice, and the chiropractor determines that CMT is not 2294 appropriate for the patient, and sends advice back to the provider who requested the consult, and 2295 all other requirements are met, the appropriate office visit code should be used. 2296 2297 6.3.1.5. Consult When CMT Is Appropriate 2298 When there is a request for evaluation and advice; the chiropractor determines that CMT would 2299 be appropriate but has not yet begun it; the chiropractor sends advice back to the consulting 2300 provider and meets all other requirements, the appropriate office visit code should be used. 2301 2302 6.3.1.6. CMT 2303 When an encounter is for CMT and the evaluation is limited to reviewing data to ensure CMT is 2304 still appropriate, there is no separately identifiable E&M and only the CMT code should be used. 2305 2306 6.3.1.7. Reevaluation 2307 When there are separately identifiable E&M services beyond those needed for CMT, such as 2308 when the chiropractor re-exams the patient to obtain objective measures of progress, and the 2309 treatment plan is modified as necessary, a separate E&M coded (usually from the established 2310 office visit range, 9921x) should be coded. 2311 2312 6.3.1.8. The AT Modifier 2313 Use the AT modifier when the treatment is for active or corrective treatment, when the 2314 documentation shows that treatment is medically reasonable or necessary under Medicare rules. 2315 The AT modifier is not used for maintenance therapy, such as services that seek to prevent 2316 disease, promote health, maintain or prevent deterioration of a chronic condition, or enhance the 2317 quality of life. 2318

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SPECIALTY CODING 6.3. Chiropractic Service

2319 6.3.2. Procedural Coding Rules 2320

2321 DoD Rule 2322 2323 The CMT procedure codes are 98940–98943. Use only one code per session unless 2324 both spinal and extra spinal are performed. 2325 2326 6.3.2.1. Manual Therapy Techniques 2327 Manual therapy techniques are coded 97140. The provider uses his/her hands to perform soft 2328 tissue massage and joint mobilization, manipulation, manual traction, or manual lymphatic 2329 drainage to one or more areas. The code requires direct one-on-one contact with the patient. 2330 2331 6.3.3. Modifiers 2332 25 Separate or distinct E&M services 2333 51 Multiple procedures (when unrelated procedures are done at the same 2334 encounter) 2335 59 Distinct procedural service (when one code is usually included in another 2336 but for an unusual reason both were done separately). 2337

6-13 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.4. Dialysis

2338 6.4. Dialysis 2339 2340 6.4.1. E&M Rules 2341 E&M services associated with or related to the performance of dialysis, performed on the same 2342 day as the dialysis, are included in the dialysis procedure; therefore, no separate E&M code is 2343 reported. If there is a separately identifiable E&M, unrelated to the dialysis, that E&M shall be 2344 coded based on documentation and appended with modifier 25. 2345 2346 6.4.2. Procedural Coding Rules. See 6.5.5 for a sample list of dialysis procedures. 2347

2348 DoD Rule 2349 2350 Dialysis, hemodialysis, and peritoneal dialysis are ancillary services. They should be 2351 given the appropriate procedure code 90935–90999 and should be coded in the D 2352 MEPRS.

2353 2354 6.4.2.1. Individual Dialysis Therapy Encounters 2355 In the MHS, each encounter is coded. Therefore, except for the first encounter of the month, 2356 each encounter is coded using an unlisted code of 90999 in the CPT/Procedure field 2357 2358 6.4.2.2. Monthly Dialysis Codes 2359 The monthly dialysis codes will always be used for the first dialysis of the new month to reflect 2360 the previous month’s treatment. For instance, it will reflect 31 days for January and 30 days for 2361 April. 2362

2363 DoD Rule

2364 2365 When a dialysis service is performed, no procedure codes will be reported, except 2366 for the first encounter of the month to reflect the previous month’s services. 2367 2368 Hint: To determine the number of dialysis encounters during the month, use the 2369 patient appointment history in AHLTA/CHCS. 2370 2371 6.4.2.3. Dialysis for Less than an Entire Month 2372 Dialysis does not always begin the first day of the month. On the first dialysis of the month 2373 following initial treatment, instead of the monthly code, use the per day codes to reflect services 2374 from the start of care through the end of the prior month. Code 90967-90970 should be reported 2375 for each day outside of inpatient hospitalization. 6-14 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.4. Dialysis

2376 2377 Example: A 10 yr. old patient is admitted to the hospital on the 11th of the month and 2378 discharged on the 27th. On the first dialysis visit in the next month, code 90968 with a 2379 quantity of 13 for the days the patient was not an inpatient the prior month. (30 days in 2380 the month minus 17 days of hospitalization = 13 days). Report inpatient E&M services 2381 as appropriate. Dialysis procedures rendered during hospitalization are coded as part of 2382 the hospitalization. 2383 2384 6.4.2.4. Dialysis for Entire Month 2385 To code dialysis, the first visit of the month will be used to record the appropriate monthly or per 2386 day code for services the previous month. All other visits will use the unlisted dialysis code of 2387 90999 for the procedure. If any of the encounters of the prior month were conducted by a non- 2388 privileged provider, the first encounter of the new month must be collected in the DGB or DGD 2389 MEPRS, with the individual performing the service that day listed as the provider. 2390 2391 6.4.2.5. Privileged Provider 2392 If a privileged provider performs the dialysis, the provider’s name should be listed as the primary 2393 provider. If a separately identifiable E&M service is performed, use the appropriate E&M code 2394 with modifier -25. When a privileged provider furnishes a dialysis service, the encounter will 2395 usually be collected in the BAJ MEPRS as a count encounter. 2396 2397 6.4.2.6. Non-Privileged Provider 2398 Dialysis procedures should only be conducted by a non-privileged provider following a written 2399 treatment plan of a privileged provider. When a non-privileged provider performs the dialysis, 2400 the non-privileged provider should be listed as the primary provider. 2401 2402 6.4.2.6.1. Dialysis treatment is usually done by non-privileged providers whose time is collected 2403 in the DGB or DGD MEPRS. Therefore, a “clinic” must be created in the DGB or DGD 2404 MEPRS where appointments will be created and marked as kept and ADM reports will be 2405 collected. When a non-privileged provider performs the service, the encounter must be entered as 2406 a non-count encounter. 2407 2408 6.4.3. Diagnosis Coding 2409 The first listed diagnosis, when the patient is only being seen for ongoing dialysis treatment, is in 2410 the V56 category. A secondary diagnosis will be used to explain why the dialysis is necessary, 2411 such as chronic kidney disease. 2412

6-15 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.5. End Stage Renal Disease Services (ESRD) (90951–90970)

2413 6.5. End Stage Renal Disease Services (ESRD) (90951–90970) 2414 2415 6.5.1. Included Services 2416 ESRD-related physician services include establishment of a dialyzing cycle, outpatient 2417 evaluation and management of the dialysis visits, telephone calls and patient management during 2418 the dialysis, provided during a full month. These codes are not used if a hospitalization 2419 occurred during the month. 2420 2421 6.5.2. E&M Rules 2422 The E&M services associated with or related to performance of dialysis for ESRD services, 2423 when performed on the same day as the dialysis, are included in the ESRD procedure. Therefore 2424 no separate E&M code is reported. If there is a separately identifiable E&M, unrelated to the 2425 dialysis procedure, that E&M shall be coded based on documentation and appended with 2426 modifier -25. 2427 2428 6.5.3. Procedural Coding Rules 2429 In general, using ESRD codes is similar to using the dialysis codes in section 6.4. Because 2430 ESRD is a Medicare-covered benefit there are specific HCPCS codes. These codes (90951- 2431 90970) are more detailed and are used when the code requirements are met. The HCPCS Level II 2432 codes are used in the same manner as the dialysis CPT (HCPCS Level I) codes. ESRD services 2433 are usually captured in the BAJ* MEPRS (Nephrology). 2434

2435 DoD Rule 2436

2437 When ESRD service is performed, no procedure codes will be reported, 2438 except for the first encounter of the month, to reflect the previous month’s services. 2439 2440 Hint: To determine the number of ESRD encounters during the month, use the 2441 patient appointment history in AHLTA/CHCS.

2442 2443 6.5.4. ESRD Diagnosis Coding 2444 Use ESRD 585.6. Use V42.0 as an additional code to identify kidney transplant status if 2445 applicable. 2446 2447 6.5.5. Dialysis and ESRD Procedure Code List. 2448 End Stage Renal Disease Services (90935-90970) 2449 2450 90951 ESRD-related services during the course of treatment, for patients under 2 years of age, 2451 including monitoring for adequacy of nutrition, assessment of growth and development and 2452 counseling of parents; with four or more face-to-face physician visits per month. 2453 6-16 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.5. End Stage Renal Disease Services (ESRD) (90951–90970)

2454 90952 ESRD-related services during the course of treatment for patients under 2 years of age, 2455 including monitoring for adequacy of nutrition, assessment of growth and development and 2456 counseling of parents; with two or three face-to-face physician visits per month. 2457 2458 90953 ESRD-related services during the course of treatment, for patients under 2 years of age 2459 including monitoring for adequacy of nutrition, assessment of growth and development, and 2460 counseling of parents; with one face-to-face physician visit per month. 2461 2462 90954 ESRD-related services during the course of treatment, for patients between 2 and 11 2463 years of age, including monitoring for adequacy of nutrition, assessment of growth and 2464 development and counseling of parents; with four or more face-to-face physician visits per 2465 month. 2466 2467 90955 ESRD-related services during the course of treatment for patients 2 to 11 years of age, 2468 including monitoring for adequacy of nutrition, assessment of growth and development and 2469 counseling of parents; with two or three face-to-face physician visits per month. 2470 2471 90956 ESRD-related services during the course of treatment, for patients 2 to 11 years of age, 2472 including monitoring for the adequacy of nutrition, assessment of growth and development, and 2473 counseling of parents; with one face-to-face physician visit per month 2474 2475 90957 ESRD-related services, during the course of treatment, for patients between 12 and 19 2476 years of age, including monitoring for the adequacy of nutrition, assessment of growth and 2477 development, and counseling of parents; with four or more face-to-face physician visits per 2478 month. 2479 2480 90958 ESRD-related services during the course of treatment, for patients between 12 and 19 2481 years of age to include monitoring for the adequacy of nutrition, assessment of growth and 2482 development, and counseling of parents; with two or three face-to-face physician visits per 2483 month. 2484 2485 90959 ESRD-related services during the course of treatment, for patients between 12 and 19 2486 years of age, including monitoring for the adequacy of nutrition, assessment of growth and 2487 development, and counseling of parents; with one face-to-face physician visit per month 2488 2489 90960 ESRD-related services during the course of treatment, for patients 20 years of age and 2490 older; with 4 or more face-to-face physician visits per month. 2491 2492 90961 ESRD-related services during the course of treatment, for patients 20 years of age and 2493 over; with two or three face-to-face physician visits per month. 2494 2495 90962 ESRD-related services during the course of treatment, for patients 20 years of age and 2496 over; with one face-to-face physician visit per month. 2497

6-17 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.5. End Stage Renal Disease Services (ESRD) (90951–90970)

2498 90963 ESRD-related services for home dialysis patients per full month; for patients less than two 2499 years of age including monitoring for adequacy of nutrition, assessment of growth and 2500 development and counseling of parents. 2501 2502 90964 ESRD-related services for home dialysis patients per full month; for patients two to 2503 eleven years of age including monitoring for adequacy of nutrition, assessment of growth and 2504 development and counseling of parents. 2505 2506 90965 ESRD-related services for home dialysis patients per full month; for patients 12 to 19 2507 years of age, including monitoring for adequacy of nutrition, assessment of growth and 2508 development and counseling of parents 2509 2510 90966 ESRD-related services for home dialysis patients per full month; for patients 20 years of 2511 age and older 2512 2513 90967 ESRD-related services less than full month, per day; for patients under 2 years of age. 2514 2515 90968 ESRD-related services less than full month, per day; for patients 2 to 11 years of age. 2516 2517 90969 ESRD-related services less than full month, per day; for patients 12 to 19 years of age. 2518 2519 90970 ESRD-related services less than full month, per day; for patients 20 years of age and 2520 older. 2521

6-18 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.6. Flight Medicine Services

2522 6.6. Flight Medicine Services 2523 2524 NOTE: Referral to flying status includes air traffic control duty. Reference to air crew 2525 member includes air traffic controller. 2526 2527 6.6.1. E&M Rules 2528

2529 DoD Rule

2530 2531 Annual/periodic flight exams are reported as comprehensive preventive medicine 2532 encounters (99384–99397). Treatment of conditions identified, regardless of 2533 whether they are pre-existing or identified in the course of the preventive medicine 2534 encounter, are coded separately per the instructions in the Preventive Medicine 2535 Services subsection of the CPT manual. To use the code range 99384–99397, an 2536 examination must be performed. 2537 2538 6.6.1.1. Encounters for Approval for Flying Status 2539 Encounters that do not meet the requirements of a comprehensive preventive medicine service 2540 are reported as either individual counseling preventive medicine services (no medical problems 2541 and meets the requirements of preventive medicine counseling, use codes 99401–99404) or as 2542 office visit or other outpatient services (for a medical issue, use codes 99201–99215). When 2543 documentation supports only the use of a 99211, it is appropriate for providers to use the 99211 2544 code. 2545 2546 6.6.2. Diagnosis Coding Rules 2547

2548 DoD Rule 2549

2550 Annual flight exams are reported with V70.5_1 as the first listed diagnosis. 2551 Any pre-existing or newly diagnosed conditions are listed as additional diagnoses. 2552 2553 Encounters for post-deployment conditions (confirmed or suspected) will have the 2554 reason for the encounter listed in the primary diagnosis field with V70.5_6 listed as 2555 a secondary code. This rule takes precedence over any other diagnosis coding rule. 2556

2557 2558 6.6.2.1. The following information provides guidance on coding flight physicals: 2559 6-19 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.6. Flight Medicine Services

2560 1. Initial flight exam, no symptoms 2561 a. Diagnosis code: V70.5 1 Aviation exam 2562 b. E&M: 993xx Age-appropriate prevention exam 2563 c. CPT procedures *: 92551/2/3 Pure tone audiometry tests (specify if air, 2564 bone, etc.) 2565 93000** EKG, interpretation & report 2566 93005 EKG, tracing only 2567 93010 EKG, interpretation & report only 2568 d. Visual Screening 99172/3 Visual Acuity Screen 2569 * Procedures are coded if performed and properly documented in flight 2570 medicine clinic note(s). 2571 ** Choose appropriate EKG test performed in flight medicine clinic 2572 2573 2. Annual flight exam, normal, no symptoms 2574 a. Diagnosis code: V70.5 1 Aviation exam 2575 b. E&M: 993xx Age-appropriate prevention exam 2576 c. CPT procedures *: 92551/2/3 Pure tone audiometry tests (specify if air, 2577 bone, etc.) 2578 93000** EKG, interpretation & report 2579 93005 EKG, tracing only 2580 93010 EKG, interpretation & report only 2581 d. Visual screening 99172/3 Visual acuity screen 2582 * Procedures are coded if performed and properly documented in Flight 2583 Medicine Clinic note(s). 2584 ** Choose appropriate EKG test performed in Flight Medicine Clinic 2585 2586 3. Annual flight exam with symptoms, disease found, or acute exacerbation of chronic 2587 condition 2588 a. Diagnosis codes: V70.5 1 Aviation exam 2589 xxxxx Code the symptom/disease found on 2590 examination 2591 b. E&M: 993xx Age-appropriate prevention exam. 2592 992xx Appropriate office encounter. Add 2593 modifier -25 to show a separate E&M 2594 service was provided. 2595 c. CPT Procedure: xxxxx List any procedures performed for the flight 2596 exam as outlined in Item 1. List any additional procedures 2597 performed that relate to the symptom or disease found on 2598 examination. 2599 2600 4. Flight exam, chronic condition (not active or influencing flight status) 2601 a. Diagnosis code: V70.5 1 Aviation exam 2602 xxx.xx Code chronic condition (e.g. hypertension) 2603 b. E&M: 993xx Age-appropriate prevention exam

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2604 c. CPT Procedures: xxxxx List any procedures performed for 2605 the flight exam as outlined in Item 1. 2606 2607 5. Flight exam, active condition or disease influencing flight status 2608 a. Diagnosis code: xxx.xx Code active condition of symptom/disease 2609 that removed individual from flight status 2610 b. E&M: 992xx Appropriate office encounter 2611 c. CPT procedures: xxxxx List any procedures performed during office 2612 visit 2613 2614 6. Return-to-flight status, (after illness/injury) currently no symptoms 2615 a. Diagnosis code: V68.09 Medical certificate 2616 b. E&M: 9921x Appropriate E&M office visit 2617 2618 7. Flight Exam, waiver renewal (face-to-face) 2619 a. Diagnosis code: V68.09 Medical certificate (waiver) 2620 b. E&M: 992xx Appropriate office visit code 2621 99358/9* Prolonged services, non-face-to-face 2622 c. CPT procedure: 99080 Special reports (service specific waiver 2623 report) 2624 2625 * Prolonged services code would be assigned when the provider reviews records, tests and 2626 communications with professionals and family. This would be in addition to time spent with 2627 the patient—99358-first hour of review of tests and communication with other professionals 2628 and family. Code 99359 identifies any additional 30 minutes. 2629 2630 8. Ground testing, no adverse effects of drugs 2631 a. Diagnosis code: V70.5 1 Aviation exam 2632 b. E&M code: 992xx Appropriate office visit 2633 (new/established) 2634 c. CPT procedure: None 2635 2636 9. Ground testing, with adverse effects of drugs 2637 a. Diagnosis code: 995.2 Adverse effect of correct drug 2638 properly administered 2639 780-789.xx Symptom code or appropriate ICD 2640 code to describe the drug interaction 2641 E930-E949.x Cause of injury code to identify the drug 2642 reaction 2643 b. E&M code: 9921x Appropriate Office Visit 2644 c. CPT procedure: List any procedures/counseling performed 2645 2646 10. Incentive Flight/Chamber/Survival Training clearance encounters 2647 a. Diagnosis code: V70.5_1 Aviation exam

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2648 V65.43 Counseling on injury prevention (survival 2649 training) 2650 b. E&M code: 99384/86 New patient preventive exam, 2651 OR 2652 99394/96 Established patient prevention exam 2653

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SPECIALTY CODING 6.7. Gynecology

2654 6.7. Gynecology 2655 2656 6.7.1. E&M Rules 2657 2658 6.7.1.1. Office Visit 2659 The most common type of E&M is the office visit for a symptom, condition, or disease. Office 2660 visits are coded 99201–99215. 2661 2662 6.7.1.2. Well Woman Exam 2663 If a complete general physical exam is performed, use preventive medicine E&M codes 99384– 2664 99387 for new patients and 99394–99397 for established patients. When a patient is seen for a 2665 physical and has a separately identifiable symptom, condition, or disease that requires significant 2666 time or resources, it should be documented and coded separately. Append the modifier -25 to the 2667 appropriate office E&M. When a patient is seen for a physical and a screening Pap smear is 2668 collected at the time, code the E&M and collect Q0091 in the CPT/HCPCS field. 2669 2670 6.7.1.3. Counseling 2671 Visits specifically for initial contraceptive management are coded to preventive medicine. 2672 Should the encounter not include an exam, counseling is reported as 99401–99404. Subsequent 2673 visits for contraceptive management are reported as established patient office visits. 2674 2675 6.7.2. Diagnosis Coding Rules 2676

2677 DoD Rule 2678

2679 Well-Woman Exams 2680 V72.31 Is reported for a complete physical exam with a gynecology 2681 component. 2682 Use these codes in addition to V72.31 when appropriate: 2683 V76.47 Special screening for malignant neoplasms, vagina (For post- 2684 hysterectomy patients) 2685 V88.01-.03 Acquired absence of the cervix and uterus 2686 Report the code(s) for any problem (s) also addressed during the encounter.

2687 2688 6.7.2.1. Screening Pap 2689 When a screening Pap smear is done, one of the following diagnosis codes is reported and 2690 linked to the HCPCS codes for the exam. 2691 2692 V67.01 Vaginal Pap Smear s/p hysterectomy for malignant condition 2693 (use additional codes for acquired absence of genital organs V88.01-.03) 2694 V76.2 Cervical Pap Smear (Routine) 6-23 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.7. Gynecology

2695 V76.47 Vaginal Pap Smear s/p hysterectomy for non-malignant condition 2696 (use additional codes for acquired absence of genital organs V88.01-.03) 2697 V76.49 Special screening for malignant neoplasm, other sites. 2698 V15.89 Other specified personal history presenting hazards to health. 2699 (Used for women considered to be at high-risk for cervical cancer. Examples 2700 would be screenings for patients with early onset of sexual activity, patients 2701 exposed to DES in the womb, patients with more than five sexual partners in a 2702 lifetime, and patients who have had a sexually transmitted disease.) 2703 2704 NOTE: If the original pap smear did not contain an adequate sample, and the patient returns to 2705 obtain a new smear, code 795.08 nonspecific abnormal Pap smear of cervix, unsatisfactory 2706 smear. 2707 2708 An additional diagnosis code may be used to identify the high-risk factor, such as V69.2 “High- 2709 Risk Sexual Behavior.” 2710

2711 DoD Rule 2712

2713 Use Q0091 to code the collection of screening Pap smear. In the MHS, it is 2714 appropriate to code the V76 screening code when using the Q0091, including when 2715 this occurs during a well-woman visit, coded V72.31. 2716 2717 The collection of a diagnostic Pap is part of the exam component of an office visit 2718 and is not coded separately. 2719 2720 When a patient receives a breast and pelvic exam only and not enough of the 2721 health/preventive requirements to satisfy a physical, the G0101 continues to be the 2722 most appropriate code. 2723 2724 6.7.2.2. Diagnostic Pap 2725 Pap smears completed on women who have had previous cancer of the female genital tract are 2726 diagnostic, not screening, Pap smears. They are for a medically necessary reason, regardless of 2727 the presence or absence of symptoms. The appropriate personal history diagnosis code is 2728 reported. 2729 2730 Example: V67.01 would be used for diagnostic vaginal pap smear s/p hysterectomy for 2731 malignant condition (use additional codes for acquired absence of genital organs V88.01- 2732 .03). 2733 2734 2735 6.7.2.3. Abnormal Followed by Normal Pap 6-24 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.7. Gynecology

2736 If a woman has an abnormal Pap smear and then a follow-up Pap smear is normal, two more Pap 2737 smears are usually done to confirm the normal result. These encounters will be coded V72.32. 2738 2739 6.7.2.4. Contraceptive Management 2740 A code from V25 is used when a contraceptive management procedure or counseling is done 2741 during an encounter. 2742 2743 6.7.2.5. Pregnancy Testing 2744 Encounters for the purpose of pregnancy testing are to be coded as follows, based on the results 2745 of the test or exam known at the time of the encounter. 2746 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 2747 2748 6.7.3. Procedural Coding Rules 2749 2750 6.7.3.1. No Coding for Contraceptives 2751 Contraceptive supplies or medications dispensed through the pharmacy are not coded. 2752 2753 6.7.3.2. Procedures for Implantable Contraceptive Capsules 2754 These are coded in the Integumentary subsection (e.g., 11980, 11981, 11982, and 11983) of the 2755 CPT manual. If the patient is coming in with an implanted contraceptive capsule (e.g., Norplant) 2756 and wants it removed, use code 11976. Non-implantable devices are in the Female Genital 2757 System subsection (e.g., 58300). 2758 2759 6.7.3.3. Pelvic Exam under Anesthesia 2760 This (57410) is commonly miscoded in the clinic setting. A pelvic is part of the exam 2761 component of an office visit and the preventive medicine service (e.g., physical). There is no 2762 separate code for a pelvic exam. 2763 2764 6.7.4. Modifiers 2765 A -25 modifier is appended to the E&M code when a procedure is performed as well as a 2766 separately identifiable E&M. Do not use the -25 modifier with E&Ms done at the same time as 2767 laboratory tests (e.g., KOH, wet prep). 2768

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2769 6.8. Mental Health 2770 2771 6.8.1. Evaluation & Management (E&M) Rule 2772

2773 DoD Rule 2774 2775 Air Force will follow guidance in the Mental Health Coding Handbook.

2776 2777 6.8.1.1. Mental Health Screenings 2778 When a patient presents for a pre-deployment, post-deployment, security clearance, in and out 2779 processing, etc., these are considered screenings and not Diagnostic Evaluations. These visits 2780 will be coded with a HCPCS code of H0031 (Mental Health Assessment) or H0046 (Mental 2781 Health Services) if performed by a Social Worker. When performed by a psychiatrist, behavioral 2782 health Nurse Practitioner, Physician Assistant or psychologist with prescribing privileges will 2783 use an E/M service code (99201-99215). 2784 2785 NOTE: Screenings are when the patient presents without signs or symptoms of a mental health 2786 condition or existing mental health diagnosis. If a patient is seeking help for a physical condition, 2787 see the guidelines for Health and Behavioral Assessment and Intervention codes. 2788 2789 6.8.1.2. Inpatient Treatment without Therapy 2790 See section 9 for other coding guidance on inpatient services. 2791 2792 6.8.2. Diagnosis Coding Rules 2793 2794 6.8.2.1. Diagnostic and Statistical Manual (DSM) 2795 Mental health diagnoses are based on terminology and codes in the Diagnostic and Statistical 2796 Manual of Mental Disorders (DSM IV). Although the terminology in ICD-9-CM or CHCS does 2797 not always match the terminology in DSM IV, use the mental health codes in the 290–320 range 2798 in ICD-9-CM. 2799 2800 NOTE: Do not use the “Axis” in AHLTA when selecting an ICD9 code. 2801 2802 2803 6.8.2.2. Patients without Mental Disorder Diagnosis 2804 Some encounters are with patients or clients who do not have a mental disorder diagnosis. Use 2805 the appropriate sign/symptom code, or there are V codes that can be used to describe these 2806 encounters, such as: 6-26 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.9. Nutritional Medicine Encounters

2807  799.21 Nervousness 2808  799.22 Irritability 2809  799.23 Impulsiveness 2810  799.24 Emotional liability 2811  799.25 Demoralization and apathy 2812  799.29 Other signs and symptoms involving emotional state 2813  799.3 Debility, unspecified 2814  799.51 Attention or concentration deficit 2815  799.52 Cognitive communication deficit 2816  799.59 Other signs and symptoms involving cognition 2817  V40 Mental and behavioral problems 2818  V60.2 Financial problems 2819  V61 Other family circumstances, including 2820 o V61.10 Counseling for marital and partner problems 2821 o V61.49 Presence of sick or handicapped person in family or household 2822 o V62.82 Bereavement 2823  V71.09 Observation for other suspected mental condition 2824

2825 DoD Mental Health Extender Codes 2826 2827 Mental health diagnosis extender codes are a group of ICD-9 codes that have 2828 been modified to meet the needs of the Services. The extender is paired with 2829 an ICD code to acquire a unique meaning. Use the appropriate extender for 2830 the type of service provided. DOD mental health diagnoses extender codes 2831 can be used in any clinical setting.

2832 2833 6.8.2.3. DOD Mental Health Diagnoses with Extender Codes 2834 2835 V65.42_0 Alcohol education 2836 V65.42_1 Substance abuse counseling 2837 V65.49_1 Medication education 2838 V65.49_7 Occupational stress education 2839 V65.49_8 Mental health education 2840 V65.49_9 Other specified counseling 2841 V65.49_A Stress education 2842 V65.49_B Suicide education 2843 6-27 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.9. Nutritional Medicine Encounters

2844 NOTE: Counseling codes are not necessary to capture when the counseling pertains to an 2845 existing diagnosis being treated. Example: V65.49 A is not needed if the patient has a 2846 diagnosis of Stress Reaction. 2847 2848 6.8.3. Procedural Coding Rules 2849 2850 6.8.3.1. Four Code Groups for Mental Health 2851 There are four major groups of procedure codes commonly used by mental health and life skills 2852 providers. They are the psychiatry and biofeedback CPT codes 90785–90899; the central 2853 nervous system assessments/tests CPT codes 96101 - 96125; health and behavior 2854 assessment/intervention CPT codes 96150–96155; and the HCPCS H codes for mental health 2855 and alcohol/drug abuse treatment services. 2856 2857 6.8.3.2. 90785 Interactive Complexity 2858 CPT code 90785 is an add-on code which is used to describe an encounter in which specific 2859 communication factors complicate the delivery of a psychiatric procedure. Examples of 2860 communication factors include: 2861 2862  Use of play equipment, other physical devices, interpreter, or translator to communicate 2863 with the patient to overcome barriers 2864 2865  Maladaptive communication problems (related to high anxiety, high reactivity, repeated 2866 questions, disagreement) that complicate delivery of care 2867 2868  Caregiver emotions or behavior interfering with understanding and ability to assist in 2869 plan of care 2870 2871  Evidence or disclosure of a sentinel event and mandated report to third party (abuse or 2872 neglect with report to state agency) with initiation of discussion of the sentinel event 2873 and/or report with patient and other vital participants 2874 2875 CPT 90785 may be reported in conjunction with codes for diagnostic psychiatric evaluation, 2876 psychotherapy, psychotherapy with an E/M service, and group psychotherapy. 2877 2878 6.8.3.3. Psychiatric Diagnostic Evaluation 2879 The Psychiatric diagnostic evaluation code, 90791 are used by all privileged mental health 2880 providers (e.g., social workers, psychologists, psychiatrists) . If the privileged mental health 2881 provider was unable to complete the psychiatric diagnostic evaluation at the initial encounter, a 2882 code would be selected for the initial encounter specifically on the basis of what 2883 services/procedures were performed. If an established patient presents with a new mental health 2884 condition, a re-assessment of a current condition, or presents for a second opinion, a new 2885 psychiatric diagnostic evaluation may be required.

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2886 Psychiatric Diagnostic Evaluation with E/M service is used only by providers that are privileged 2887 to use an E/M service, such as psychiatrist, BH Nurse Practitioners, BH Physician Assistants. 2888 2889 Refer to CPT® guidelines for the description of psychiatric diagnostic evaluation with medical 2890 services (90792). The psychiatric diagnostic evaluation codes may not be reported more than 2891 once per day, and not on the same day as an E/M service performed by the same provider for the 2892 same patient. 2893 2894 6.8.3.3. Therapy with E&M 2895 The therapy with E&M codes are usually used only by psychiatrists and psychologists, or other 2896 qualified healthcare providers with prescriptive privileges. The E&M component must be 2897 documented separately and include the history, exam, and decision making. For therapy, the 2898 actual start and stop time or the total amount of time spent with a patient should be documented, 2899 because the therapy codes are time based. Time spent conducting the E&M component is not 2900 included in the therapy time. A separate diagnosis is not required for the reporting of E/M and 2901 psychotherapy on the same date of service. To report therapy with E/M services, the appropriate 2902 E/M code and psychotherapy code would be reported. 2903 2904 6.8.3.4 Psychotherapy for Crisis (90839, 90840) 2905 Psychotherapy for crisis is an urgent assessment and history of a crisis state, a mental status 2906 exam, and a disposition. It includes psychotherapy and use of resources and psychotherapeutic 2907 interventions to help mitigate the crisis and potential for psychological trauma. The presenting 2908 problem is typically life threatening or complex and requires immediate attention to a patient in 2909 high distress. Face-to-face time does not have to be continuous, but the total face-to-face time 2910 must be documented. As with critical codes, the provider must devote his or her full attention to 2911 the patient for the time reported. The psychiatric diagnostic interview codes are not reported with 2912 codes 90839 and 90840. 2913 2914 6.8.3.5. 90885 Psychiatric Evaluation of Records 2915 This is a non-face-to-face code and is included in the initial diagnostic interview and therapy 2916 codes and is not used if codes 90791-90853 are used. Evaluation of all available applicable data 2917 is always part of treatment. This code is for a paper review of the patient, without seeing or 2918 treating the patient, to make a diagnosis. The documentation should reflect a review of the 2919 patients past medical and psychological history, current medications and treatments, and test 2920 results to gain an insight into the patient’s present condition and possible medical diagnosis and 2921 recommendations for further treatments. 2922 2923 6.8.3.6. 90887 Advising Family and Others How to Assist Patient 2924 This code is used when a provider summarizes results to the family when the patient is unable to 2925 communicate. It is not used in conjunction with 90791–90853. NOTE: this code is not used with 2926 multi-disciplinary meeting with other providers or medical staff members. 2927 2928 6.8.4. Documentation

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2929 When both therapy and an E&M are provided in the same encounter, the E&M documentation 2930 should be noted separately, after the end of the therapy note or on a separate page. 2931 2932 6.8.5. Auditing and Coding 2933 Mental health documentation coding and auditing will be performed in the mental health clinic 2934 by coding professionals in order to meet privacy and disclosure requirements. 2935 2936 DoD 6025.18R, para DL1.1.29. defines psychotherapy notes as, “Notes recorded (in any 2937 medium) by a healthcare provider who is a mental health professional documenting or analyzing 2938 the contents of conversation during a private counseling session or a group, joint, or family 2939 counseling session and that are separated from the rest of the individual’s medical record.” 2940 Psychotherapy, as defined in CPT, is the treatment for mental illness and behavioral 2941 disturbances in which the clinician establishes a professional contract with the patient and, 2942 through definitive therapeutic communication, attempts to alleviate emotional disturbances, 2943 reverse or change maladaptive patterns of behavior, and encourages personality growth and 2944 development. 2945 2946 An entry in the hard copy outpatient medical record or AHLTA, about the mental health 2947 encounter should include items excluded from the psychotherapy note as defined in DoD 2948 6025.18R, para DL1.1.29. “Psychotherapy notes exclude medication prescription and 2949 monitoring, counseling session start and stop times, the modalities and frequencies of treatment 2950 furnished, results of clinical tests, and any summary of the following items: diagnosis, functional 2951 status, the treatment plan, symptoms, prognosis, and progress to date.” 2952 This documentation should be sufficient to code a psychotherapy counseling encounter. 2953 However, if E&M services are provided, additional documentation may be required for auditing 2954 purposes. When outpatient documentation is sufficient, access to the separate mental health 2955 record or psychotherapy note may not be necessary for auditing. When such documentation is 2956 not sufficient, further documentation substantiating the coding will be made available to the 2957 auditor. 2958 2959 6.9. Nutritional Medicine Encounters 2960 2961 6.9.1. Evaluation & Management (E&M) Rules 2962 Nutritional medicine does not generate E&M services. 2963 2964 6.9.2. Privileged Providers, Dieticians 2965 2966 6.9.2.1. Physicians and Other Privileged Providers Not Registered Dieticians. 2967 Privileged providers other than registered dieticians should use an office E&M (e.g., 99201– 2968 99215) when consulting on nutritional therapy or intervention. These privileged providers (not 2969 Registered Dieticians) should use the preventive medicine codes (e.g., 99401–99412) when 2970 counseling individuals or groups on nutritional topics when the patients do not have symptoms, 2971 conditions, or diagnoses related to the topics being addressed. These privileged providers should

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2972 use the group education code (99078) when educating groups with symptoms, conditions or 2973 diagnoses related to the education topic. 2974 2975 6.9.2.2. Registered Dieticians 2976 2977 6.9.2.2.1. Preventive Medicine 2978 Registered dieticians may use the preventive medicine codes (99401–99412) when providing 2979 counseling or risk-factor reduction interventions. To use these codes, the patient should not have 2980 a symptom, condition, or diagnosis related to the topics covered. For example, registered 2981 dieticians may teach a Healthy Heart eating group. 2982 2983 6.9.2.2.2. Telephone Consultation 2984 Registered dieticians may use the appropriate telephone consultation code, as long as the 2985 documentation reflects the encounter was for a new issue, providing additional information on a 2986 nutrition-related topic. Telephone consults are not to be used for administrative encounters, such 2987 as reminding patients of appointments. Telephone consults are not to be used for continuations 2988 of previous encounters, such as providing websites for help groups when information was not 2989 available at the previous encounter. 2990 2991 6.9.2.2.3. Outpatient Consultation 2992 Both referrals and consults are requested using Standard Form (SF) 513. It is very infrequent 2993 when a provider requests advice (a consult) from a registered dietician on management of a 2994 medical condition (e.g., for this 211-pound male, which diet should I use to treat him?). Usually, 2995 the provider refers (a referral) the medical nutritional management of the patient to the registered 2996 dietician. The registered dietician’s medical nutritional therapy should be coded using the 2997 97802–97804 codes. 2998 2999 6.9.2.3. Non-Privileged Providers or Diet Technicians 3000 All diet technician visits are coded with the procedure code. If the technician is involved in the 3001 patient appointment conducted by a dietician (e.g. assesses the food diaries prior to the group 3002 encounter, which the dietician will conduct), the technician is considered an 3003 additional provider in ADM and the dietician is credited with the visit(s). Merely checking a 3004 patient in does not meet the requirement of an additional provider. 3005 3006 6.9.3. Diagnosis Coding Rules 3007 An outpatient visit to a nutrition clinic is coded with the ICD-9-CM code V65.3, Dietary 3008 Surveillance and Counseling. Other existing conditions would be coded as a secondary or 3009 additional diagnostic code. With ADM version 3.0, up to four diagnosis codes may be entered. 3010 3011 Examples of codes include the following: 3012  Colitis—558.9 3013  Diabetes mellitus—250.0_ (5th digit sub-classification 0–3)

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3014 . Requires an additional code for diabetic manifestations (e.g., acute angle- 3015 closure glaucoma, 365.22; peripheral neuropathy, 355.8; skin ulcer of 3016 lower extremity, 707.10) 3017  Dermatitis caused by food (allergies)—693.1 3018  Pure hypercholesterolemia—272.0 3019 3020 When a patient is seen for the cause of his weight gain (thyroid, etc.), use code V77.8 special 3021 screening for obesity in addition to the overweight/obese ICD codes. 3022 3023 Refer to 2.2.8.7. for BMI guidance 3024 3025 6.9.4. Procedural Coding Rules 3026 3027 6.9.4.1. Medical Nutritional Therapy (MNT) CPT codes 3028 3029 6.9.4.1.1. MNT; Initial Assessment and Intervention 3030 97802 is to be used only once each year, for initial assessment of a new patient, unless the patient 3031 is seen for a different condition with different therapy requirements than the prior initial 3032 assessment. Documentation must reflect the amount of face-to-face time with the patient. Enter 3033 the number of units (each 15 minutes) in the unit field. 3034 3035 6.9.4.1.2. MNT, Reassessment, and Intervention 3036 97803 should be used when there is a change in the patient’s medical condition that affects the 3037 nutritional status of the patient. Documentation must reflect the amount of face-to-face time 3038 with the patient. Enter the number of units (e.g., if the reassessment took 45 minutes, code a 3039 quantity of 3) in the unit field. 3040 3041 NOTE: MNT CPT codes (97802–97804) cannot be used in conjunction with the 3042 preventive medicine E&M codes (99401–99412). If the patient is receiving medical 3043 nutritional therapy and risk-factor reduction nutritional guidance (e.g., being briefed 3044 on low-sodium diet, but also receives counseling on general nutritional topics), the 3045 entire time would be coded for the MNT. 3046 3047 6.9.4.1.3. Registered Dieticians 3048 These individuals should use the appropriate medical nutritional therapy code (97802–97804) 3049 when conducting nutritional assessments and specific diet training. As these codes are time 3050 sensitive, the documentation must reflect the amount of time spent face-to-face with the patient. 3051 Time spent reviewing the food diary with the patient would be coded as part of the MNT 3052 encounter. 3053 3054 6.9.4.1.4. Certified Diet Technicians 3055 These individuals should use the nutritional medicine codes 97802–97804 for MNT. Diet 3056 technicians are authorized to provide instruction on those diets on which they have been 3057 certified.

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3058 3059 6.9.4.2. Education and Training for Patient Self-Management 3060 Services prescribed by a physician and provided by a qualified non-physician healthcare 3061 professional designed to teach patients how to effectively self-manage illness (es) or 3062 disease(s) including asthma and diabetes may be coded as follows when a standardized 3063 curriculum is used: 3064 98960 Face-to-face with patient each 30 minutes; individual patient 3065 98961 2-4 patients 3066 98962 5-8 patients 3067 3068 6.9.4.3. Group Counseling Performed by a Non-Privileged Provider 3069 Documentation of group counseling, per session, is required in each individual’s medical 3070 record, along with topics addressed and any specific patient-related issues. 3071  S9449 Weight management classes, non-physician 3072  S9451 Exercise class, non-physicians 3073  S9452 Nutrition class, non-physician 3074  S9455 Diabetic management program, group session 3075  S9460 Diabetic management program, nurse visit 3076  S9465 Diabetic management program, dietician visit 3077  S9470 Nutrition counseling, dietician visit 3078 3079 6.9.5. Units of Service 3080 3081 6.9.5.1. Time Spent as Unit of Service 3082 By marking the quantity column on the superbill, indicate the time spent with the patient as units 3083 of service for CPT code assignment. Example: One 30-minute reassessment visit equates to two 3084 units of service. 3085 3086 3087 6.9.5.1.1. Dietitian Outpatient Examples: 3088

3089 DoD Rule 3090 3091 Recording of documentation in AHLTA is not a separately code-able event. 3092 Encounters that do not meet minimum visit criteria are administrative and are not 3093 a coded visit.

3094 3095 1. A dietitian teaches a 45 minute nutrition segment of a multidisciplinary team 3096 diabetes education program (following the American Diabetes Association standardized 3097 curriculum). The dietitian reviews the patient diet history questionnaire which 6-33 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.9. Nutritional Medicine Encounters

3098 includes meds, labs, and exercise history. An individualized meal plan is provided to 3099 each patient and explained during the class. All patients are scheduled to return for two 3100 more follow-up visits to complete the series of classes. Once the class is completed, the 3101 RD documents the patient condition/diagnosis, initial assessment, diagnosis, counseling 3102 provided, and goals/action plan. 3103 Codes for example: 3104 3105  ICD-9-CM: V65.3, additional diagnosis of diabetes 250.00 or other diabetes 3106 related medical condition code, obese or overweight code and BMI code (if 3107 patient overweight/obese) 3108  E&M: N/A 3109  CPT: 97804 with 2 units of service 3110 3111 2. A dietitian spends 45 minutes reading about an uncommon medical condition and 3112 then develops a handout for a patient. The RD spends 30 minutes face-to-face with the 3113 patient, discussing the information on the handout and providing detailed diet 3114 instruction. After the appointment, the RD takes 15 minutes to input the note into 3115 AHLTA. Codes for example: 3116 3117  ICD-9-CM: V65.3 and the condition/diagnosis code 3118  E&M: N/A 3119  CPT code 97802 with 2 units of service. Only the actual face-to-face time 3120 with the patient is part of the procedural (MNT CPT) code. 3121 3122 3. A physician sends a request for assessment to the RD to see an obese patient 3123 for weight loss and consideration for bariatric surgery. The RD conducts a 60 3124 minute in-depth assessment for the patient’s readiness for behavior change, 3125 usual diet and exercise habits, measures current height and weight, and provides 3126 diet education and written materials. Codes for example: 3127 3128  ICD-9-CM: V65.3, morbid obesity 278.01, V85.39 (BMI range 39.0- 3129 39.9) 3130  E&M: N/A 3131  CPT: 97802 with 4 units of service 3132 3133 4. A dietitian teaches a 90 minute class on sports nutrition to a group of eight. 3134 The patients’ height, weight, and BMI are calculated. The dietitian works with 3135 each patient to determine estimated energy, protein, fluid, and carbohydrate 3136 needs. Individualized documentation for each patient is entered into AHLTA. 3137 Codes for example: 3138 3139  ICD-9: V65.3 only 3140  E&M: 99412 preventive medicine group code

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SPECIALTY CODING 6.9. Nutritional Medicine Encounters

3141  CPT: no NMT CPT codes are used with a preventive medicine E&M 3142 code 3143 3144 6.9.5.1.2. Diet Technician Outpatient Examples 3145 3146 1. A diet technician teaches a one-hour group cholesterol class. The technician 3147 has each patient fill out an information sheet, reviews each patient’s laboratory 3148 values, and documents the visit by assessing the patient condition, describing 3149 the education provided and educational materials, and the follow-up plan. 3150 Codes for example: 3151 3152  ICD9-CM: V65.3, dietary surveillance and counseling 3153  E&M: N/A 3154  CPT: 97804 with 2 units of service 3155 3156 2. The diet technician has a 30-minute follow-up visit with a patient who 3157 attended the cholesterol class described above. The technician analyzes the 3158 patient’s food diary, reviews any new relevant labs, provides specific 3159 recommendations on dietary changes, and documents the visit. ICD9-CM code 3160 V65.3, dietary surveillance and counseling. Codes for example: 3161 3162  ICD-9: V65.3, dietary surveillance and counseling 3163  E&M: N/A 3164  CPT: 97803, reassessment and intervention, with 2 units of service 3165 3166 NOTE: 99078 may be used as an additional code if physician education services are 3167 provided in a group setting. 3168 3169 3. A diet technician teaches the 30-minute nutrition segment of an obstetrics 3170 orientation. The diet tech assesses self-reported data on an SF 600 overprint for 3171 each attendee includes: current pregnancy weight, week’s gestation, total weight 3172 gain compared to expected weight gain, and usual diet intake or food frequently. 3173 The diet technician meets with each patient individually to ensure her 3174 understanding of the assessment and nutritional recommendations. Codes for 3175 example: 3176 3177  ICD-9: V65.3 and applicable pregnancy code (e.g., V22.0, supervision of 3178 normal first pregnancy or V22.1, supervision of subsequent pregnancy) 3179  E&M: N/A 3180  CPT: 97804 with 1 unit of service 3181 3182 6.9.6. Inpatient Therapy Examples: 3183

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SPECIALTY CODING 6.9. Nutritional Medicine Encounters

3184 DoD Rule 3185

3186 Inpatient nutrition consultation encounters are reported in ADM. When 3187 the screen prompts, Are you from the attending service? select no. This will create the 3188 encounter in ADM and will be reported in the B MEPRS. Nutritional screenings 3189 are not code-able services and will not be brought back as workload to the B 3190 MEPRS clinic. 3191

3192 3193 6.9.6.1. A physician consults an RD to assess an ICU patient with COPD with acute exacerbation 3194 for alternate nutrition sources e.g. TPN (total parenteral nutrition). The RD reviews the patient 3195 medical record, conducts a brief interview with the patient and spouse, talks with the nursing 3196 staff about the patient’s usual oral intake, and then make a detailed recommendation for TPN in 3197 the medical chart. The RD completes the assessment in 45 minutes. Codes for this example: 3198 3199  ICD-9-CM: V65.3, additional diagnosis code for current medical condition COPD 491.21 3200  E&M: N/A 3201  CPT: 97802 with 3 units of service 3202 3203 6.9.6.2. The diet technician screens a cardiac patient and indicates the patient is high nutrition 3204 risk due to post-CABG surgical procedure, recent weight loss and poor appetite/intake. The diet 3205 tech refers the patient to the dietitian for further assessment and intervention. The dietitian 3206 interviews the patient and family, reviews the medical record, assesses the patient current 3207 condition and calorie needs, and makes recommendations to the physician for a liberal diet. The 3208 nutrition screening and assessment process are integral to the inpatient stay and are considered an 3209 institutional component of care, therefore are not separately code-able. 3210

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SPECIALTY CODING 6.10. Obstetrics Services

3211 6.10. Obstetrics Services NOTE: When a patient’s pregnancy is incidental:

Code the pregnant state with V22.2 diagnosis code. An incidental pregnancy cannot be the reason for the encounter, so V22.2 will not be the first listed 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 procedure codes.

For instance, a three-months-pregnant patient breaks her wrist. This would be coded with an office visit E&M; a diagnosis code for the fracture, an E code for the injury, the V22.2 code for the incidental pregnancy and a procedure code for treatment of the fracture.

3212 3213 3214 3215 6.10.1. E&M Rules 3216

3217 DoD Rule 3218

3219 UNCOMPLICATED obstetric encounters do not have an E&M 3220 component in the 99201–99499 series. 3221 3222 Most obstetric encounters involving complications of pregnancy do have an 3223 appropriate E&M in the 99201–99499 series and the appropriate E&M should be 3224 entered in the E&M field. 3225

3226 DoD Rule 3227 3228 As policy, global OB codes that represent work in two different MEPRS codes and 3229 the bundled ante partum visit codes (59425 and 59426) are not coded in the ADM.

3230 3231 To account for workload, the MHS cannot use the global codes. 3232 3233 6.10.1.1. Do not use the following codes:

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SPECIALTY CODING 6.10. Obstetrics Services

3234 59400 Routine obstetric care including ante partum care, vaginal delivery (includes 3235 services in both the outpatient and inpatient MEPRS codes) 3236 59410 Routine obstetric care including postpartum care (includes services in both 3237 outpatient and inpatient MEPRS codes) 3238 59425 Ante partum care only, 4–6 visits (use 0500F, initial prenatal care visit, and 0502F 3239 subsequent prenatal care, for ante partum encounters) 3240 59426 Ante partum care, 7 or more visits (use 0500F, initial prenatal care visit, and 0502F, 3241 subsequent prenatal care, for ante partum encounters) 3242 59510 Routine obstetric care including ante partum care—Cesarean delivery (includes 3243 services in both outpatient and inpatient MEPRS codes) 3244 59515 Cesarean delivery—postpartum care (includes services in both outpatient and 3245 inpatient MEPRS codes) 3246 59610 Vaginal birth after a previous C-section (VBAC) delivery including ante partum, 3247 delivery, and post-partum (includes services in both outpatient and inpatient 3248 MEPRS codes) 3249 59614 VBAC delivery and postpartum care (includes services in both the outpatient and 3250 inpatient MEPRS codes) 3251 59618 Attempted VBAC ante partum, delivery and postpartum care (includes services in 3252 both outpatient and inpatient MEPRS codes) 3253 59622 Attempted VBAC delivery and postpartum care (includes services in both 3254 outpatient and inpatient MEPRS codes) 3255 3256 6.10.1.2. Billing vs. Data Collection Codes 3257 The codes listed above are a billing convention, as insurance companies do not want 13 separate 3258 bills for the professional services associated with a full-term pregnancy. The codes listed above 3259 cannot be used for data collection when each encounter reflects services provided. By using the 3260 new category II CPT obstetrical codes, obstetrical encounters will be collected without 3261 unbundling the obstetrical global codes. 3262

3263 DoD Rule

3264 3265 Use the appropriate E&M for office visits/hospital when something other than 3266 uncomplicated, routine obstetrical care is furnished. 3267 3268 For first visit with nurse for screening, vaccinations and counseling, code services as 3269 appropriate. Code 99211 for face to face visit with no procedures. 3270 3271 3272 6.10.2. Diagnosis Coding Rules 3273 3274 6.10.2.1. Fifth Digit Requirement for Obstetric Diagnoses 6-38 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.10. Obstetrics Services

3275 The range of diagnosis codes 640–648, complications mainly related to pregnancy, requires a 3276 fifth digit. Follow ICD-9-CM coding guidance for reporting obstetric diagnoses. 3277 3278 Fifth Digits 3279 0 Unspecified episode of care 3280 1 Delivered this episode, may or may not have had ante partum condition 3281 2 Delivered the episode of care, had postpartum complication 3282 3 Ante partum care (patient still pregnant at end of this episode of care) 3283 4 Postpartum care (patient delivered during previous episode of care) 3284 3285 3286 6.10.2.2. Co-morbidities 3287 Some obstetric cases have co-morbidities that influence the pregnancy. Ensure that the 3288 pregnancy and manifestation codes are listed. 3289 3290 6.10.2.2.1. Example: A pregnant patient presents to the clinic with a diagnosis of Type I 3291 diabetes, which complicates the pregnancy. This encounter is coded in the following 3292 manner: 3293 3294 Fifth Digits 3295 648.03 Current conditions in the mother classifiable elsewhere, but complicating 3296 pregnancy, childbirth, or the puerperium, diabetes mellitus 3297 3298 250.01 Type I diabetes, without mention of complication 3299 3300 6.10.2.3. Diagnosis codes 647–649 3301 Coders unfamiliar with obstetrical coding should review the codes in the 647–649 range and 3302 understand their application. If a patient 3 months pregnant sprains her ankle while jogging, but 3303 it does not affect the pregnancy and the pregnancy does not affect the care, the code 648.7X 3304 would not be appropriate. However, smoking is a systemic issue with decreased oxygenation 3305 that will affect the pregnancy. A pregnant patient with tobacco use disorder would usually be 3306 coded with 649.0X. 3307 3308 6.10.2.4. Congenital Anomalies 3309 When the infant has a congenital anomaly, it is coded on the infant’s record, not the mother’s. 3310 Be careful with the codes 740–759. For the mother’s record, consider 655, known or suspected 3311 fetal abnormality affecting management of mother. 3312 3313 3314 6.10.2.5. Outcome of Delivery Codes V27 3315 These codes are used on the mother’s record at delivery, which is usually an inpatient event. 3316 Therefore, the V27 codes would be in the A MEPRS CAPER if delivered at an MTF. This 3317 would be coded in ADM and will appear on the inpatient rounds encounter at delivery. 3318

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SPECIALTY CODING 6.10. Obstetrics Services

3319 6.10.2.6. Live-born Infants According to Type of Birth, Codes V30–V39 3320 These codes are not used on the mother’s record. They are used in the infant’s record. 3321 3322 6.10.2.7. Pregnancy Testing 3323 Encounters for the purpose of pregnancy testing are to be coded as follows, based on the results 3324 of the test or exam that are known at the time of the encounter. 3325 3326 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 3327 3328 6.10.3. Procedural Coding Rules 3329

3330 Category II CPT obstetric coded 0500F, 0502F, 0503F and Level I CPT code 59430. 3331 3332 0500F Initial prenatal care visit. Reported for those portions of the first prenatal 3333 encounter that are routine for that point in the pregnancy, with health care 3334 professional providing obstetrical care. 3335

3336 0501F Prenatal flow sheet documented. Do not use, because the DoD will 3337 use 0500F, initial prenatal care visit, when the prenatal flow sheet is initiated and 3338 0502F for each subsequent obstetrical encounter. 3339 3340 0502F Subsequent prenatal visits (continuing care). Use for subsequent obstetrical 3341 visits that are routine for that point in the pregnancy. This code does not include 3342 complications or issues not related to the pregnancy. 3343 3344 Use 0503F for one uncomplicated postpartum care encounter ( usually done six to 3345 eight weeks after delivery), signifying the end of the global period. Code all other 3346 postpartum complications or unrelated problems addressed with the appropriate 3347 established patient office visit E&M code. Use this code if the delivery and 3348 postpartum visit are performed by the same group practice. 3349 3350 Use 59430 if postpartum care is provided by a different group practice other than 3351 the group practice that performed the ante partum care or delivery.

3352 3353 6.10.3.1. Obstetrical Services

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SPECIALTY CODING 6.10. Obstetrics Services

3354 Included are: obstetric care (routine and non-routine), ante partum care, vaginal delivery (with or 3355 without episiotomy or forceps) and postpartum care uses 0500F, 0501F, 0502F, 0503F, and 3356 59430. 3357 3358 6.10.3.2. Ante Partum Services 3359 To document ante partum services, indicate the following when given: 3360  Pap Smear 3361  Monthly visit up to 28 weeks’ gestation, biweekly visit to 36 weeks’ gestation and 3362 weekly visits until delivery 3363  Initial history and physical exam (code 0500F) and subsequent history and physical 3364 examinations (code 0502F) 3365  Recording of weight, blood pressures, and fetal heart tones. When routine chemical 3366 urinalysis is done and interpreted in the clinic and is not bundled with routine 3367 obstetrical care, it may be coded using a laboratory code (e.g., 81000 or 81002). 3368  For first visit with nurse for screening, vaccinations and counseling, code services as 3369 appropriate. Code 99211 for face-to-face visit with no procedures. 3370  0500F, initial prenatal care visit reported for the first prenatal encounter with 3371 healthcare professional providing obstetrical care. After confirmation of pregnancy, 3372 the 0500F code is the trigger code to indicate the start of the pregnancy episode. The 3373 code is not appropriate when the only prenatal service during an office visit is 3374 pregnancy test. 3375  0501F, prenatal flow sheet documented. Do not use. 3376  0502F, subsequent prenatal visits (continuing care) 3377  0503F, uncomplicated outpatient visit by the same group practice that performed the 3378 delivery until six weeks postpartum. The AMA uses this code to define the number of 3379 women who receive care on or between 21 and 56 days after delivery. 3380  59430, uncomplicated outpatient postpartum follow-up by a group practice other than 3381 the group practice that performed the delivery. 3382 3383 6.10.3.3. The following is a list of services that reflect routine, uncomplicated care and are 3384 included in the routine codes. 3385 3386 Procedures outlined below, will not be coded separately. Positive findings during screening will 3387 be coded. 3388 3389  Prenatal risk assessment checklist—administering and history taking, ordering applicable 3390 tests 3391 o Auscultation of fetal heart tones 3392 o Screening fundal height 3393 o Screening for hypertension (HTN) disorders 3394 o Assessing inappropriate weight gain 3395 o Educate about symptoms of preterm labor 3396 o Review for development of contraindications 3397 o Assessment of fetal kick counts 6-41 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.10. Obstetrics Services

3398 3399  Interventions at all visits 3400 o Screening for HTN disorders 3401 o Breast feeding education 3402 o Exercise during pregnancy 3403 o Influenza vaccine (season-related, 6–20 weeks) 3404 3405  First visit with nurse (6-8 weeks)–Screening for 3406 o Tobacco use, alcohol use, drug abuse 3407 o Domestic abuse 3408 o Anti-D/non-anti-D antibodies 3409 o Rubella, varicella, hepatitis B, syphilis (RPR), asymptomatic bacteriuria 3410 o HIV counseling 3411 o Immunization–TB booster (1st trimester), hepatitis B (1st trimester) 3412 3413  First visit with provider (10–12 weeks) 3414 o Assessing weight gain (inappropriate) 3415 o Auscultation fetal heart tones 3416 o Screening fundal height 3417 o Screening for gonorrhea and chlamydia 3418 o Counseling for cystic fibrosis screening 3419 3420  Weeks 16–24 3421 o Assessing weight gain (inappropriate) 3422 o Auscultation fetal heart tones 3423 o Screening fundal height 3424 o Screen for domestic abuse 3425 o Maternal serum analyte screening 3426 o Counseling for family planning 3427 o Educate regarding preterm labor 3428 3429  Weeks 28–37 3430 o Assessing weight gain (inappropriate) 3431 o Auscultation fetal heart tones 3432 o Screening fundal height 3433 o Screen for domestic abuse (week 32) 3434 o Assess for preterm labor 3435 o Daily fetal movement counts 3436 o Screening for gestational diabetes 3437 o Iron supplementation 3438 o Anti-D prophylaxis for Rh-negative women 3439 o Screening for group B streptococcal (week 36) 3440 o Assessment of fetal presentation (week 36) 3441 6-42 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.10. Obstetrics Services

3442  Weeks 38–41 3443 o Assessing weight gain (inappropriate) 3444 o Auscultation fetal heart tones 3445 o Screening fundal height 3446 o Weekly cervical check (stripping) 3447 o Post-dates antenatal fetal testing 3448 3449 6.10.3.4. Codes for Medical Problems Complicating Pregnancy 3450 All encounters for OB care will have a code from the 0500F series coded. Significant separately 3451 identifiable medical conditions complicating obstetric management may require additional 3452 resources and should be identified by using the E&M codes in addition to those codes for 3453 maternity. Modifier -25 will not be assigned to an E&M in this chapter only. These significant 3454 separately identifiable medical conditions will be coded when documented in the medical record. 3455 Documentation must meet minimal requirements. Procedures other than those routine procedures 3456 listed above should also be coded. 3457 3458 Examples of complicating conditions are: 3459 Pre-existing diabetes 3460 Gestational diabetes mellitus (GDM) 3461 Pregnancy-induced hypertension or pre-eclampsia 3462 Fetal anomaly or abnormal presentation (older than or equal to 36 weeks) 3463 Multiples 3464 Placenta previa 3465 Chronic hypertension 3466 Systemic disease that requires ongoing care (e.g., severe asthma, lupus, inflammatory 3467 bowel disease) 3468 Drug abuse 3469 HIV (or abnormal screen) 3470 Age (<16 or >40 years at delivery) 3471 Past complicated pregnancy 3472 Prior preterm delivery (<37 weeks) 3473 Prior preterm labor requiring admission (e.g., early cervical change) 3474 Intrauterine fetal demise—10 weeks after cardiac activity was first noted 3475 Prior cervical or uterine surgery 3476 Fetal anatomic abnormality (e.g., open neural tube defects in prior child or first-degree 3477 relative) 3478 Abnormal fetal growth 3479 Preterm labor requiring admission (i.e., regular uterine contractions and cervical change) 3480 Abnormal amniotic fluid 3481 2nd or 3rd trimester bleeding 3482 Relative BMI <16.5 3483 Hematologic disorders 3484 Severe anemia (<24 percent hematocrit) 3485 Cancer

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SPECIALTY CODING 6.10. Obstetrics Services

3486 Seizure disorders 3487 Recurrent urinary tract infections or stones 3488 Substance use disorders (alcohol or tobacco) 3489 Eating disorders 3490 Surgery 3491 Abnormal screen—antibody, hepatitis, syphilis, and Pap 3492 Abnormal maternal triple screen 3493 Current mental illness requiring medical therapy 3494 3495 Examples of separately reportable services: 3496 All routine ultrasound 3497 Additional non-routine Ultrasound 3498 Echocardiography 3499 Fetal biophysical profile 3500 Amniocentesis, cordocentesis 3501 Chorionic villus sampling 3502 Fetal contraction stress test 3503 Fetal non-stress test 3504 Hospital admission and observation for preterm labor, except within 24 hours of delivery 3505 Management of surgical problems arising during pregnancy (e.g., appendicitis, 3506 incompetent cervix, ruptured uterus) 3507 Insertion of cervical dilator by physician 3508 External cephalic version, if done in the clinic 3509 Administration of Rh immune globulin 3510 Cerclage of cervix, during pregnancy—vaginal or abdominal 3511 3512 6.10.3.5. Postpartum Care 3513 3514 6.10.3.5.1. Routine Postpartum Care 3515 For postpartum encounters code 0503F/59430 in the CPT/HCPCS field code. Following is a list 3516 of services that reflect routine, uncomplicated postpartum care and are included in the routine 3517 codes. They will not be coded separately. 3518 3519 Postnatal tests—administering and history taking, ordering applicable tests 3520 o Pelvic exam 3521 o Breast exam 3522 Topics addressed: 3523 o Contraception 3524 o Postpartum depression, screening for 3525 o Sexual activity 3526 o Weight 3527 o Exercise 3528 o Woman’s assessment of her adaptation to motherhood 3529

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SPECIALTY CODING 6.10. Obstetrics Services

3530 6.10.3.5.2. Non-routine Postpartum Care 3531 Collection of Pap smears is not included and should be documented and coded separately and 3532 appropriately with reason (e.g., high risk or not). Additional services may be provided during a 3533 postpartum visit. 3534 3535 Patients who present with a history of an abnormal Pap smear and are being seen for a diagnostic 3536 Pap will require an added E&M code. If the obstetric follow up code 59430 is used, then a 3537 modifier -25 will be required on the E&M code. 3538 3539 Code non-routine postpartum issues separately. Treatment of these would be coded using an 3540 E&M. A few examples: 3541  Disruption of wounds 3542  Infections of breast and nipples 3543  Disorders of lactation 3544 3545 6.10.4. Inpatient Obstetric Coding. 3546 For more guidance on inpatient coding, see section 9. This section addresses inpatient 3547 professional services, including OB rounds and appointments that generate automatically in the 3548 name of the attending provider. 3549 3550 6.10.4.1. Recording in MEPRS 3551 To record the delivery, code inpatient professional services in the ACxx, AGxx or AHxx 3552 MEPRS. After a patient is admitted, an inpatient rounds ADM record is generated each inpatient 3553 day under the name of the attending physician. 3554 3555 6.10.4.1.1. Hospital Days prior to Delivery 3556 3557 6.10.4.1.1.1. OB Observation Status 3558 Pre-term labor/Labor Observation 3559 (See also Appendix H for Coding for Observation) 3560 3561 Patient is seen in the OB-GYN clinic or Emergency Department. The provider writes an 3562 order to place the patient in observation status. Changing the patient from observation status is a 3563 decision of the privileged provider. 3564 3565 For normal, uncomplicated pre-natal care (which could include some labor) use procedure code 3566 0502F for encounters leading up to delivery. 3567 3568 For problems other than normal pre-natal and labor care: 3569 3570 IF THERE IS NO ORDER FOR OBSERVATION: 3571 3572  For clinic services, use E&M code 9921X based on documentation. For Emergency 3573 department services, use E&M 9928x based on documentation. In those instances when 6-45 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.10. Obstetrics Services

3574 a non-emergency service is provided by a non-emergency provider (e.g., obstetrician 3575 treats patient in the Emergency Department on a weekend when the OB clinic is closed), 3576 code the services as clinic services. 3577  If more than 70 minutes (99215= 40 minutes, modifier 21 = 30 minutes) is spent face-to- 3578 face with the patient AND THE TOTAL TIME AND PROVIDER’S ACTIVITIES 3579 DURING THAT TIME ARE DOCUMENTED in the medical record, code 99215 and 3580 99354-99355 for clinic OR 99285 only for Emergency Department. 3581  Code for fetal stress/non-stress/monitoring in addition to the E&M code. 3582 3583 IF THERE IS AN ORDER FOR OBSERVATION: 3584 3585  Provider documents written order for observation, no delivery on same date of service 3586 (99218-99220). Diagnosis will reflect medical necessity. Observation services are 3587 outpatient services. Therefore, if the patient is observed for a condition not verified, code 3588 the symptoms. Do not use the V71 Observation for Condition not found. 3589  To generate a code-able encounter, an appointment must be created manually for each 3590 day of observation. Contact your Service Representative for guidance on manual 3591 creation of code-able observation encounters. 3592  Provider documents written order for observation, no delivery on subsequent date of 3593 service, use E&M 99218-99220. 3594  Provider documents written order for observation, no delivery, discharged same date of 3595 service; use E&M 99234-99236. 3596  Provider documents written order for observation, no delivery, discharged on subsequent 3597 date of service; use E&M 99217 for the last day of observation. 3598 3599 Scenarios: 3600 3601 Admit from observation/trial labor 3602 3603 Patient is in observation, is admitted and delivers the same date. 3604 3605 1. Observation: close out the observation using the 0502F for routine prenatal and 3606 labor. Complications are coded based on documentation. 3607 3608 2. Admission: the round (RND) encounter for this day may have an E&M based 3609 on documentation and the procedure will be the delivery (vaginal 59409; cesarean 3610 section 59514). This is an MHS deviation from civilian standards of coding. Refer 3611 to DoD Rule for E&M in section 6.10.1.2. 3612 3613 Patient is in observation and is admitted and does not deliver during this admission. 3614 3615 1. Observation: close out the observation using the 0502F for routine prenatal 3616 care and labor. Complications are coded based on documentation. 3617 6-46 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.10. Obstetrics Services

3618 2. Admission: the RNDs encounter will be based on the documentation from the 3619 time of admission. 3620 3621 Patient delivers on the second date of observation status. 3622 3623 1. Observation: code the observation encounter for day 1 using the 0502F for 3624 routine prenatal care and labor. Complications are coded based on 3625 documentation. 3626 3627 2. Code the observation encounter for day 2 using the 0502F for routine prenatal 3628 care and labor. 3629 3630 3. Admission: the RNDs encounter will be based on the documentation from the 3631 time of admission. Use appropriate delivery codes based on documentation. 3632 3633 6.10.4.1.1.2. Preterm Admission/Bed-Rest Admission 3634 For problem pregnancies that need inpatient monitoring (pre-mature labor, diabetic patient, 3635 toxemic, high blood pressure), the attending service will code one RNDs per day for admission 3636 until date of delivery or discharge as follows: admission date (99221-99223) subsequent days 3637 (9923X), date of delivery (59XXX). 3638 3639 6.10.4.1.1.3. Labor 3640 All E&M services prior to labor are considered ante partum care. If the delivery does not take 3641 place until after the initial day of admission, delete the rounds encounter for the initial day. For 3642 example, when a healthy-term, uncomplicated singleton female is admitted at 1800 and delivers 3643 vaginally 12 hours later, the following codes are used: delete the automatically generated rounds 3644 appointment for the day of admission and code the delivery 59409 on the rounds appointment for 3645 the day of delivery. 3646 3647 3648 6.10.4.1.1.4. Complicated 3649 For complicated inpatient ante partum care, use the appropriate initial hospitalization and 3650 subsequent hospitalization codes. 3651 3652 6.10.4.1.2. Delivery 3653 On the day of delivery, use 3654 3655  59409 for vaginal delivery 3656  59514 for C-section 3657  59612 for successful vaginal delivery after previous C-section 3658  59620 for an attempted vaginal delivery after a previous C-section when ultimately the 3659 newborn is delivered C-section 3660 3661 The delivery codes include: 6-47 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.10. Obstetrics Services

3662  Management of uncomplicated labor, including fetal monitoring 3663  Placement of internal fetal or uterine monitors 3664  Catheterization or catheter insertion 3665  Preparation of perineum with antiseptic solution 3666  Forceps or vacuum extraction 3667  Delivery of placenta, any method 3668  Injection of local anesthesia 3669  Administration of intravenous oxytocin 3670 Code any other appropriate procedures done. 3671 3672 For complicated deliveries, use the appropriate procedure codes, e.g., surgical fixation for 3673 prolapsed uterus. For medical complications, e.g., asthma, the provider would use the 3674 appropriate E&M code. 3675 3676 6.10.4.1.2.1 Multiple Births 3677  For all newborns born vaginally, code 59409 (or 59612) for a vaginal birth after a 3678 previous C-section (VBAC) with a unit of the number of newborns. For instance, 3679 vaginally delivered twins would be coded 59409, unit of service 2. 3680  All newborns delivered C-section, code 59514 (or 59620 for a VBAC that results in a C- 3681 section), with a unit of service of 1. There is only one C-section. 3682  Multiple births with at least one vaginal and one C-section are coded with the appropriate 3683 type of vaginal birth code and the number of vaginal births using the unit’s field. Code 3684 the appropriate C-section code with a unit of service of 1 for all the infants delivered by 3685 the one C-section. 3686 3687 6.10.4.1.3. Associated C-section Procedures 3688 Code both the C-section and the associated procedure (e.g., hysterectomy, tubal ligation). 3689 3690 6.10.4.1.4. Routine Post-Partum Days 3691 Code CPT 99024. For complications, code the appropriate procedure and E&M. 3692 Add diagnosis for post-partum condition. (V24.x). 3693

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SPECIALTY CODING 6.11. Occupational Therapy (OT)

3694 6.11. Occupational Therapy (OT) 3695 3696 6.11.1. E&M Rules 3697 E&M codes are not appropriate for occupational therapy. The evaluation and management 3698 components of routine outpatient office E&Ms are included in special occupational therapy 3699 evaluation (97003) and reevaluation (97004) procedural codes as indicated below. 3700 3701 6.11.2. Diagnosis Coding Rules 3702 3703 6.11.2.1. Outpatient Occupational Therapy 3704 All outpatient occupational therapy encounters for the purpose of receiving therapy are always 3705 coded with the V57.21 as the first listed diagnosis unless the need for therapy is related to a 3706 deployment. In that case, abide by the MHS Coding Guidance for deployment related issues. 3707 3708 6.11.2.2. Occupational Therapy Evaluation 3709 Occupational therapy encounters for the purpose of evaluation only or group educational classes 3710 (no therapy done during the encounter) are not identified by V57.21. 3711

3712 DoD Rule 3713

3714 V57.21 will be the first listed code for all occupational therapy encounters 3715 involving therapy only. The condition(s) for which the patient is receiving therapy 3716 are listed in the second or third position. Occupational therapy encounters for post- 3717 deployment therapy sessions have V70.5_6 as the third or fourth listed code. 3718

3719 3720 NOTE: When a patient presents for evaluation and therapy is initiated on the same day, do 3721 not use V57.21. Code the condition as primary diagnosis. 3722 3723 6.11.2.3. E Codes for Occupational Therapy 3724 Occupational therapy encounters should not report E codes, as the occupational therapy 3725 encounter will not be the initial medical encounter at the MTF for the injury. If it is documented 3726 that the patient was initially seen for the injury at another MTF without occupational therapy, 3727 and this is the initial encounter at this MTF, then the E code(s) should be used. Most therapy 3728 encounters will not be for an acute injury (e.g., fracture). In rare instances, treatment will be to 3729 address the immediate resulting limitations from the injury (e.g., reduced movement of fingers 3730 following hand fracture). 3731 3732 6.11.3. Procedural Coding Rules 3733 CPT codes for occupational therapy procedures are in the Physical Medicine and Rehabilitation 3734 subsection of the Medicine Section (97003–97799). Activities of daily living (ADL) mock-ups 6-49 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.11. Occupational Therapy (OT)

3735 for self-care home living are coded 97535 (and should not be used for education activities, like 3736 teaching the person to self-administer diabetic injections). 3737 Osteopathic Manipulative Treatment codes may be used by Physical Therapist if authorized 3738 under their scope of practice (98925-98929). 3739 3740 6.11.4. Evaluations and Reevaluations 3741 3742 6.11.4.1. New vs. Established Patients 3743 There is no distinction for new or established patients. Code either an: evaluation 97003 or 3744 reevaluation 97004 with or without modalities, or code just the modalities performed. The initial 3745 assessment of the problem is used to determine the appropriate therapy and prognosis. Various 3746 movements required for ADL are examined. Dexterity, range of motion, and other elements may 3747 also be studied. Reevaluations are for subsequent assessments to determine treatment success 3748 and make modifications as needed. 3749 3750 6.11.4.2. Reevaluation Is Part of Normal Service 3751 Reevaluation is part of the normal pre- and post-service. As with an E&M service, these 3752 evaluations should only be separately reported if the patient’s condition requires significant, 3753 separately identifiable E&M services. 3754 3755 6.11.5. Modalities 3756 3757 6.11.5.1. Modalities Included in Evaluation, Reevaluation 3758 Certain modalities (e.g., injection of anesthetic agents, range of motion measurements) are 3759 included in the evaluation and reevaluation procedural codes. For a list of these modalities refer 3760 to the National Correct Coding Initiative (NCCI) at the CMS Web. 3761 http://www.cms.hhs.gov/NationalCorrectCodInitEd/ 3762 3763 6.11.5.2. One-on-One Contact 3764 Therapeutic procedures (97110–97546) require direct (one-on-one) patient contact by the 3765 provider. Basically, this means the provider must maintain visual, verbal, or manual contact with 3766 the patient throughout the procedure. For a technician to code an encounter, the technician must 3767 be working under a privileged provider’s plan of care. When the occupational therapist is 3768 actively involved in the therapy and assisted by a technician, the technician should be listed as an 3769 additional provider when coding the encounter. 3770 3771 6.11.6. Modifiers 3772 The HCPCS modifier GO is used in the civilian sector by occupational therapy to indicate that 3773 the therapy is being performed under an outpatient occupational therapy plan of care. It does not 3774 specify a therapist furnished the care. The GO modifier is not used in the DoD system. 3775 3776 6.11.7. Documentation of Occupational Therapy 3777 3778 6.11.7.1. Requirements for CPT Code

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SPECIALTY CODING 6.11. Occupational Therapy (OT)

3779 To support a CPT code, at a minimum each occupational therapy note needs to include therapist 3780 name, date, modality, treatment assessment (patient tolerated treatment), and adjustment to the 3781 therapy plan. Documentation based on a checklist alone is not sufficient for coding. 3782 3783 6.11.7.2. Required Elements 3784 The following elements need to be recorded by the therapist (or technician), 3785  The specific modalities or procedures (supervised or attended), 3786  The body area involved, and 3787  The start and stop times or total time for each treatment. 3788 3789 6.11.7.3. Coding for Pregnant Patients 3790 When a patient is pregnant, and the pregnancy affects the services provided (e.g., not pregnancy 3791 incidental, coded V22.2), the patient’s last menstrual period and estimated date of delivery need 3792 to be documented so they can be recorded in ADM. 3793 3794 6.11.8. Units of Service 3795 3796 6.11.8.1. Unit of Service Is 8-15 Minutes 3797 Constant attendance modalities and therapeutic modalities include “each 15 minutes” in the code 3798 descriptions. Therefore, one unit of service is reported for each 15 minutes (or major portion 3799 thereof) of therapy rendered per date of service. The table below is used to calculate units of 3800 service. A minimum of eight minutes must be performed to qualify for 1 unit of service. 3801 3802 6.11.8.2. Reporting Time Intervals 3803 For any single CPT procedure where unit of service is a factor, report time intervals for units of 3804 service as follows: 3805 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 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 3806

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SPECIALTY CODING 6.11. Occupational Therapy (OT)

3807 Units are calculated in the same manner for therapy that exceeds two hours. 3808 3809 6.11.8.3. Multiple CPT Procedures 3810 For multiple CPT procedures performed on the same calendar day, the total number of units does 3811 not equal the individual units of service for each service; rather, it equals the units of service for 3812 the total treatment time. 3813 3814 6.11.8.4. Group Therapy 3815 Multiple patients being given modalities or procedures during the same time are reported as 3816 group therapy. (See 97150) 3817 3818 6.11.9. Inpatient Therapy 3819

3820 DoD Rule

3821 3822 Inpatient therapy consults will be reported in ADM. When the screen prompts Are 3823 you from the attending service? select NO. This will create the encounter in ADM. 3824 Therapy related to the patient’s reason for admission is not coded in the B MEPRS.

3825

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SPECIALTY CODING 6.12. Ophthalmology

3826 6.12. Ophthalmology/Optometry 3827

3828 DoD Rule 3829 3830 Optometry clinic services are coded in an ambulatory service BHCx MEPRS clinic. 3831 Ophthalmology clinic services, including services for pay patients are coded in the 3832 ambulatory service BBDx MEPRS. 3833 3834 3835 6.12.1. E&M Rules 3836 3837 6.12.1.1. Optometrists 3838 An optometrist seldom uses an E&M office visit code in the 99201–99215 range. 3839 3840 6.12.1.2. Ophthalmologists 3841 Depending on the patient population and the number of associated optometrists, 3842 ophthalmologists commonly have 30 percent to 40 percent of their visits coded with E&M codes 3843 in the 99201–99499 range. Referrals and consults are coded 99201-99215. 3844 . 3845 6.12.1.3. An E&M code may be used when a patient is seen for a medical reason that does not 3846 require any eye examination procedures. The most common instances when an E&M code is 3847 used are: 3848 3849  Limited exams that do not meet the exam elements of an intermediate eye exam, but do 3850 meet the elements of a low-level E&M code (e.g., follow-up contact lens visit). 3851 3852  Highly complex or risk-prone exams that meet the documentation elements of a 99204/14 3853 or 99215 E&M encounter. 3854 3855  Examinations for medical reasons when no eye procedures are performed (e.g., an acute 3856 care visit for a subconjunctival hemorrhage). 3857 3858 6.12.2. Diagnosis Coding Rules 3859 3860 6.12.2.1. Routine Exams (DoD Unique Visits) 3861 Encounters for DoD unique visits, such as aviation, military school screening, periodic, or 3862 termination exams, are reported using V70.5 with the appropriate extender (e.g., Aviation exam 3863 V70.5_1). Any condition diagnosed during the examination is listed as an additional diagnosis. 3864 V CODES DESCRIPTION V70.5 0 Armed Forces Medical Examination 6-53 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.12. Ophthalmology

V70.5 1 Aviation Examination V70.5 2 Periodic Prevention Examination V70.5 3 Occupational Examination V70.5 4 Pre-Deployment Examination 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 3865 3866 6.12.2.2. Routine Exams 3867 3868 6.12.2.2.1. Diagnosis Coding Based on Documentation 3869 Other than the DoD-required first-listed codes, diagnosis coding in optometry and 3870 ophthalmology is based on documentation. If the patient’s reason for the encounter is vision 3871 problems (e.g., myopia, presbyopia), that will be the first listed code. If the patient’s reason for 3872 the encounter is “here for annual exam,” the most appropriate V code would be used. 3873 3874 6.12.2.2.2. Routine Eye Exams 3875 For patients without any complaints or previously diagnosed ophthalmologic conditions, routine 3876 exams are coded V72.0, and any condition identified during the exam is an additional diagnoses. 3877 V 65.5 Feared Complaint—No symptoms 3878 V 67.59 Condition Resolved 3879 V 68.0 Driver’s Test 3880 V 72.0 Exam of Eyes and Vision 3881 V20.2 Routine infant or Child health check 3882 3883 6.12.2.2.3. Routine Exams with Complaints 3884 For routine exams (reason for encounter), with complaints or ophthalmologic conditions, the 3885 most appropriate V code would be the first-listed code with the applicable codes for the 3886 complaints or conditions listed as additional codes. 3887 3888 367.1 Myopia 3889 367.21 Astigmatism, regular 3890 367.4 Presbyopia 3891 379.90 Disorder of the Eye—Unspecified 3892 379.91 Pain in or Around Eyes 3893 379.99 Other Ill-Defined Disorder of Eyes 3894 3895 6.12.2.2.4. Non-Routine Encounters 3896 Diagnostic codes are to be used at their highest level of specificity (fourth and fifth digits) and 3897 explicitness (e.g., chronic, acute, regular, irregular) to support medical necessity for procedures 3898 such as extended ophthalmology. Fourth and fifth digits should be used when available. 3899 3900 6.12.2.2.5. Special Screening for Glaucoma 6-54 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.12. Ophthalmology

3901 See glaucoma screening below for documentation requirements. 3902 3903 6.12.2.2.6. Diabetic Retinopathy 3904 3905 Code 250.5x first, then use one of the following codes: 3906 362.01 Background diabetic retinopathy 3907 362.02 Proliferative diabetic retinopathy (NOS) 3908 362.03 Non-proliferative diabetic retinopathy (NOS) 3909 362.04 Mild non-proliferative diabetic retinopathy 3910 362.05 Moderate non-proliferative diabetic retinopathy 3911 362.06 Severe non-proliferative diabetic retinopathy 3912 362.07 Diabetic macular edema 3913 3914 6.12.3. Procedural Coding Rules 3915 3916 6.12.3.1. Optometrists 3917 Optometrists usually use the ophthalmology codes in the 92002–92396 range (e.g., diagnosis and 3918 treatment) as well as the HCPCS codes V2020–V2799 and various other HCPCS codes. The most 3919 commonly used codes by optometrists are 92002–92014 for eye exams and 92015 for refractions. 3920 Optometrists associated with a refractive surgery program who do postoperative assessments will 3921 also frequently use 99024, postoperative follow-up visit. 3922 3923 6.12.3.2. Ophthalmologists 3924 Ophthalmologists also code a number of visits using the 92002–92014 ophthalmologic services 3925 codes, the diagnosis and treatment codes 92015–92396, and surgical eye and ocular adnexa codes 3926 65091–68899. Ophthalmologists also frequently perform refractive surgery, coded S0800–S0830. 3927 Refractive surgery procedures tend not to have RVUs assigned by the CMS as they are not a CMS- 3928 covered benefit. It is very important that these services be coded correctly as they are specifically 3929 evaluated to determine the effectiveness of various refractive surgery programs. 3930 3931 6.12.3.3. Use of 92002–92499 Codes 3932 Usually optometrists and ophthalmologists use the 92002–92499 codes. When a technician does a 3933 simple acuity or visual function, the procedure codes 99172 and 99173 are appropriate. Dispensing 3934 glasses is a continuation of the visit when the glasses were prescribed or ordered and is not coded 3935 separately. 3936 3937 6.12.4. Eye Exams 3938 3939 6.12.4.1. CPT Codes for New and Established Patients 3940 CPT codes 92002, 92004, 92012, and 92014 for new and established ophthalmology or 3941 optometry patients include an evaluation and management of a patient. These codes are 3942 appropriate when the level of service includes several routine optometric or ophthalmologic 3943 examination techniques, such as slit lamp examination, keratometry, ophthalmoscopy,

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SPECIALTY CODING 6.12. Ophthalmology

3944 retinoscopy, tonometry, and sensorimotor evaluation that are integrated with and cannot be 3945 separated from the diagnostic evaluation. 3946 3947 6.12.4.2. Documentation Guidelines for 92 Series Eye Exam and Treatment Codes: 3948 3949 There is no specific history or medical decision-making guidelines for these codes. 3950 There are 13 exam elements that must be documented to validate a coding level: 3951  Testing visual acuity 3952  Gross visual fields 3953  Eyelids and adnexae 3954  Ocular motility 3955  Pupils 3956  Iris 3957  Conjunctiva 3958  Cornea 3959  Anterior chamber 3960  Lens 3961  Intra-ocular pressure 3962  Retina 3963  Optic disc 3964 3965 If three to eight of these elements are documented, an intermediate exam (92012 or 92002) 3966 should be coded. If nine or more of these elements are documented, a comprehensive exam 3967 (92014 or 92004) should be coded 3968 3969 If fewer than three of these elements are documented, the lowest level E&M code (based on 3970 the documentation) should be coded along with the primary diagnosis (reason for visit or 3971 chief complaint). 3972 3973 Note that some procedures are bundled-included as part of / the 92 series exam codes. This 3974 means you would NOT put a separate CPT code for these procedures if done as part of the 3975 exam using a 92 series exam code. 3976 3977 The bundled procedures are: 3978  Amsler grid 3979  Brightness acuity test (BAT) 3980  Corneal sensation 3981  Exophthalmometry 3982  General medical observation 3983  Glare test 3984  History 3985  Keratometry 3986  Laser interferometry 6-56 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.12. Ophthalmology

3987  Pachymetry 3988  Potential acuity meter (PAM) 3989  Schirmer test 3990  Slit lamp tear film evaluation and transillumination 3991 3992 NOTE: Corneal Pachymetry (76514) is separately reportable if a thorough evaluation of 3993 the cornea is performed along with image documentation, interpretation and report; no 3994 technical or professional modifiers should be reported. Code 76514 is reported only once, 3995 since it is considered a bilateral service. Therefore, if corneal pachymetry is performed on 3996 both eyes, modifier 50 would not be used. 3997 3998 If medically indicated other services, tests, or procedures performed can be added as 3999 additional CPT codes, e.g., contact lens fitting, photography, foreign body removal, or 4000 refraction. It is inappropriate to code for a limited visual field examination when performed 4001 as part of a routine screening examination 4002 4003 6.12.4.3. Refraction Code 4004 Any time refraction is performed, it is reported as an additional code. 92015 Refraction can only 4005 be use once, no multiple units. This is not reported with routine postoperative care or reported 4006 by auto refraction. 4007 4008 6.12.4.4. Dilated Retinal Exams for Diabetics, S3000 4009 Diabetic indicator, retinal eye exam, dilated, bilateral. Diabetic patient exam encounters with a 4010 dilated, bilateral retinal eye exam as part of the comprehensive exam should be coded with 4011 additional code S3000 for the diabetic indicator. 4012 4013 6.12.4.5. Visual Acuity Screening 4014 When doing an occupational health screening use 99172 or 99173 (screening codes) for 4015 optometry. These codes should not be used with 92002, 92004, 92012, and 92014 (General 4016 Ophthalmologic Services). In addition 99172 cannot be used with any E&M code and 99173 4017 cannot be used with any E&M service of the eye code. 4018 4019 6.12.4.6. Fitting of Spectacles 4020 Minimal documentation requirements for optometrist or technician for the use of codes 92340- 4021 92342 include: measurements of anatomical facial characteristics, records the laboratory 4022 specifications and performs the final adjustment of the spectacles to the visual axes and 4023 anatomical topography. If the final adjustment is performed on a later date, use V53.1. The 4024 supporting documentation must be contained within the medical record. 4025 4026 6.12.5. Glaucoma Screening (both military and nonmilitary) 4027 4028 4029 6.12.5.1. Patients without a Primary Glaucoma Diagnosis

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SPECIALTY CODING 6.12. Ophthalmology

4030 For patients without a primary diagnosis of glaucoma, glaucoma screening is reported separately 4031 as V80.1. If this is part of an annual exam, list the annual examination V code of V70.5__2 4032 followed by V80.1 as the secondary diagnosis. 4033 4034 6.12.5.2. Patients at High Risk for Glaucoma 4035 Charting documentation is specifically streamlined for the patient at high risk for glaucoma. The 4036 history will include the obvious risk factors for glaucoma (e.g., age, race, family history, trauma, 4037 corticosteroid use, and diabetes). Elements of the exam must be clearly documented if glaucoma 4038 screening is the only ophthalmologic or optometric service reported for high-risk patient’s code. 4039 4040 G0117 Glaucoma screening for high-risk patients, furnished by an optometrist or 4041 ophthalmologist 4042 G0118 Glaucoma screening for high-risk patients, furnished under the direct supervision 4043 of an optometrist or ophthalmologist 4044 4045 6.12.5.3. Screening for Glaucoma 4046 Glaucoma screening is defined to include: 4047  A dilated eye examination with an intraocular pressure measurement; and 4048  A direct ophthalmoscopy examination, or slit-lamp biomicroscopic examination 4049 4050 6.12.5.4. Glaucoma Screening for Diabetics 4051 Glaucoma screening performed on diabetics during a general ophthalmologic exam is identified 4052 with an additional HCPCS Level II code, S3000, diabetic indicator, retinal eye exam, dilated, 4053 bilateral. This is for population health data collection purposes only, not for reimbursement. 4054 4055 6.12.6. Coding for the Optometric or Ophthalmology Technician 4056 4057 6.12.6.1. When the technician provides services for a patient in conjunction with an optometrist 4058 or ophthalmologist, the technician is reported in ADM as an additional provider using the 4059 designation paraprofessional. Additional codes for any procedures the technician performs (e.g., 4060 spectacle ordering, visual field) are to be reported. 4061 4062 6.12.6.2. When a technician provides services at a separate encounter, the correct procedures 4063 (e.g. 99173, visual acuity screening) are entered in the CPT/HCPCS field. 4064 4065 Example: Patient seen by technician for vision exam portion of routine physical 4066 V70.5_2 Routine annual physical 4067 99173 Screening test of visual acuity 4068 4069 If a technician performs one of these procedures (99172 or 99173) at a separate encounter no 4070 E&M level is assigned and one of these codes is assigned. (See section 6.12.4.5.) 4071 4072 4073 6.12.7. Refractive Surgery

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SPECIALTY CODING 6.12. Ophthalmology

4074

4075 DoD Rule 4076 4077 S0800 will be used for both LASIK and LASEK procedures until a code is created 4078 for LASEK procedures. 4079 4080 Use modifier -54 and -55 with S0800 and S0810 codes.

4081 4082 Examples for lasik/lasek: 4083 4084 Pre-op: 4085 Diagnosis 1: V72.83 Other Specified Pre-Op Exam 4086 E&M N/A 4087 Procedure Code(s) as applicable: 4088 92004 Comprehensive New 4089 92014 Comprehensive Established 4090 92015 Refraction (can only use once, no multiple units) 4091 S0820 Computerized Corneal Topography (Has been replaced with 4092 92025 and should be used if available.) 4093 76514 Pachymetry (no 50 modifier, code is automatically bilat.) 4094 4095 Diagnosis 2: Hypermetropia 367.0, Myopia 367.1, Astigmatism 376.2, etc. 4096 4097 Procedure: 4098 Diagnosis: Hypermetropia 367.0, Myopia 367.1, Astigmatism 376.2, etc. 4099 E&M N/A 4100 Procedure Code(s) as applicable: 4101 S0800 LASIK 4102 S0810 PRK 4103 Use 50 modifier for bilateral, use 54 modifier if all f/u at another MTF 4104 Cannot use 65760 Keratomileusis or 92071 Fitting of contact lens for 4105 treatment of ocular surface disease 4106 Post-op: 4107 At same MTF: 4108 Diagnosis 1: V58.71Aftercare Following Surgery of the Sense Organs, NEC 4109 E&M: N/A 4110 Procedure Code: 99024 (Exception: post-op complication, code diagnosis 4111 first and code as 92014 Comprehensive Established) 4112 4113 Diagnosis 2: V45.69 Postsurgical State of the Eye and Adnexa

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4114 4115 At different MTF: 4116 Diagnosis 1: V58.71Aftercare Following Surgery of the Sense Organs, NEC 4117 4118 Procedure Code: S0800 or S0810 with 55 modifier for first f/u encounter, 4119 subsequent encounters 99024 (Exception: post-op complication, code 4120 diagnosis first and code as 92014 Comprehensive Established) 4121 4122 Diagnosis 2: V45.69 Postsurgical State of the Eye and Adnexa 4123 4124 Pre-op Exams: 4125  The primary Dx code should be V72.83 “other specified pre-op exam”. Secondary are 4126 things like myopia, etc. The referral exam should be coded as a comprehensive eye exam 4127 (92004 for new patient or 92014 for prior patient). 4128  Corneal Topography: CPT code 92025- “Computerized corneal topography, unilateral or 4129 bilateral, with interpretation and report” is reported when topography is not performed in 4130 conjunction with keratoplasty procedures (65710, 65730, 65750 and 65755). 4131  Pachymetry: When this is documented with interpretation it can be coded as 76514. The 4132 requirement does not specify the exact instrument used, and “permanently recorded 4133 images are not required”. 4134 4135 6.12.7.1. V72.83 Other Specified Preoperative Exam 4136 This code will be the first listed. The diagnosis that is the reason for the surgery will be a 4137 secondary code, followed by any conditions that may affect treatment. 4138 4139 6.12.7.2. Postoperative Care 4140 Postoperative care following eye surgery may be performed or shared between providers (e.g., 4141 when the surgery is done at another facility). When one provider performs the surgery, and 4142 postoperative care will be provided at a different MTF, the surgeon will code the procedure 4143 followed by modifier -54 to indicate only performance of intraoperative care, (e.g., S0810–54). 4144 The provider at a different MTF performing the first episode of postoperative care codes the 4145 encounter using modifier -55, (e.g., S0810–55) postoperative. Additional uncomplicated follow- 4146 up care for this service is coded with 99024, indicating subsequent visits within the 90-day 4147 global period. The provider may be entitled to code additional services performed in the 4148 evaluation of a new patient in accordance with procedural coding rules. When providing 4149 postoperative care, the date of procedure is included in the documentation. Utilize ICD-9-CM 4150 code V58.71 for aftercare provided within the global period. 4151 4152 6.12.8. Extended Ophthalmoscopy with Retinal Drawing 4153 4154 6.12.8.1. Ophthalmoscopy 4155 Extended (92225) and subsequent (92226) ophthalmoscopy are considered reasonable and 4156 necessary services for evaluation of tumors of the retina and choroid (the tumor may be too 4157 peripheral for an accurate photograph), retinal tears, detachments, hemorrhages, exudative

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4158 detachments, and retinal defects without detachment, as well as other ocular defects when the 4159 patient’s medical record meets the documentation requirements set forth in this policy. These 4160 codes are reserved for the meticulous evaluation of the eye and detailed documentation of a 4161 severe ophthalmologic problem when photography is not adequate or appropriate. 4162 4163 6.12.8.2. Frequency of Service 4164 Frequency for providing these services depends on the medical necessity of each patient and this, 4165 of course, relates to the diagnosis. A serious retinal condition must exist or be suspected, based 4166 on routine ophthalmoscopy, which requires further detailed study. 4167 4168 6.12.8.3. Medical Necessity 4169 In all instances, extended ophthalmoscopy must be medically necessary. It must add information 4170 not available from the standard evaluation services or information that will demonstrably affect 4171 the treatment plan. It is not medically necessary, for example, to confirm information already 4172 available by other means. 4173 4174 6.12.8.4. Major Criteria 4175 These criteria must be met: 4176 4177  A serious retinal condition is present based on ophthalmoscopy, which requires 4178 further study, such as the detailed study of pre-retinal membrane, a retinal tear 4179 detachment, a suspected retinal tear with sudden onset of symptomatic floaters or 4180 vitreous hemorrhage. 4181  Another diagnostic technique in addition to routine direct and indirect 4182 ophthalmoscopy is necessary and documented; for example 360 º scleral depressions, 4183 fundus contact lens, or 90-diopter lens. 4184  The technique and findings of the extended ophthalmoscopy must be documented, 4185 including a three-dimensional representation or an extended colored retinal drawing. 4186 Sketches and templates are not acceptable. The documentation of follow-up services 4187 (92226) must include an assessment of the change from previous examinations. 4188  Documentation supporting the medical necessity of this item, such as ICD-9 codes, 4189 must be submitted with each encounter. 4190 4191 6.12.9. Modifiers 4192 The most commonly used modifiers (and most frequently found to be missing in audits) in 4193 optometry or ophthalmology are the LT for left and the RT for right when unilateral codes are 4194 used; such as removal of foreign body. Many of the procedures for the eye are inherently 4195 bilateral. When one of these procedures is done on only one eye, add modifier -52, reduced 4196 services, as well as the modifier RT for right or LT for left. 4197

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4198 6.13. Physical Therapy (PT)—Coding for Physical Therapist or Technician 4199 4200 6.13.1. E&M Coding Rules 4201 E&M codes are not appropriate for routine physical therapy (PT). The evaluation and 4202 management components of an outpatient office E&M are already included in special physical 4203 therapy evaluation and reevaluation procedural codes, as indicated below. 4204 4205 6.13.2. Diagnosis Coding Rules 4206 4207 6.13.2.1. Outpatient Physical Therapy 4208 Outpatient PT encounters for the purpose of receiving therapy are always coded with V57.1 as 4209 the first listed diagnosis. 4210 4211 NOTE: When a patient presents for evaluation and therapy is initiated on the same day, do 4212 not use V57.1. Code the condition as primary diagnosis. 4213 4214 6.13.2.2. Evaluative PT 4215 PT encounters for evaluation only, or for attending runner’s clinics, or group educational classes, 4216 would not be identified by V57.1. Exercise counseling (e.g., runner’s clinic) is an education V 4217 code, V65.41. If the purpose of the encounter is evaluation, use the appropriate ICD-9-CM 4218 diagnosis or symptom code in the first CAPER position. 4219

4220 DoD Rule

4221 4222 V57.1 will be the first listed code for all PT encounters involving therapy only. The 4223 condition(s) for which the patient is receiving therapy will be listed in the second or 4224 third position. PT encounters for post-deployment therapy sessions will have 4225 V70.5_6 as the third or fourth code. 4226 4227 6.13.2.3. Injuries 4228 When functioning in the role of physician extender, physical therapists may render a diagnosis. 4229 If this is the first time the patient has been seen at the facility for the current injury, use the 4230 appropriate injury code followed by the appropriate E code. You must also document date of 4231 injury. PT services are only coded with aftercare, follow-up care, and pain-, muscle-, or joint- 4232 related diagnoses. 4233 4234 Example: A patient comes in with back pain that is the result of lifting a heavy item. The 4235 patient has not been seen in the ED or by any other provider for this pain. Physical therapist 4236 examines the back and determines there is a strained muscle. PT evaluation was done and 4237 therapy was not started that day. 4238 6-62 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.13. Physical Therapy (PT)

4239 Codes: ICD-9 847.1 (thoracic back strain), E927 (lifting injury) 4240 E&M N/A 4241 CPT 97001 (evaluation) 4242 4243 Example: Patient encounter for first PT session for a previously treated thoracic back sprain. 4244 PT evaluation was conducted at the previous visit. Modalities provided to the patient on this day 4245 were electrical stimulation and hot packs. 4246 4247 Codes: ICD-9 V57.1, (physical therapy) 4248 847.1 (thoracic back strain) 4249 E&M N/A 4250 CPT 97014 (electrical stimulation) 4251 97010 (hot pack) 4252 4253 6.13.3. Procedural Coding Rules 4254 CPT codes for rehabilitation procedures are in the Physical Medicine and Rehabilitation 4255 subsection of the Medicine Section (97001—97799). A clinic visit for evaluation only with no 4256 therapy is given a CPT code of 97001. For education by a non-privileged provider (PT 4257 technician) the appropriate HCPCS S codes are S9451 exercise and S9454 stress management. A 4258 clinic encounter for education and/or counseling of an established problem by a physical 4259 therapist, where no evaluation and management services were provided, will be coded as a 4260 98960. 4261 4262 6.13.4. Evaluations and Reevaluations 4263 There is no distinction for new or established patients. Code an evaluation, 97001 or 4264 reevaluation, 97002 with or without modalities, or code just the modalities performed. The 4265 initial assessment of the problem is to determine the appropriate therapy, the increments, 4266 frequency, duration, and other factors necessary to enhance healing. Reevaluations are for 4267 subsequent assessments to determine the success of the treatment and make modifications as 4268 needed. 4269 4270 6.13.5. Modalities 4271 Certain modalities are inclusive of the evaluation and reevaluation procedural codes. For a list of 4272 these modalities you may refer to the NCCI. NCCI edits are at: 4273 http://www.cms.hhs.gov/NationalCorrectCodInitEd/. 4274 4275 Constant attendance modalities (97032–97039) and therapeutic procedures (97110–97546) 4276 require direct, one-on-one patient contact by the provider. Basically, this direct one-on-one 4277 contact requires that the provider maintain visual, verbal, or manual contact with the patient 4278 throughout the procedure. For a technician to code an encounter, the technician must be working 4279 under a privileged provider’s plan of care. When the physical therapist is actively involved in 4280 the therapy and assisted by a technician, the technician should be listed as an additional provider 4281 when coding the encounter. 4282

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SPECIALTY CODING 6.13. Physical Therapy (PT)

4283 6.13.6. Units of Service 4284 4285 6.13.6.1. Time as Unit of Service 4286 Constant attendance modalities and therapeutic modalities are each 15 minutes in the code 4287 descriptions. Therefore, one unit of service is reported for each 15 minutes of therapy rendered 4288 per date of service. The table below is used to calculate units of service. A minimum of 8 4289 minutes must be performed to qualify for 1 unit of service. 4290 4291 6.13.6.2. Reporting Time Intervals 4292 For each CPT procedure where unit of service is a factor, report time intervals for units of 4293 service as follows: 4294 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 4295 4296 Units are calculated in the same manner for therapy that exceeds two hours. 4297 4298 6.13.6.3. Treatment Time for Multiple Procedures 4299 For multiple CPT procedures performed on the same calendar day, the total amount of treatment 4300 time determines the number of units for the day. Each modality and amount of time needs to be 4301 documented, not a total time given for all modalities. A minimum of 8 minutes for each 4302 modality provided is needed in order to report time. 4303 4304 6.13.6.4. Group Therapy Procedures 4305 Group therapy involves constant attendance by the physician or therapist, but by definition does 4306 not require one-on-one patient contact by the physician or therapist. Report code 97150 for each 4307 member of the group and provide documentation for the therapies the patients received, 4308 including minutes of activity. 4309 4310 6.13.7. Modifiers 4311 The HCPCS modifier GP is used in the civilian sector by physical therapy to indicate that the 4312 therapy is being performed under an outpatient physical therapy plan of care. It does not specify 4313 a therapist furnished the care. The GP modifier is not used in the DoD system. 4314 4315 6.13.8. Documentation of Physical Therapy 4316 4317 6.13.8.1. Note Requirements

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SPECIALTY CODING 6.13. Physical Therapy (PT)

4318 To support a CPT or HCPCS code, at a minimum each physical therapy note needs to include 4319 therapist’s name, modality, treatment assessment (patient tolerated treatment), and adjustment to 4320 the therapy plan. Documentation based on a checklist alone is insufficient. 4321 4322 6.13.8.2. Required Elements 4323 The following elements need to be recorded by the therapist or technician 4324  The specific modalities or procedures (supervised or attended), 4325  The body area involved, 4326  The start and stop times or total time for each modality, 4327  Access to a plan of care for reference to modalities and therapies being provided by the 4328 technician. 4329 4330 6.13.8.3. For pregnant patients, the date of the patient’s last menstrual period and estimated date 4331 of delivery must be recorded in ADM. 4332 4333 6.13.9. Inpatient Therapy 4334 Evaluations and Re-evaluations for physical therapy are coded in the B MEPRS. Physical 4335 therapy modalities related to the admission are not coded. 4336

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SPECIALTY CODING 6.14 Preventive Medicine Services

4337 6.14. Preventive Medicine Services 4338 There are two basic types of preventive medicine services, physicals or well-baby visits and 4339 counseling or risk-factor reduction intervention. Section 6.14.1 is about physicals and well-baby 4340 visits. Section 6.14.2 is about counseling and risk factor reduction intervention. 4341

4342 DoD Rule 4343 4344 If an additional problem or issue is identified and treated, an additional office E&M 4345 code may be warranted.

4346 4347 If the encounter intent is preventive (e.g., a physical), code the preventive E&M 4348 encounter (e.g., 99384–7, 99394–7) first, even though problems or issues addressed 4349 constitute an additional problem-oriented E&M code (e.g., 99212) based on the 4350 separate problem-oriented documentation. Append modifier -25 to the problem- 4351 oriented E&M (e.g., 99212-25). 4352 4353 6.14.1. Physicals and Well-Baby Visits 4354 4355 6.14.1.1. E&M Rules 4356 4357 6.14.1.1.1. Categorization 4358 Preventive medicine E&M services, such as physicals and well-baby checks, are categorized by 4359 patient age and status. It is the privileged provider’s clinical judgment as to what constitutes age 4360 and gender appropriate history and exam. The history obtained as part of the preventive 4361 medicine service is not problem-oriented and does not involve a chief complaint or present 4362 illness. 4363 4364 6.14.1.1.2. Visit Comparisons 4365 The following table provides preventive medicine visit comparisons: 4366 Preventive Medicine Problem Oriented Preventive Medicine Visit with 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 complaints. specified complaint Insignificant or trivial problem History Not problem oriented. Description of the Include history 1) related to No description of history of present age/gender and 2) present illness present illness. illness as appropriate Assessment of for the presenting pertinent risk factors problem 6-66 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.14 Preventive Medicine Services

Preventive Medicine Problem Oriented Preventive Medicine Visit with Visit Visit Problem 993xx and 992xx with 99381–99397 99201–99215 modifier -25 Review of Comprehensive To the extent Combine system review and systems—past, system review. appropriate for the presenting problem family, social *Comprehensive past, presenting problem 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) present patient and risk factors presenting problem illness identified Assessment Screening for ancillary Ancillary services Combination of screening and and plan services without ordered for specific medical decision making complaint. medical problem(s). Typically related to Medical decision- counseling, making reflected anticipatory guidance, risk factor reduction 4367 *For preventative medicine services, the term “Comprehensive” reflects an age and gender appropriate 4368 history/exam and is not synonymous with the “comprehensive” examination required in Office E&M 4369 codes. 4370 4371 6.14.1.1.3. Determining Proper Code Category 4372 The issue is not how healthy the patient is, but rather how much work the provider does. Use 4373 problem-oriented office visit codes when the documentation shows significant medical decision 4374 making. 4375 4376 Documentation points to preventive medicine codes when a patient presents for routine services 4377 (annual exam) and documentation does not show that a significant problem is addressed. 4378 Documentation points to preventive medicine codes when there are no patient complaints, no 4379 symptoms, and no significant problem or abnormality is recorded. 4380 4381 6.14.1.1.4. A Physical and a Condition 4382 Frequently, a patient will schedule an appointment but identify other issues at the encounter that 4383 require medical intervention. When the condition requires significant time and resources, it 4384 should be documented separately from the physical. There is usually a second SOAP 4385 (Subjective, Objective, Assessment, and Plan) note after the physical documentation. Code the 4386 physical E&M (i.e., 99381–99397) linking the physical diagnosis to the physical E&M. Then 4387 code an office visit E&M (e.g., 99212) with a modifier -25, linking the medical condition to the 4388 office visit E&M. 4389 4390 Example: Well-baby visit with a second diagnosis of acute otitis media. The first E&M 4391 code, 993xx, would be linked to the well-baby visit (V20.2), while the 992xx-25 would be 4392 linked to the acute otitis media diagnosis (382.9). 6-67 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.14 Preventive Medicine Services

4393 4394 6.14.1.2. Diagnosis Coding Rules 4395 4396 6.14.1.2.1. The V codes identify diagnoses when a person is not currently or acutely ill, but 4397 requires healthcare services. Some of the commonly used codes include: 4398 4399 V20.2 Well-baby examinations 4400 V68.09 Issue of medical certificate for full flying duties (FFD)/Return to flight 4401 status (RTFS) 4402 V70.3 Sports physicals/ school physicals 4403 V70.5_ _ 1 Annual flight examinations 4404 V70.5_ _ 4 Pre-deployment prevention examinations 4405 V70.5_ _ 6 Post-deployment prevention examinations 4406 V72.31 Annual GYN examinations 4407 4408 6.14.1.2.2. Post-Deployment Visits 4409 The provider should assess if the visit is deployment related. All deployment-related visits 4410 must have the deployment code listed in one of the first four positions. See section 2.2.8.2. of 4411 this manual. The deployment related codes are V70.5_4/5/6. 4412 4413 6.14.1.3. Procedure Coding Rules 4414 4415 6.14.1.3.1. Immunizations 4416 Those given at point of service (in the clinic performing the well-baby visit or other physical) are 4417 coded on the same encounter as the physical. 4418 4419 6.14.1.3.2. Visual Acuity Screening 4420 Refer to 6.12.4.5. for guidance. 4421 4422 6.14.1.3.3. Blood Pressure 4423 Measurement of blood pressure is a vital sign and collected as a part of the constitutional 4424 evaluation with other vital signs. It is inappropriate to use 93770 for arterial blood pressure 4425 measurement obtained at patient intake. 4426 4427 6.14.1.3.4. Codes to Assist in Population Health Management 4428 Consider using the Level II codes for smoking if the MTF emphasizes smoking cessation (i.e., 4429 G0436 and G0437 as appropriate). Refer to Section 3.7. Tobacco Cessation Counseling 4430 4431 6.14.2. Counseling and Risk Factor Reduction Interventions 4432 The second basic type of preventive medicine services is counseling or risk factor reduction 4433 intervention. 4434 4435 One of the more common coding errors in the DoD is using a preventive medicine, 4436 individual, or group counseling code, when an education code should have been used. Use

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SPECIALTY CODING 6.14 Preventive Medicine Services

4437 a counseling or risk factor reduction intervention code when there is no condition, 4438 symptom, or disease. 4439 4440 For instance, a couple is considering having a child and the woman’s nephew has Tay-Sachs. 4441 The couple does not have a child with Tay-Sachs, but there is a risk they could since a nephew 4442 has it. This is therefore a counseling session. If the couple had already had a child with Tay- 4443 Sachs and was seeing a provider to learn more about the disease and how to manage their child, 4444 it would be education. 4445 4446 Another example: Discussion about having a prophylactic mastectomy because a woman’s 4447 mother and sister both had breast cancer is counseling. Discussion on treatment options for a 4448 woman diagnosed with breast cancer is an office visit. Occupational therapy to improve ADL 4449 after the mastectomy is occupational therapy. Classes addressing post-mastectomy issues are 4450 education. Prenatal, obesity, and diabetes classes are education. 4451 4452 NOTE: When an applicable education class code is not available in HCPCS (many are 4453 around S9436), use the 99078 CPT code, if applicable. These are procedure codes and 4454 would be coded in the procedure field of the ADM. 4455 4456 6.14.2.1. E&M 4457 The appropriate E&M codes should be assigned based on the documentation of the services 4458 performed: Counseling or risk factor reduction E&M codes include 99401–99404 and 99411– 4459 99412. To determine if the counseling or risk factor reduction codes are appropriate, ask: Was 4460 the encounter for an examination, education, or counseling? 4461 4462 If the provider sees the patient for a problem, reviews the patient’s health assessment form as 4463 part of the visit, and does risk factor reduction intervention (e.g., noticed on health assessment 4464 form that the patient does not wear sunscreen and has been sunburned a number of times), assign 4465 the office-outpatient codes 99201–99215. If the counseling (e.g., about protection from the sun) 4466 takes more than 50 percent of the time of the encounter, and it is documented, the encounter may 4467 be coded based on time instead of the history, exam and decision making. 4468 4469 Office visits not documented as a new visit should be coded for established patients. 4470 4471 Diagnosis coding is based on the provider’s assessment of problems or illnesses and any 4472 counseling provided. It is also based on the type of exam or counseling performed and any 4473 problems or illnesses assessed as part of the examination. 4474 4475 If the provider is conducting preventive medicine counseling or risk factor reduction counseling, 4476 (e.g., counseling on safe sex) the 99401–99404 codes should be assigned. 4477 4478 NOTE: These codes are not to be used to report counseling and risk factor reduction 4479 interventions provided to patients with symptoms or established illness. The code selection 4480 is based on time. Documentation must support the reason for the amount of time used.

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SPECIALTY CODING 6.14 Preventive Medicine Services

4481 For instance: Counseled on safe sex, 30 minutes would not adequately explain the amount 4482 of time involved. 4483 4484 Example: The 99411–99412 codes are appropriate for all students when the provider is 4485 teaching a healthy heart class for a general audience, even if one of the participants is 4486 diabetic, another is hypertensive, and a third is obese. 4487 4488 6.14.2.2. Diagnosis Coding for Preventive Encounters 4489 Diagnosis coding is based on the type of counseling provided. When counseling is 4490 provided, frequently used ICD-9-CM codes include: 4491 4492 V16.X Family history of malignant neoplasm 4493 V17.X Family history of certain chronic disabling diseases 4494 V25.09 Family planning (counseling for contraceptive mgt) 4495 V65.3 Dietary surveillance and counseling 4496 V65.40 Other counseling, no other symptoms 4497 V65.41 Exercise counseling 4498 V65.42 Counseling on substance use and abuse (this is a root code, use the 4499 appropriate DoD extender code) 4500 V65.43 Counseling on injury prevention 4501 V65.44 HIV counseling 4502 V65.45 Counseling on other sexually transmitted diseases 4503 V65.46 Encounter for insulin pump training 4504 V65.49_x Other specified counseling (this is a root code, use the appropriate DoD 4505 extender code) 4506 V69.0 Lack of physical exercise 4507 V69.1 Inappropriate diet and eating habits 4508 V69.2 High-risk sexual behavior 4509 V69.3 Gambling and betting 4510 V69.8 Other lifestyle-related problems 4511 V69.9 Problem related to lifestyle, unspecified 4512 4513 6.14.2.3. Procedures 4514 Separate procedures for counseling or risk factor reduction are rarely done during an encounter. 4515 4516 6.14.3. Modifiers 4517 -25 Append to any separate office visit E&M services provided. 4518 Reported in addition to the preventive medicine service codes. 4519 4520 6.14.4. Documentation 4521 For counseling, the amount of time spent with the patient as well as the time counseling the 4522 patient must be included in the documentation in addition to the date (e.g.. 12 Oct 04, 0900– 4523 0930, counseling 20 minutes). Additional documentation guidelines are: 4524

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SPECIALTY CODING 6.14 Preventive Medicine Services

4525  Patient presents for annual physical when using preventive medicine codes. 4526  Patient presents for multiple concerns as well as health maintenance when using both a 4527 low-level office visit and a preventive medicine code. 4528  When reporting preventive medicine counseling codes, document the nature of the 4529 counseling and any education provided during the encounter. 4530  Do not document patient presents for yearly exam when using a problem-oriented visit 4531 code. 4532

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SPECIALTY CODING 6.15. Radiation Oncology Services

4533 6.15. Radiation Oncology Services 4534 4535 6.15.1. E&M Coding Rules 4536 E&M codes are used in radiation oncology for services such as consultation, pre-treatment 4537 evaluations, and non-routine follow-up visits. Select the appropriate code from the 4538 documentation in the E&M section. For example, an inpatient might be evaluated by the 4539 therapeutic radiologist to determine treatment options before a decision for treatment is made. 4540 This visit would be coded as an initial inpatient consultation or subsequent hospital care, as 4541 appropriate. 4542 4543 6.15.2. Diagnosis 4544 Code the reason for the encounter. For instance, if the patient is being seen for radiation therapy, 4545 the first code will be: 4546 4547 V58.0 Radiotherapy. However, coding convention holds that this therapy is conducted if the 4548 malignancy still exists. Therefore, the malignancy should also be coded. The neoplasm table in 4549 the ICD-9-CM book is simple to use and codes may be taken directly from it without referring to 4550 the tabular. 4551 4552 6.15.3. Procedural Treatment Planning Rules 4553 4554 6.15.3.1. Radiation Oncology 4555 This treatment is used to destroy tumors and has professional and technical components. 4556 Procedure codes are for initial consultation through patient management of the entire course of 4557 treatment. 4558 4559 6.15.3.2. Treatment and Planning Codes 4560 Privileged providers document treatment and planning using codes 77261, 77262 and 77263. 4561 These codes include the initial consultation, so there is no separate E&M. 4562 4563 6.15.3.3. Clinical Treatment, Planning, and Tumor Mapping 4564 This is used to identify the location, extent, volume of tumor(s) to be treated, and all critical 4565 structures surrounding them. The privileged provider plans an individualized course of radiation 4566 therapy that allows maximum benefit while protecting surrounding tissues and structures. These 4567 codes include clinical treatment planning, which may involve interpreting special tests. These 4568 professional services are usually provided once during the course of treatment and include a 4569 follow-up period of up to three months after treatment, unless a separate plan is implemented. 4570 4571 6.15.3.4. Simulation (77280–77295) 4572 4573 6.15.3.4.1. Simulation 4574 The purpose of simulation is to determine treatment options and the placement of ports for 4575 radiation treatment. It does not include the administration of radiation. The complexity of a

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SPECIALTY CODING 6.15. Radiation Oncology Services

4576 simulation is based on the number of ports, volumes of interest, inclusion and type of treatment 4577 devices. 4578 4579 6.15.3.4.2. Simulations Not Reported Separately 4580 Simulations that are not to be reported separately are: (1) portal changes based on unsatisfactory 4581 initial simulations, (2) minor changes in port size without changes in beam and simulation set up. 4582 The simulation set up is part of a period of treatment management, usually in units of five. 4583 4584 6.15.3.4.3. Additional Simulations 4585 These may be necessary during treatment to account for changes in port size, boost dose, or 4586 tumor volume. Simulations need to be ordered by the privileged provider and documentation 4587 should be completed and signed with the results. Documentation should include the date, reason 4588 (initial, block check, subsequent, etc.), and a summary of the procedure. 4589 4590 6.15.3.4.4. Teletherapy Isodose 4591 If the documentation of the simulation supports CPT 77295, then teletherapy isodose (77305– 4592 77315) plans are also reported. 4593 4594 6.15.3.4.5. Level of Complexity of Treatment Planning and Simulation Services 4595 The levels of complexity for these services are clearly identified in the CPT code. All criteria do 4596 not have to be met to establish the level of complexity. For example, three or more separate 4597 treatment areas with simple blocking or no blocking would qualify as a complex service. 4598 4599 6.15.4. Medical Radiation Physics 4600 4601 6.15.4.1. Basic Dosimetry 77300 4602 The calculation of the radiation dose and placement is called dosimetry. The radiation oncologist 4603 must order these services as part of the treatment plan. These are reported once per port and may 4604 be repeated if documentation supports the reason for the new calculation. 4605 4606 6.15.4.2. IMRT-Intensity Modulated Treatment Delivery 4607 IMRT Planning—77301 4608 4609 6.15.4.3. Teletherapy Isodose Plans 77305–77315 4610 Teletherapy Isodose plans are coded once for a specific treatment area. An additional plan 4611 maybe coded if documentation supports that it was medically necessary to change fields or 4612 equipment, or if clinical variations are made during the course of treatment. 4613 4614 6.15.4.4. Special Therapy Port Plan 77321 4615 This should be coded only once per treatment area (volume of interest) and not in conjunction 4616 with 77300. 4617

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SPECIALTY CODING 6.15. Radiation Oncology Services

4618 6.15.4.5. Special Dosimetry 77331 4619 This service is the measurement of the actual amount of radiation a patient has received at any 4620 given point. The radiation oncologist must order this service. This code may be used more than 4621 once per day per treatment course. 4622 4623 6.15.4.6. Treatment Devices 77332–77334 4624 Multiple devices may be coded if documentation substantiates. If two devices of separate levels of 4625 complexity are documented, code only the one of the higher level. 4626 4627 6.15.5. Radiation Physics Consultations 4628 4629 6.15.5.1. Continuing Medical Physics Consultation 77336 4630 CPT clearly identifies the documentation requirements. This code may be reported weekly. 4631 4632 6.15.5.2. Special Medical Radiation Physics Consultation 77370 4633 This code may only be reported once per course of treatment. This is used when a problem or 4634 situation arises during treatment. It requires a written analysis or report of the course of 4635 treatment, and is done at the direct request of the radiation oncologist. 4636 4637 6.15.6. Radiation Treatment Delivery Codes 77401–77416 4638 Radiation treatment delivery codes are used for the actual delivery of the radiation and consist of 4639 the technical component only. This code is chosen by level of service and energy used. Multiple 4640 treatment sessions on the same day may be coded when there is a break in sessions. The record 4641 should document a distinct break in therapy. 4642 4643 6.15.7. Radiation Treatment Management 77427–77499 4644 4645 6.15.7.1. Radiation treatment management codes consist of the professional component only. 4646 CPT identifies documentation requirements for these services. This includes review of port films 4647 and dosimetry, dose delivery, and treatment parameters, review of treatment set up, and 4648 examination of patient for medical evaluation and management. The documentation must clearly 4649 identify that the radiation oncologist examined the patient. Nursing notes that the doctor adds, 4650 agree or patient doing well will not qualify as the examination of the patient for this 4651 management. 4652 4653 6.15.7.2. 77427 Reporting 4654 This is done every five treatments. For the first, second, third, and fourth treatment, use diagnosis 4655 V58.0 and the code for the neoplasm. Do not code 77427 until the fifth treatment. 77431 is 4656 reported if the course of treatment consists of one or two fractions. 4657 4658 6.15.8. Final Note 4659 Some radiation oncology services may be bundled and may be modified under Correct Coding 4660 Initiative, as discussed previously. 4661 References:

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SPECIALTY CODING 6.15. Radiation Oncology Services

4662 CPT 2004 Professional Edition 4663 ”Cancer Care Network— 4664 A User’s Guide For Radiation Oncology Management & Billing Procedures.” 4665 Coding Strategies, Inc. 4666 The Medical Management Institute—CUB All-In-One Coding Utility Book—Coding and 4667 Medicare for Radiation Oncology 4668 ”AETC Radiation Oncology Training Modules,” by Patricia Bridges RHIT, CCS, CCS-P and 4669 Victoria Flisk BHA, CPC 4670

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SPECIALTY CODING 6.16. Radiology, Interventional

4671 6.16. Radiology, Interventional 4672 Interventional radiology is used to describe the use of cross-sectional imaging techniques, such 4673 as ultrasound, CT and MRI, and digital processing of fluoroscopy. These techniques are used 4674 not only for diagnostic but also therapeutic applications. 4675 4676 6.16.1. E&M Coding Rules 4677 4678 6.16.1.1. No Separate E&M Codes 4679 Usually there is no separately identifiable E&M associated with an interventional radiology 4680 encounter. 4681 4682 6.16.1.1.2. Coding E&M Separately 4683 To code an E&M separately from a procedure, there must be a separately identifiable reason. 4684 For instance, a provider determines the need for a procedure. At that encounter, there would be a 4685 discussion of risks and benefits, informed consent would be obtained, and there would be an 4686 evaluation to determine contraindications and other issues affecting the procedure (such as 4687 allergies, previous adverse issue, or review of lab tests). If it is a major procedure (usually with a 4688 global post-operative period of 90 days), there would be a preoperative physical. In this case, 4689 there would be an E&M code. For minor procedures (usually with a global postoperative period 4690 of 0–10 days), the pre-procedural assessment is a component of the procedure. The 4691 postoperative encounter, usually for a suture removal, does not have an E&M, but is coded with 4692 99024 in the CPT field. 4693 4694 6.16.2. Diagnosis 4695 4696 6.16.2.1. First-Listed Diagnosis 4697 The first-listed diagnosis is the reason the patient is having the procedure. If a definitive 4698 diagnosis is not available by the end of the encounter and there will not be a pathology report, 4699 code what is known. Do not code rule out. Code any additional diagnoses that affect the 4700 encounter, such as diabetes, pregnancy, or a history of carcinoma. 4701 4702 6.16.2.2. Diagnosis Contingent on Pathology Report 4703 When the diagnosis is contingent on a pathology report, wait to code the encounter until the 4704 pathology report is available. For example, if the provider’s pre-procedure diagnosis is mass and 4705 after the procedure, it is the provider’s assessment that the mass is benign, it would be coded as a 4706 benign neoplasm. If after the procedure, the provider suspects the mass may be malignant, the 4707 provider should wait to code the diagnosis and procedure until the pathology results are 4708 available. For instance, if a patient presents for rule out neoplasm of breast, but all that is known 4709 is that there is a mass in the breast, code a mass, not a neoplasm. 4710 4711 6.16.3. Procedures 4712 4713 6.16.3.1. Interventional radiology usually involves two components: the imaging procedural 4714 component and the therapeutic or diagnostic procedural component. In this section, the term

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SPECIALTY CODING 6.16. Radiology, Interventional

4715 imaging guidance usually indicates a procedure in the 7xxxx range of CPT codes. The term 4716 procedural component usually indicates a procedure from the 10000–69999 or 9xxxx CPT 4717 codes. 4718 4719 6.16.3.2. When performing the procedural component, (e.g., 19102, biopsy of breast; 4720 percutaneous, needle core, using imaging guidance), collect the procedural component in ADM. 4721 Collect the imaging guidance used in conjunction with the procedure (e.g., 76095, stereotactic 4722 localization guidance for breast biopsy or needle placement, each lesion, radiological supervision 4723 and interpretation) in the radiology module. 4724 4725 6.16.4. Modifiers 4726 4727 6.16.4.1. Modifier -26 4728 Most procedures in the 10000–69999 and 9xxxx ranges do not have a professional and technical 4729 component. Usually, the procedures are performed by a privileged provider in one setting. 4730 Therefore, it is not necessary to use the modifier -26 for the professional component. 4731 4732 6.16.4.2. Technical Component Modifier 4733 Most procedures in the 10000–69999 range do not have a separate technical component. There 4734 are a few in urology, but these would not usually be involved with interventional radiology. In 4735 those cases when there is a technical component, the appropriate modifier would be TC. The 4736 urology procedures may be performed by a urology technologist or nurse but the data must be 4737 interpreted by the urologist. A radiology imaging exam performed by a radiological technologist 4738 (imaging of the patient) must also have the data interpreted by the radiologist. 4739 4740 6.16.4.3. MEPRS 4741 Collect the procedural component of interventional radiology for procedures that do not require 4742 medically supervised recovery (e.g., patient is able to respond to verbal stimulus for the entire 4743 procedure and is able to depart upon termination of the procedure), in the BBMA MERPS 4744 account. Collect the procedural component of interventional radiology, for procedures requiring 4745 medically supervised recovery (e.g., patient needs to be supervised in the post-anesthesia care 4746 unit), in the BBM5 MEPRS account when the radiologist is AD or civil service. 4747

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SPECIALTY CODING 6.17. Health Exams of Defined Subpopulations, V 70.5_x

4748 6.17. Health Exams of Defined Subpopulations, V 70.5_x 4749 4750 6.17.1. E&M Guidance 4751 ENCOUNTER TYPE E&M Encounter with exam, <1 years 99391 Encounter with exam, 1-4 years 99392 Encounter with exam, 5-11 99393 Encounter with exam, 12-17 99394 Encounter with exam, 18-39 99395 Encounter with exam, 40-64 years 99396 Encounter with exam, 65 years or older 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 99201-99205 Encounter Tech Visit, face to face, no privileged provider contact 99211 4752 *Air Force, see your service representative. 4753 4754 6.17.1.1. Privileged Provider Performs Assessment 4755 The appropriate E&M codes should be assigned based on the documentation. Was the encounter 4756 for a DoD evaluation of the patient’s ability to perform his mission? Was the encounter for 4757 counseling or an examination? The definition of counseling is a dialogue with patient or family 4758 on one or more of the subsequent areas: 4759  diagnostic results, impressions, or recommended diagnostic studies 4760  prognosis 4761  risks and benefits of management (treatment) options 4762  instructions for management (treatment) or follow-up 4763  risk factor reduction 4764  patient and family education (CPT Assistant, January 1998, p. 6) 4765 4766 For annual mission specific exams (e.g. Personnel Reliability Program (PRP)), medical decision 4767 making might not be the determining factor for the E&M assignment. 4768 4769 6.17.1.2. Prevention Counseling 4770 If the provider is conducting preventive medicine counseling or risk factor reduction counseling, 4771 (e.g., counseling on safe sex so long as the patient is not doing anything that could be considered 4772 unsafe sex) use codes 99401–99404. 4773 4774 NOTE: These codes are not to be used to report counseling and risk factor reduction 4775 interventions given to patients with symptoms or established illness. The code selection is 4776 based on provider counseling time. Time spent on risk-factor reduction must be

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SPECIALTY CODING 6.17. Health Exams of Defined Subpopulations, V 70.5_x

4777 documented. Time spent evaluating the patient for ability to perform the mission or 4778 educating the patient is not included in the time used to determine a preventive medical 4779 counseling or risk factor reduction. 4780 4781 99401 Preventive medical counseling or risk factor reduction intervention(s) given 4782 to an individual (separate procedure): 15 minutes 4783 99402 Preventive medical counseling or risk factor reduction intervention(s) given 4784 to an individual (separate procedure): 30 minutes 4785 99403 Preventive medical counseling or risk factor reduction intervention(s) given 4786 to an individual (separate procedure): 45 minutes 4787 99404 Preventive medical counseling or risk factor reduction intervention(s) given 4788 to an individual (separate procedure): 60 minutes 4789 4790 Example: The privileged provider is rendering individual counseling on lifestyle 4791 modifications for risky behavior, preventive counseling based on family history and 4792 occupational exposure. The duration of this visit is 60 minutes with 15 for evaluation to 4793 perform the mission (do not include this time), 15 minutes discussing why the patient should 4794 stop smoking, exercise, and lose weight (education, do not include this time), and 30 minutes 4795 for counseling or risk-factor reduction. Code this as 99402 —counseling 4796 4797 If the provider is conducting a wellness or screening exam (e.g., pelvic examination for 4798 women or prostate examination for men) during the PHA, the preventive medicine codes are 4799 to be used. A pelvic exam or prostate examination by itself does not justify use of these 4800 codes. The appropriate comprehensive history, comprehensive exam and risk factor 4801 reduction must be completed. 4802 Patient Age (Years) New Patient Established Patient 18–39 99385 99395 40–64 99386 99396 4803 4804 If the provider sees the patient for a problem (e.g., patella femoral syndrome for physical 4805 fitness waiver or profile), and reviews the patient’s medical record (e.g. DD Form 2766) as 4806 part of the visit, assign the office or outpatient codes 99201–99215. 4807 4808 NOTE: Code selection is based on documentation and new vs. established patient status. 4809 4810 6.17.2. Non-privileged Provider Performs the Assessment 4811 Code selection is based on what takes place during the encounter. 4812 4813 If a review of the medical record and DD Form 2766 results in preventive medicine or risk factor 4814 reduction counseling, assign E&M code 99211. Diagnosis coding is based on the type of 4815 counseling provided. (See the ICD-9-CM counseling code listing below.) 4816

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SPECIALTY CODING 6.17. Health Exams of Defined Subpopulations, V 70.5_x

4817 If a review of the medical record and DD Form 2766 does not result in preventive medicine or 4818 risk-factor reduction counseling, assign code V68.89 for the diagnosis. 4819 4820 6.17.3. Diagnosis Coding Rules 4821 4822 6.17.3.1. Use of V70.5 is located in Section 2.2.8. 4823 4824 6.17.3.2. Diagnosis coding is based on the type of counseling given. When counseling is 4825 provided, refer to the following series of ICD-9-CM codes: 4826 4827 V25.09 Family planning (counseling for contraceptive management) 4828 V65.3 Dietary surveillance and counseling 4829 V65.40 Other counseling, no other symptoms (NOS) 4830 V65.41 Exercise counseling 4831 V65.42 Counseling on substance use and abuse (this is a root code; use the 4832 appropriate DoD extender code) 4833 V65.43 Counseling on injury prevention 4834 V65.44 HIV counseling 4835 V65.45 Counseling on other sexually transmitted diseases 4836 V65.49_x Other specified counseling (this is a root code, use the appropriate DoD 4837 extender code) 4838 V69.0 Lack of physical exercise 4839 V69.1 Inappropriate diet and eating habits 4840 V69.2 High-risk sexual behavior 4841 V69.3 Gambling and betting 4842 V69.8 Other problems related to lifestyle 4843 V69.9 Problem related to lifestyle, unspecified 4844 4845 6.17.3.3. Hearing Conservation and Hearing Loss 4846 4847 DoD unique extender tracking codes: 4848 V41.2_1 Hearing Conservation (HC), PH-1 4849 V41.2_2 HC, PH-2 4850 V41.2_3 HC, PH-3 4851 V41.2_4 HC, PH-4 4852 V41.2_0 Other and Unspecified problems with hearing 4853 4854 Hearing loss caused by injury: 4855 E923.8 Other Explosive Materials 4856 E928.1 Exposure to Noise 4857 4858 6.17.4. Documentation—What to Document 4859 For counseling, the amount of time spent with a patient must be included in the documentation, 4860 with the date (e.g., 12 Oct 04, 0900–0930).

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SPECIALTY CODING 6.17. Health Exams of Defined Subpopulations, V 70.5_x

4861  Patient presents for annual physical: use preventive medicine codes. 4862  Patient presents for multiple concerns as well as health maintenance: use both a low-level 4863 office visit and a preventive medicine code. 4864  When reporting preventive medicine counseling codes, document the nature of the 4865 counseling and any education provided during the encounter. 4866 4867 6.17.5. Procedural Coding 4868 4869 6.17.5.1. Education and Training for Patient Self-Management 4870 Services prescribed by a physician and provided by a qualified non-physician healthcare 4871 professional designed to teach patients how to self-manage illness (es) or disease(s) 4872 effectively. The following codes may be reported when a standardized curriculum is used: 4873 4874 98960 Face-to-face with patient each 30 minutes; individual patient 4875 98961 2–4 patient 4876 98962 5–8 patients 4877 4878 6.17.5.2. Procedures in Conjunction with Readiness Encounter 4879 Immunizations, 90465–90749 Prostate cancer screening, G0102 Venipuncture, 36415 Pap smear collection, Q0091 Audiometry: KOH, 87210, 87220 Pure tone (threshold), 92252 Testing of groups, 92559 Tympanometry, 92567 Guaiac Test, 82270 Visual acuity and color vision screening, Dip Stick US, 81002 99172–99173 EKG, 93000, 93010 Pulmonary Function Test (PFT), 94010–60 4880

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SPECIALTY CODING 6.18. Reconstructive and Cosmetic Surgery

4881 6.18. Reconstructive and Cosmetic Surgery 4882 Cosmetic procedures improve the patient’s appearance by plastic restoration, correction, and 4883 removal of blemishes. Many cosmetic procedures are coded with the same procedure codes as a 4884 reconstructive procedure. 4885 4886 Reconstructive procedures are not cosmetic. Reconstructive procedures are performed on 4887 abnormal structures, generally to improve function and to approximate normal appearance. 4888 Reconstructive procedures are coded using codes in CPT. 4889

4890 DoD Rule. Regardless of training or skills maintenance for the provider, the patient 4891 must pay for all cosmetic procedures through the Medical Services Accounts (MSA)

4892 office and present a paid bill for the services prior to receiving services.

4893 4894 6.18.1. Diagnosis Coding Rules 4895 4896 6.18.1.1. Cosmetic Procedure 4897 The provider determines if a procedure is reconstructive (e.g., to improve function) or cosmetic 4898 (e.g., to improve the patient’s appearance or self-esteem). When a provider documents that a 4899 procedure is cosmetic, use codes: 4900 4901 V50.0 Hair transplant 4902 V50.1 Other plastic surgery for unacceptable cosmetic appearance 4903 The term plastic surgery in this case includes cosmetic procedures such as laser tattoo 4904 removal and hair removal. 4905 V50.3 Ear piercing 4906 V50.8 Other. This includes piercing other than the ear. 4907 V50.9 Unspecified 4908 4909 6.18.1.2. Post-Procedure Services 4910 For routine follow up for cosmetic procedures, use the appropriate V codes, such as V58.30, 4911 attention to surgical dressings and sutures, V67.9, follow-up exam following other surgery, and 4912 V67.59, follow-up exam following other treatment—other. 4913 4914 6.18.2. Procedural Coding Rules 4915 4916 6.18.2.1. Many procedures can be reconstructive or cosmetic, such as blepharoplasty. Others are 4917 only cosmetic, such as hair transplant or lipectomy. When there is a CPT or HCPCS code that 4918 accurately reflects the service provided, use the CPT or HCPCS code. 4919 4920 6.18.2.2. Post-Procedure Services

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SPECIALTY CODING 6.18. Reconstructive and Cosmetic Surgery

4921 Routine post-procedure services are coded with 99024 for each visit within global period in the 4922 CPT/HCPCS field. Complications are coded based on the documented complication and 4923 procedures. 4924 NOTE: See section 5.3.2. for a detailed explanation of global period. 4925 4926 6.18.2.3. Botox for Cosmetic Surgery 4927 Code J0585. The number of injections involved is not considered in coding. The physician is 4928 required to document the number of units administered to the patient. The number of units is 4929 entered in the unit’s field. Units feed to TPOCS and reside on the local server. Units are not a 4930 field in the CAPER and are not transmitted to a central database injection codes are not used in 4931 coding Botox used for cosmetic reasons. There is an injection code for therapeutic use of Botox. 4932

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SPECIALTY CODING 6.19. Social Work and Family Advocacy Services

4933 6.19. Social Work and Family Advocacy Services 4934 Social workers in the mental health and life skills clinic should refer to section 6.8, Mental 4935 Health. 4936 4937 6.19.1. E&M Coding Rules 4938 Social work providers do not use outpatient office E&M codes in addition to their procedural 4939 services. When social work providers furnish diagnostic interviews, psychotherapy, 4940 assessments, counseling, and other social work services, the services should be coded as 4941 procedures. 4942 4943 6.19.2. Diagnosis Coding Rules 4944

4945 DoD Rule

4946 4947 Encounters for post-deployment related conditions will have V70.5_6 as the second 4948 code and the patient’s mental health condition listed first. 4949 4950 6.19.2.1. Diagnostic and Statistical Manual (DSM IV) 4951 Mental health diagnoses are based on terminology and codes found in the Diagnostic and 4952 Statistical Manual of Mental Disorders (DSM IV). Although the terminology in ICD-9-CM or 4953 CHCS does not always match the terminology in DSM IV, the majority of the codes are the 4954 same. 4955 4956 6.19.2.2. Coding for Clients Without Mental Disorder Diagnosis 4957 Use V codes for encounters with patients or clients who do not have a mental disorder diagnosis. 4958 For example: 4959 4960 V60.2 Financial problems 4961 V61.10 Counseling for marital and partner problems 4962 V61.49 Presence of sick or handicapped person in family or household 4963 V62.82 Bereavement 4964 Any conditions that may contribute to the patient’s mental condition, affect treatment (e.g., 4965 depression, anxiety) are coded as additional diagnoses. 4966 4967 6.19.2.3. Suspected Conditions 4968 Encounters for suspected conditions, including abuse or neglect, that do not have any reportable 4969 physical signs, symptoms, or conditions when the suspected condition is ruled out are to be 4970 coded: 4971 V71 Observation and Evaluation for Suspected Conditions not found. 4972 6-84 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.19. Social Work and Family Advocacy Services

4973 6.19.2.4. HIV-Related Conditions 4974 Patients who have been diagnosed with HIV or AIDS may be evaluated to determine if they are 4975 experiencing depression or anxiety that needs the services of a psychiatrist (e.g., 4976 pharmacological management of the mental problem). HIV will be reported as the reason for the 4977 encounter, then the mental condition, because the mental condition being evaluated is related to 4978 the HIV. 4979 4980 6.19.2.5. Family Advocacy Encounters 4981 4982 NOTE: For Air Force, AD and Defense Health Program-funded civilians, report family 4983 advocacy program (FAP) encounters. Refer to “Behavioral Health Coding Handbook.” 4984 4985 Initial domestic violence encounters for crisis intervention are reported with a code from 995.5 4986 Child Maltreatment Syndrome or 995.8 Other Specified Adverse Effects, not elsewhere 4987 classifiable (NEC). The code(s) for any physical injuries sustained, plus the appropriate E codes 4988 for external cause of injury, will be additional codes. Subsequent encounters for counseling will 4989 be reported with a V code such as: 4990 4991 V61.10 Counseling for marital and partner problems 4992 V61.12 Counseling of perpetrator of spousal and partner abuse 4993 V61.21 Counseling of victim or child abuse 4994 V61.22 Counseling for perpetrator of parent or child abuse 4995 V62.83 Counseling for perpetrator of physical or sexual abuse (used for a perpetrator who 4996 is not a parent, spouse, or partner of the victim) 4997 4998 6.19.3. Procedural Coding Rules 4999 5000 6.19.3.1. Social workers will use 90791, the CPT psychiatric diagnostic interview examination 5001 codes for many initial encounters. 5002 Description ICD-9-CM E&M CPT Initial FAP assessment; no V71.9 N/A 90791 evidence or allegation Initial FAP assessment; evidence 995.80 N/A 90791 or allegation present; adult maltreatment Initial FAP assessment; evidence 995.50 N/A 90791 or allegation present; child maltreatment Individual follow-up for 995.80or 995.50 and N/A 90832-30 min maltreatment V61.10 90834- 45 min 90837-60 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 6-85 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.19. Social Work and Family Advocacy Services

5003 6.19.3.2. Use of HCPS Level II Codes 5004 Social workers will also use HCPCS Level II codes. For example, an initial encounter for 5005 domestic violence is coded S9484, crisis intervention mental health services, per hour. 5006 5007 6.19.3.3. Health and Behavior Assessment/Intervention (96150–96155). 5008 Health and behavior assessment or intervention codes are to be used by social workers and other 5009 non-physicians. These codes are not intended for use by physicians. Non-physician providers 5010 assess patients with acute or chronic medical illnesses who might benefit from counseling. 5011 Patients have psychiatric issues that may affect their illness or hinder treatment. Patients treated 5012 for psychiatric diagnoses are not coded using the Health and Behavior Assessment/Intervention. 5013 5014 6.19.3.4. Modifiers 5015 The following modifiers are used to identify the type of provider or to provide more specificity 5016 about a service than is listed in the CPT or HCPCS Level II coding manuals. 5017 MODIFIER DESCRIPTION PROVIDER APPEND EXPLANATION TO 22 Increased 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

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SPECIALTY CODING 6.19. Social Work and Family Advocacy Services

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 5018 * HCPCS II modifiers are not available in AHLTA. 5019 5020 6.19.4. Documentation of Time-Based Encounters 5021 The actual start and stop time or the total amount of time spent with a patient must be 5022 documented to support coding for encounters based on time. 5023 5024 6.19.5. Case Management Services 5025 The Case Management coding and reporting framework can be found in Appendix E. 5026

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SPECIALTY CODING 6.20. Substance Abuse Program Services

5027 6.20. Substance Abuse Program Services 5028 How to Report 5029

5030 Workload performed by Non-Defense Health Program-funded personnel is NOT 5031 captured in ADM. 5032 5033 Air Force Rule 5034

5035 Air Force substance abuse rehabilitation services provided by AD and 5036 Defense Health program-funded civilians will begin coding for ambulatory services 5037 provided. See “Mental Health Coding Handbook.” 5038 5039 Navy and Army Rule 5040 5041 Navy Substance Abuse and Rehabilitation Program (SARP) and Army Substance 5042 Abuse Program (SAP) encounters will be reported in an ambulatory service B 5043 MEPRS clinic in the ADM. Workload performance is measured in visits for this 5044 service. 5045 5046 *Army, contact the Service representative for specific guidance on use of HCPCS II 5047 and CPT codes.

5048 5049 6.20.1. E&M Coding Rules 5050 5051 6.20.1.1. HCPCS H Codes 5052 Generally, behavioral health evaluation services related to substance abuse programs should not 5053 be reported with E&M codes. HCPCS Level II codes will be used to report these encounters. 5054 5055 6.20.1.2. Lab Results 5056 An encounter solely for the purpose of reviewing laboratory results will be reported with an 5057 E&M code. 5058 5059 6.20.1.3. Structured Screening Tools 5060 These E&M codes are used when structured screening tools or brief intervention services are 5061 used with individuals who are not currently enrolled in a substance abuse program. 5062 5063 99408 Alcohol and/or substance (other than tobacco) abuse structured 5064 screening (e.g., AUDIT, DAST), and brief intervention (SBI) 5065 services; 15-30 minutes 5066 5067 99409 ; greater than 30 minutes

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SPECIALTY CODING 6.20. Substance Abuse Program Services

5068 6.20.2. Diagnosis Coding Rules 5069 5070 6.20.2.1. Reporting Substance Abuse Disorders 5071 Substance abuse disorders are never to be reported as dependence without specific 5072 documentation of the dependence. Licensed chemical dependency counselors (LCDC) or 5073 certified alcohol drug abuse counselors (CADAC) can diagnose a substance abuse problem, but a 5074 privileged provider must evaluate the patient for a diagnosis of dependence to be established. 5075 5076 6.20.2.2. Coding for Patients Without Substance Abuse Diagnosis 5077 Patients who present to the clinic seeking program information or advice without a diagnosed 5078 substance abuse problem are coded V65.42—a root code—with the appropriate DoD extender. 5079 Encounters with a person seeking information or advice for someone else (e.g., for a family 5080 member) are coded V65.19, person consulting on behalf of another. 5081 5082 6.20.2.3. Medical Treatment for Physical Condition 5083 Medical treatment for an acute physical condition caused by substance abuse or dependence is 5084 coded and sequenced as a poisoning, with the E code for the substance and circumstance. The 5085 abuse will be an additional diagnosis. 5086 5087 6.20.3. Procedural Coding Rules 5088 Most encounters by CADAC, including evaluation for eligibility for a SAP, will be reported 5089 using H codes from the HCPCS Level II coding manual. 5090 CPT Codes 82075 Breath analyzer 99082 Transportation 90885 Psychiatric evaluation of records, tests, etc. 90887 Fitness for evaluation 90889 Prepare reports for agencies 5091 5092 6.20.4. Modifiers Used in Substance Abuse Programs 5093 The following modifiers are used to identify the type of provider or to provide more specificity 5094 to a service than is listed in the CPT or HCPCS Level II coding manuals. 5095 5096 Modifiers Used in Substance Abuse Programs MODIFIER DESCRIPTION PROVIDER APPEND EXPLANATION TO 22 Increased Mental/behavioral CPT & Indicates service was more procedural 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. codes 6-89 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.20. Substance Abuse Program Services

MODIFIER DESCRIPTION PROVIDER APPEND EXPLANATION TO 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 6-90 MHS Professional Services Coding Guidelines March 2013

SPECIALTY CODING 6.20. Substance Abuse Program Services

MODIFIER DESCRIPTION PROVIDER APPEND EXPLANATION TO relationships during a single treatment encounter 5097 5098 Examples: A master’s level LCDC conducts substance abuse counseling with an AD 5099 patient and his wife as part of the soldier’s treatment program. 5100 5101 A patient in the SAP who is being treated by a psychiatrist with Antabuse is seen for 5102 management of the medication. 90863 Pharmacological management modifier HF 5103 indicates this is being done for a patient in an SAP. 5104 5105 6.20.5. Documentation of SAP Treatment 5106 Documentation of SARP treatment is governed by Navy regulations. Referral of patients to the 5107 SARP or SAP through medical channels is documented on an SF 513. Military health records 5108 (HREC) and outpatient treatment records (OTR) will only contain the following notation for 5109 outpatient mental health treatment: “Patient seen, refer to file number 40-216k1” for adults or 5110 “Patient seen, refer to file number 40-216k2” for minors. The referenced file will contain the 5111 actual documentation of any mental health treatment. 5112 5113 6.20.6. Documentation of Time-Based Encounters 5114 The actual start and stop time or the total amount of time spent with a patient must be 5115 documented to support coding for encounters based on time. 5116

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CODING AMBULATORY PROCEDURE VISIT (APV) ENCOUNTERS ______5117 Chapter 7 CODING AMBULATORY PROCEDURE VISIT (APV) ENCOUNTERS 5118 5119 Coding audits indicate that the DoD needs to improve coding of APV procedures in five areas: 5120 procedure or service not coded, code(s) not supported by documentation, appropriate use of 5121 modifiers, appropriate use of quantity, and future focus on coding improvement (codes not 5122 matched to correct diagnosis, sequencing, and application of ancillary services). APV 5123 procedures can occur in the ambulatory procedure unit, emergency department, clinic, or 5124 outpatient activities on a ward. Diagnostic radiology and laboratory procedure codes should not 5125 be coded in the ADM, since that workload is reported in other MHS systems. Administration of 5126 local anesthesia is not reported separately because it is considered part of the procedure. 5127 5128 7.1. Definitions 5129 The definition of APV per Department of Defense Instruction (DoDI) 6025.8, Subject: APV, dated 5130 September 23, 1996, was modified by the UBU effective 01 Oct 2004. The complete list of CMS- 5131 approved ambulatory surgical center (ASC) procedures is at 5132 http://www.cms.hhs.gov/ASCPayment/. 5133 5134 7.1.1. Ambulatory Procedure Visit 5135 APVs are defined as procedures or surgical interventions that require pre-procedure care, a 5136 procedure, and immediate post-procedure care, directed by a qualified healthcare provider. 5137 Minor procedures performed in an outpatient clinic that do not require post-procedure care by a 5138 medical professional are not considered APVs. The nature of the procedure and the medical 5139 status of the patient combine to require short-term, but not inpatient care. These procedures are 5140 appropriate for all types of patients (obstetrical, surgical, and non-surgical) who, by virtue of the 5141 procedure or anesthesia, require post-procedure care or monitoring by medical personnel. 5142 Requiring an individual to remain in the area for a period of time, such as 20 minutes after an 5143 injection, is not post-procedure care. 5144 5145 7.1.2. Ambulatory Surgery Program 5146 A facility program for the performance of elective surgical procedures is defined as an APV in 5147 DODI 6025.8. APV care is not to exceed 23 hours and 59 minutes; measured from the time 5148 patient care begins in the MTF to the time the patient no longer requires medical supervision. 5149 Being checked in CHCS does not begin patient care. Frequently, care begins a significant 5150 amount of time after the nurse activates the encounter in CHCS. An APV patient who stays 5151 beyond 24 hours past actual patient care start time must be admitted to a hospital as an inpatient, 5152 if medically necessary. APV patients staying beyond 24 hours after start of care are not 5153 automatically admitted. As with any admission, there must be a written order from a provider to 5154 change an APV to an admission. 5155 5156 Observation is not an APV. 5157 5158 7.1.3. Ambulatory Procedure Units (APUs) 5159 APUs are designated MTF-approved locations or areas that are specially equipped and staffed to 5160 perform the level of care associated with APV services. APUs provide a coordinated program of 5161 care for patients usually requiring care that lasts less than 24 hours. 7-1 MHS Professional Services Coding Guidelines March 2013 ______

CODING AMBULATORY PROCEDURE VISIT (APV) ENCOUNTERS ______5162 5163 7.2. Coding Pre- and Post-Procedure APV Encounters 5164 5165 7.2.1. Global Surgery Coding 5166 Refer to Section 5.3.2 5167 5168 7.2.2. Uncomplicated Post-Operative Encounters 5169 Code these with a 99024 procedure code 5170 5171 7.2.3. History and Physical 5172 Usually a preoperative history and physical is done a few days prior to the scheduled surgery to 5173 ensure the patient is a candidate for surgery. The history and physical is coded based on 5174 documentation. It becomes part of the APV record. If a pre-op is done within 24 hours of a major 5175 operation (having a 90-day global postoperative period), it is not coded unless the decision for 5176 surgery was made at that time. In that case, use modifier –57 to indicate the decision for surgery 5177 was made during that E&M. Preoperative encounters to check that there have been no significant 5178 changes in the patient’s condition are not coded. If there is a significant change that requires 5179 medical intervention or a completely different issue is addressed, the encounter should be coded. 5180 5181 7.2.4. Complications 5182 Unlike some civilian coding guidance, all complications (conditions not expected at that time after 5183 the surgery) must be documented and coded with an E&M based on the complication 5184 documentation. 5185 5186 7.2.5. Postoperative Visits 5187 Visits during the postoperative period that are unrelated to the surgery should be coded and 5188 appended with the modifier -24. 5189 5190 7.2.6. Preoperative Appointments 5191 If visits the day before major surgery involve a nurse, but no independent medical judgment 5192 (although perhaps following medical staff-approved decision tables), they are usually performed 5193 outside the clinic visit and are not collected in the ADM. 5194 5195 7.2.7. Chronic Conditions 5196 Refer to section 2.2.7. Chronic Conditions 5197 5198 7.3. Patient Admitted from APV 5199 If a patient is admitted from an APV, the ADM record should be coded and closed out with 5200 disposition type admitted. The procedure codes associated with the APV will not be included in the 5201 inpatient stay. 5202 5203 7.4. Consultation for APV 5204 When an APV patient requires a consultation, the consulted provider will code the appropriate 5205 office visit code in his or her specialty clinic.

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CODING AMBULATORY PROCEDURE VISIT (APV) ENCOUNTERS ______5206 5207 7.5. Assistant at Surgery 5208 When coding an APV, capture the additional providers (assistant surgeons) in the Provider field of 5209 the ADM screen. The assistant surgeon should be linked to the same CPT code as the operating 5210 physician. Code the anesthesia provider on the same ambulatory data record as the surgeon. For 5211 anesthesia coding, see section 6.1. 5212 5213 7.5.1. Co-Surgeon 5214 The individual operative report submitted by each surgeon should indicate the distinct service each 5215 surgeon provided. 5216 5217 7.6. Code 99199: Institutional Component of an APV 5218 5219 7.6.1. Coding APV’s Institutional Component 5220 There is no CPT or HCPCS code for the institutional component of an APV. To bill, the MHS will 5221 use the CPT code 99199 to indicate the institutional component of an APV. 5222 5223 7.6.2. Discontinuance of Code 99199 5224 All MTFs discontinued using the CPT code 99199 as an unlisted code by 30 September 2004. CPT 5225 defines 99199 as “unlisted special service, procedure or report.” Most MTFs do not use the CPT 5226 code 99199. A few have used it to track unlisted services that currently do not have a code, such as 5227 a pediatrician sedating a patient so a radiologist can do a diagnostic imaging procedure. 5228 5229 7.6.3. No RVU with Code 99199 5230 As of 1 October 2004, to ensure correct billing, the MHS only uses the CPT code 99199 for APV 5231 data collection and billing. As the code is only for billing, no RVU is associated with it. Using the 5232 CPT code 99199 in the MHS now means Institutional Component, APV. Code 99199 will be 5233 reported as the last procedure on the lead surgeon’s CAPER. 5234 5235 7.7. Cancelled APVs 5236 5237 7.7.1. Coding Cancelled APVs 5238 A patient may present for an APV, but the procedure is cancelled because: 5239  Patient develops a condition that contra-indicates surgery (V64.1). For example, patient 5240 experiences arrhythmia that causes the procedure to be terminated. 5241  Patient decides not to have the planned surgery (V64.2). 5242  The provider is unavailable to perform the APV, or 5243  Supplies or necessary resources are not available to support the APV (V64.3). 5244 5245 7.7.1.2. Additional Coding 5246 Mark the appointment or encounter as kept. Code 2000F (blood pressure, measure) as a placeholder. 5247 5248 7.7.1.3. Coding Presenting Medical Conditions

7-3 MHS Professional Services Coding Guidelines March 2013 ______

CODING AMBULATORY PROCEDURE VISIT (APV) ENCOUNTERS ______5249 It may also be necessary to code presenting medical conditions (e.g., fever, elevated hypertension) 5250 that prevented the procedure from being carried out. The first diagnosis coded should be the 5251 preoperative diagnosis, secondary diagnosis should be the conditions that prevented the procedure 5252 to be performed, then the appropriate V64*. 5253 5254 7.7.1.4. Incomplete Procedures 5255 If a scheduled procedure was started but not completed, use the appropriate surgical CPT code with 5256 appropriate modifier; 5257 -52 Reduced Services: Service or procedure partially reduced or eliminated at provider’s 5258 discretion. 5259 -53 Discontinued Procedure: Anesthesia has been started or the patient has been prepped 5260 in the operating room suite. 5261 5262 7.7.1.5. Anesthesia Cancellations 5263 See Anesthesia section 6.1.11 for coding anesthesia procedures that are cancelled. 5264 5265 7.8. Procedures Not Performed in the APU 5266 Since DoD only reports four procedures in the CAPER, the highest risk or most resource- 5267 intensive procedure needs to be listed first. Examples of procedures that are not APVs are 5268 services associated with a magnetic resonance imaging (MRI), suturing a laceration, wart 5269 removal, removal of wisdom teeth, or unlisted dental procedures. The list of office procedures 5270 excludes the DoD ambulatory surgical procedures.

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OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL SCENARIOS ______5271 Chapter 8 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR 5272 CLINICAL SCENARIOS 5273 5274 This section provides coding guidance for specific functions and situations. 5275 5276 8.1. Use of the MAIL Function 5277 In the menu across the bottom of the ADM entry screen, mail permits providers with coding 5278 questions to forward them to the MTF. The coder who receives this mail determines the most 5279 appropriate code for the condition or encounter and replies in a timely manner. This relieves 5280 providers from spending excessive amounts of time determining appropriate codes. The provider 5281 may also elect to have the coder complete the ADM encounter documentation, according to the 5282 policies of the clinic or facility. 5283 5284 8.2. For Clinic Use Only, an ADM function 5285 This function permits each clinic to collect data unique to that clinic. These data are not part of the 5286 CAPER and remain at the facility level. 5287 5288 8.3. Additional Providers 5289 This function permits data collection of names and categories of personnel who assist with an 5290 encounter. It is especially useful to indicate when a second provider assists in performing a 5291 procedure. The second privileged provider may bill a percentage of the procedure in which he/she 5292 assists. For nurses and paraprofessional personnel, this function should be used when the data 5293 collected justify the time and effort involved in data collection. The categories for additional 5294 providers are: 5295  Attending 5296  Assisting 5297  Supervising 5298  Nurse 5299  Paraprofessional 5300  Operating provider #1 (will only appear if APV field is YES) 5301  Surgeon 5302  Anesthesia 5303  GME (resident) 5304 5305 8.4. Resident/GME Services 5306 5307 8.4.1. Definitions for Staff and Providers 5308 For DoD purposes, the following definitions are applicable for staff or providers in a GME 5309 program. 5310 5311 Chief Resident. An individual who has completed an accredited residency program, then 5312 engaged in an additional year of training and responsibility. Chief residents are board-eligible or 5313 board-certified and are able to be privileged in the discipline of their completed specialty training

8-1 MHS Professional Services Coding Guidelines March 2013 ______

OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL SCENARIOS ______5314 program. Chief residents are frequently licensed independent practitioners. This model is 5315 common in internal medicine programs. 5316 5317 Fellow. A physician or dentist, who has enrolled in a special fellowship program for additional 5318 training, primarily in research. 5319 5320 Resident. An individual engaged in a graduate training program in medicine (including all 5321 specialties, e.g., internal medicine, surgery, psychiatry, radiology, nuclear medicine, dentistry, 5322 podiatry or optometry), who participates in patient care under the direction of supervising 5323 practitioners. Such programs must be accredited or certified as appropriate. 5324 5325 NOTE: The term resident includes individuals in a recognized ACGME (Accreditation 5326 Council for Graduate Medical Education) program and individuals in approved 5327 subspecialty graduate medical education programs who historically have also been referred 5328 to as fellows by some sponsoring institutions. 5329 5330 Intern. A physician typically in the first year of training after medical school, often described as 5331 PGY1. Interns typically do not have a license. 5332 5333 8.4.2. GME Documentation Requirements 5334 5335

5336 DoD Rule 5337

5338 Physicians at Teaching Hospitals (PATH)/Primary Care Exception. 5339 PATH, which includes the Primary Care exception, does not apply to the MHS, 5340 because the MHS funds its own GME programs. GME participants, except for 5341 PGY1, are permitted to use any code based on the documentation.

5342

5343 DoD Rule 5344

5345 Providers who participate in a residency program for GME usually do so 5346 with the oversight of an attending or teaching provider. Licensed physicians have 5347 the full range of E&M and procedure codes available. For unlicensed physicians 5348 (typically interns or PGY1), coding is limited to lower or mid-range E&M codes and 5349 office visit procedure codes. 5350

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5351 When an attending and resident are both involved in a procedure, the primary 5352 provider must be identified in the documentation. The record is coded under the 5353 primary and the other individual is assigned the role of either supervising (staff) or 5354 GME (resident). The primary provider is the individual who performs critical and 5355 key portions of the procedure.

5356 5357 8.4.2.1. Medical Student Documentation 5358 All students, including medical students, may document in the medical record; for appropriate 5359 E&M on encounters that involve medical student documentation, refer to 3.1.1.1. 5360 5361 8.4.2.2. Supervision Documentation 5362 Documentation of supervision must be entered into the medical record by the supervising 5363 practitioner or reflected in the resident progress notes or other appropriate entries in the medical 5364 record (e.g., procedure reports, consultations, discharge summaries). Pathology and radiology 5365 reports must be verified by a supervising practitioner. 5366 5367 NOTE: Co-signatures for coding purposes are required unless the notes meet the 5368 documentation standards outlined in 1 (d). 5369 5370 (1) Allowable documentation: 5371 (a) SF 600/Progress note or other entry into the medical record by the supervising 5372 practitioner, or 5373 (b) Addendum to the resident SF 600 or progress note by the supervising 5374 practitioner, or 5375 (c) Co-signature of the SF 600 or progress note or other medical record entry by 5376 the supervising practitioner, or 5377 (d) Resident SF 600 or progress note or other medical record entry documenting 5378 the name of the supervising practitioner with whom the case was discussed, a 5379 summary of the discussion, and a statement of the supervising practitioner’s 5380 oversight responsibility for the assessment, diagnosis, plan for evaluation, or 5381 treatment. 5382 5383 NOTE: Statements such as the following are acceptable to demonstrate the supervising 5384 practitioner’s oversight responsibility. “I have seen and discussed the patient with my 5385 supervising practitioner, Dr. X, and Dr. X agrees with my assessment and plan.” “I have 5386 discussed the patient with my supervising practitioner, Dr. X, and Dr. X agrees with my 5387 assessment and plan.” The supervising practitioner of record for this patient care 5388 encounter is Dr. X. 5389 5390 (2) Allowable documentation varies by clinical setting and kind of patient encounter. In 5391 all cases, the responsible supervising practitioner must be clearly identifiable in the 5392 documentation of the patient encounter or report of reviews of patient material.

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5393 Chapter 9 PROFESSIONAL CODING FOR INPATIENT PROFESSIONAL SERVICES 5394 5395 9.1. Background 5396 The MHS captures inpatient workload with professional and institutional data. All CAPERs 5397 generated have a flag that indicates if the patient is inpatient or outpatient. The flag can be used 5398 to identify all inpatient professional services. 5399 5400 9.2. Definitions 5401 5402 9.2.1. Attending Service 5403 The attending service is the medical or surgical unit to which the patient is officially admitted via 5404 admission or transfer orders. 5405 5406 9.2.2. House Staff 5407 House staff consists of medical students, interns (PGY1), and residents working under approved 5408 GME program guidelines. 5409 5410 9.2.3. Diagnosis 5411 The documentation records the progression of the workup and treatments leading to the final 5412 diagnosis. The coding will reflect what is addressed each day; except for the discharge day when 5413 non-surgical admissions coding reflects the discharge diagnoses as outlined in the discharge 5414 progress note or narrative summary. 5415 5416 9.2.4. Inpatient Consult 5417 A privileged provider being consulted by the attending provider on an inpatient case will code 5418 their initial face-to-face service using inpatient codes 99221-99223. This service will be 5419 differentiated from the attending provider’s initial service by the attending provider appending 5420 modifier “AI” to their initial service code (99221-99223). This initial service will only be used 5421 once per service per admission. All subsequent face-to-face encounters by the consulting 5422 provider will be coded with the subsequent inpatient codes (99231-99233). Follow-up inpatient 5423 care from that service are coded with subsequent E&M hospital day codes and will also be 5424 captured in the consultant’s B clinic. 5425 5426 9.2.5. Institutional Services 5427 Healthcare services provided by interns, residents, fellows, technicians, and some physician 5428 extenders and non-privileged providers. It includes resources used or consumed during a patient’s 5429 encounter with the healthcare system (e.g., equipment, facilities, utilities, and supplies) including 5430 cardiac care units and intensive care units. 5431 5432 9.2.6. Interservice Transfers 5433 If an inpatient is transferred from one clinical service to another for care and the transfer is noted in 5434 CHCS, an inpatient CAPER may be generated for both the losing and gaining clinical services for 5435 that day. 5436 9-1 MHS Professional Services Coding Guidelines March 2013 ______

PROFESSIONAL CODING FOR INPATIENT PROFESSIONAL SERVICES ______

5437 9.2.7. Professional Services 5438 Healthcare services provided directly to the patient by a privileged provider or GME personnel with 5439 appropriate documentation. This excludes ancillary services. 5440 5441 9.2.8. Rounds (RNDS) 5442 An appointment type in DoD information systems (CHCS/AHLTA) is designed to capture 5443 professional services delivered in the inpatient environment by the service of the attending provider 5444 of record. 5445 5446 9.3. Business Rules 5447 5448 9.3.1. Institutional Service or Cost 5449 Inpatient services provided by nurses, technicians, allied health providers, some physician 5450 extenders, and non-privileged providers are counted as a part of institutional service/cost and will 5451 not produce an inpatient professional service round in CHCS. Documentation by interns, residents, 5452 and physician assistants in and of itself is insufficient to support coding of a rounds encounter. 5453 5454 NOTE: To utilize hospital discharge day management code 99239, time must be 5455 documented. 5456 5457 9.3.2. ADT Module in CHCS 5458 Inpatient professional services rely on appropriate use of the ADT Module. The correct specialty 5459 service is designated by the MEPRS code. The attending physician’s name and MEPRS code 5460 must be associated with the patient to accurately identify and allocate professional services and 5461 costs. This is especially important when patients are transferred from one service to another. 5462 5463 9.3.3. MTFs with GME Program 5464 MTFs that operate a GME program are particularly affected by this effort. For example, MTF 5465 medical staff bylaws typically permit the attending (teaching) physician to place documentation 5466 in the inpatient record once every three days. If the house staff or attending work is to be 5467 captured using the rounds (RNDS) process, the attending provider is required to provide more 5468 frequent and detailed documentation. Residents will document the involvement of the staff 5469 attending provider’s management of the patient. Residents may be included as the secondary 5470 provider on the rounds encounter. 5471 5472 Documentation of supervision must be entered into the medical record by the supervising 5473 practitioner or reflected in the resident progress notes or other appropriate entries in the medical 5474 record (e.g., procedure reports, consultations, discharge summaries). Pathology and radiology 5475 reports must be verified by a supervising practitioner. 5476 5477 NOTE: Co-signatures for coding purposes are required unless the notes meet the 5478 documentation standards outlined in 1 (d). 5479 5480 9-2 MHS Professional Services Coding Guidelines March 2013 ______

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5481 (1) Allowable documentation: 5482 (a) Progress note or other entry into the medical record by the supervising 5483 practitioner, or 5484 (b) Addendum to the resident progress note by the supervising practitioner, or 5485 (c) Co-signature of the progress note or other medical record entry by the 5486 supervising practitioner, or 5487 (d) Resident progress note or other medical record entry documenting the name of 5488 the supervising practitioner with whom the case was discussed, a summary of 5489 the discussion, and a statement of the supervising practitioner’s oversight 5490 responsibility for the assessment, diagnosis, plan for evaluation, or treatment. 5491 5492 NOTE: Statements such as the following are acceptable to demonstrate the supervising 5493 practitioner’s oversight responsibility. “I have seen and discussed the patient with my 5494 supervising practitioner, Dr. X, and Dr. X agrees with my assessment and plan.” “I have 5495 discussed the patient with my supervising practitioner, Dr. X, and Dr. X agrees with my 5496 assessment and plan.” The supervising practitioner of record for this patient care 5497 encounter is Dr. X. 5498 5499 (2) Allowable documentation varies by clinical setting and kind of patient encounter. In 5500 all cases, the responsible supervising practitioner must be clearly identifiable in the 5501 documentation of the patient encounter or report of reviews of patient material. 5502 5503 9.3.4. Inpatient Professional Services for Surgery 5504 See surgical services guidelines 9.5. 5505 5506 9.3.5. Ancillary Services 5507 For the purposes of the MHS and these guidelines, ancillary services include radiology, laboratory, 5508 pharmacy post-operative pain management, and anesthesiology. These services are not coded in 5509 rounds. 5510 5511 9.4. Inpatient Professional Services Data Capture 5512 There are two methods for capturing this workload in ADM/AHLTA/P-GUI. 5513 5514 9.4.1 Auto Generation 5515 The RNDS appointment type will automatically be generated upon admission and each night at 5516 the census hour in the A MEPRS code of the inpatient service to which the patient is admitted. 5517 (Example: A nephrologist admits a patient to internal medicine. The MEPRS code will be AAA 5518 based on the service to which the patient is admitted; ADT determines both the attending 5519 provider and the service. 5520 5521 Example: When a surgical consult is performed on an internal medicine patient who is 5522 subsequently transferred to the surgical service on the same day, the surgeon cannot get 5523 credit for the consultation and the RNDS on the same patient on the same day. 5524 9-3 MHS Professional Services Coding Guidelines March 2013 ______

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5525 9.4.1.1 Default to Admitting Provider 5526 If the attending provider field is not filled in, the default will be the admitting provider. In a 5527 GME program, this is extremely important since the ambulatory data record-generated IBWA 5528 round will default to the house staff, if the house staff is listed as admitting provider. Per MHS 5529 policy, house staff do not have admitting privileges. If a house staff officer receives an inpatient 5530 RNDS, the record needs to be redirected to the attending provider and the ADT module must be 5531 updated appropriately. 5532 5533 9.4.1.2. Appointment Status Default to Kept 5534 CHCS automatically sets the appointment status to kept. This will generate an encounter to be 5535 completed by the physician/provider. 5536 5537 9.4.2. Manual Creation 5538 Use the RNDS Appointment Processing option to create new RNDS appointments. There are 5539 two common reasons for creating a RNDS manually. 5540 5541 1. Interservice transfers at the same facility: When a transfer is not precipitated by a consult, 5542 or the consult was done on a day preceding the transfer, a RNDS encounter will be 5543 initiated using the manual creation feature in DoD systems. 5544 5545 2. Transfer precipitated by the consult module on the same day. Instead of collecting the 5546 inpatient consult in the B MEPRS, use the Data Entry Menu/Rounds Appointment 5547 Processing to generate a RNDS visit in the A MEPRS. 5548 5549 NOTE: The inpatient admission E&M is collected by the admitting clinical service 5550 and is appended with modifier AI; an E&M is not collected in the clinic (or B 5551 MEPRS). The workload for an inpatient consult that results in the transfer to a new 5552 service is collected in the RNDS E&M for the new service for that day. 5553 5554 9.4.2.1. Inter-service Transfer at Same Facility Without Referral Initiated in the Consult 5555 Module. 5556 When an inpatient is transferred from one clinical service to another for care and the transfer is 5557 noted in CHCS, an inpatient E&M may be generated for both the losing and the gaining clinical 5558 service for that day. 5559 5560 NOTE: The gaining clinical service will have to manually generate a new encounter. The 5561 E&M will be based on the rounds documentation for that service for that day. 5562 5563 Example: A patient changes services (e.g., a surgical patient with a post-surgical 5564 embolism is transferred to internal medicine). One E&M may be coded in the initial 5565 service (surgery) and one E&M may be coded in the new service for that day (internal 5566 medicine). 5567

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5568 Example: When a patient is transferred from service A to service B and the attending 5569 on service B sees the patient and had completed an inpatient consult earlier that day, 5570 an RNDS record for the attending on service B will need to be manually generated 5571 and completed. 5572 5573 9.4.2.2. Recording a Procedure by another Provider at the Same Clinical Service 5574 5575 Example: Dr. A makes rounds on patient X in the morning. Dr. A documents 5576 sufficiently for E&M code 99232 for the rounds with appropriate diagnoses. Dr. B 5577 (same clinic service, covering for Dr. A) is called to see patient X that same calendar 5578 day. Dr. B documents patient’s fever, headache, and stiff neck and wants to rule out 5579 meningitis. Dr. B performs a lumbar puncture. Additional diagnosis codes would be 5580 added to Dr A’s ADM RNDS encounter. Enter Dr. B as an additional provider on Dr. 5581 A’s ADM record for the total E&M services. 5582 5583 9.4.2.3. A separate RNDS encounter would be created for Dr B with diagnosis codes for fever, 5584 headache and stiff neck. These diagnosis codes support the medical necessity for the procedure 5585 (lumbar puncture). The lumbar puncture code (62270) would be coded on Dr B’s ambulatory 5586 data record. Dr B’s E&M was included in Dr A’s CAPER. 5587 5588 9.4.3. RNDS Record Completion 5589 Complete the RNDS encounter based on the patient interaction and the documentation in the 5590 inpatient record. The physician or provider is responsible for documenting all patient encounters 5591 in the medical record in accordance with hospital and Service policies. Codes will be assigned 5592 based on documentation. 5593 5594 9.4.3.1. Dates for RNDS Documentation 5595 RNDS encounters will be completed for the dates the attending physician sees and documents 5596 the encounter with the patient. If house staff sees the patient and the attending provider is not 5597 physically present during the portion of the service that determines the level of service and the 5598 attending does not document the key components of those services, no RNDS encounter will be 5599 completed. The RNDS appointment for that date should be cancelled by the physician or 5600 provider (or by the coder upon completion of the inpatient stay), although it will automatically 5601 disappear after 30 days. Once cancelled or after 30 days, the RNDS appointment cannot be re- 5602 created. 5603 5604 NOTE: Even though the rounds appointment is canceled, patients may appear on other 5605 reports as “kept” appointments. 5606 5607 9.4.4. E&M Coding 5608 5609 9.4.4.1. Services Recorded Once Daily 5610 E&M services may only be recorded once per patient per clinical specialty day. The correct 5611 codes are based on the sum of the documentation of all E&M services. 9-5 MHS Professional Services Coding Guidelines March 2013 ______

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5612 NOTE: If the admission E&M is not documented within 24 hours by the attending, 5613 then only the E&M code for a subsequent day of care can be used. The attending 5614 provider must append modifier “AI” to their E&M admission (99221-99223). Once 5615 the initial hospital care visit is completed and fully documented, only two of the 5616 three components for an E&M are required to be documented on subsequent visits. 5617 Multiple E&M codes can be reported in a cost center but they must all be recorded 5618 on one RNDS encounter. Generally, one E&M code is sufficient. 5619 5620 9.4.4.2. Coding for Multiple Providers 5621 When multiple providers from the same clinical specialty cover for the attending provider, and 5622 the attending provider does not see the patient at all that day, the E&M services will be coded 5623 under the name of the last provider who documents services on that calendar day. This will 5624 require the default provider on the ADM to be changed to the last provider of the day. All other 5625 providers may be listed as additional providers on the encounter record. 5626 5627 9.4.4.3. Providers Covering for Attendings 5628 Providers covering for the attending are considered to be in the same specialty as the attending, 5629 even if the provider is from a different specialty. For example, if it is an internal medicine 5630 patient, then it is internal medicine work, even if the provider covering is a family practice 5631 provider. 5632 5633 9.4.4.4. Inter-Service Transfer. 5634 When an inpatient is transferred from one clinical specialty to another for care, and the transfer is 5635 noted in CHCS, an inpatient ambulatory data record may be generated for both the losing and 5636 gaining clinical specialty for that day. NOTE: The gaining clinical specialty will have to 5637 manually generate a new RNDS encounter if the patient is not transferred through a 5638 consult. 5639 5640 Example: Patient is transferred from one clinical service to another for care and the 5641 transfer is noted in CHCS, an inpatient round will be auto generated for the losing 5642 clinical service and the gaining clinical service will have a manually created round for 5643 that day. 5644 E&M Service Day 1 99221-23 1 Round Medicine Day 2 99231-33 1 Round Medicine Day 3 99231- 1st Round (Transferring Attending) Medicine 99231-33 2nd Round (Receiving provider gets the created round) Orthopedic Service Day 4 99231-33 1 Round Orthopedic Service Day 5 99238-39 Discharge Orthopedic Service 5645 5646 5647

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5648 9.4.4.5. Transfer on Day of Consult 5649 If the patient is transferred to a new specialty on the day of the consult, no RNDS appointment 5650 is completed. As noted in the example below, the consultation is attributed to the Psychiatry B 5651 Clinic. NOTE: A consult must be in the chart. 5652 5653 Example: A patient who has taken an overdose as a suicide attempt is admitted to the 5654 internal medicine service. The internist requests a psychiatry consult. The psychiatrist 5655 sees the patient and recommends the patient be transferred to the psychiatry service 5656 when medically stable. The next day, the patient is deemed medically stable and the 5657 transfer occurs. 5658 E&M Service Day 1 99221-23 1 Round Medicine Day 2 99231-33 1 Round Medicine Day 3 99231-33 1st Round (Transferring Attending) Medicine 99251-55 Consult to B Clinic Psychiatry Day 4 99231-33 1 Round Psychiatry Day 5 99238-39 Discharge Psychiatry 5659 5660 9.5. Surgical Services 5661 5662 9.5.1. Elective Surgery 5663 When elective/non-elective surgery is determined to be necessary, assign appropriate E&M code 5664 with modifier -57 in addition to any surgical procedure codes performed by the same provider. 5665 5666 9.5.2. Surgery More Than Two Days after Admission 5667 If surgery is not the day of or the day after admission, use inpatient hospital care E&M codes. 5668 Review rules for modifiers if care involves a separately identifiable E&M service on the day of 5669 procedure (-25) or an unrelated E&M service during the post-op period (-24). 5670 5671 9.5.3. Assigning CPT Codes 5672 Assign CPT codes for any operating room or bedside procedures. 5673 5674 9.5.4. Post-Surgical Codes 5675 Assign code 99024 for routine postoperative follow-up visits. 5676 5677 9.5.5. Surgical Specialty 5678 Following are scenarios that surgical specialists may encounter. The following codes are 5679 reported by surgical specialists: 5680 SCENARIO E&M CPT Elective surgical admission: scheduled total knee N/A 27447 replacement

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Non-elective surgical admission: patient presents to 9922_-57 44950 ED with abdominal pain; admitted for appendectomy Medical admission for pneumonia; patient develops If applicable, E&M code with 33910 pulmonary embolism and requires embolectomy with modifier -57 if decision for surgery cardiopulmonary bypass is made that day or within 24 hours of surgery 5681 5682 9.5.6. Professional Services Scenarios for Inpatient Encounters 5683 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. 5684 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 complication Day 3 Aftercare N/A 99024 GYN Discharge Uterine fibroids N/A 99024 GYN 5685 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. 5686 ICD-9 E&M CPT Responsible Clinic Medical Day 1 Abdominal Pain 99221–99223 ~~ Family Practice condition Day 2 Abdominal Pain 99231–99233 ~~ Family Practice w/global Day 3 Appendicitis 992xx-57 Appendectomy General Surgery event Discharge Appendicitis N/A 99024 General Surgery 5687 5688 OB Care Example: 5689 Patient admitted for planned C-section. There were no complications during delivery or 5690 admission. 5691 Responsible ICD-9 E&M CPT Clinic OB with DAY 1 Delivery codes N/A 5XXXX OB planned DAY 2 Post-partum aftercare N/A 99024 OB C-section DAY 3 Post-partum aftercare N/A 99024 OB Discharge Per discharge summary/progress note N/A 99024 OB

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5692 OB Care Example: 5693 Patient admitted in labor. Baby was delivered the following day. There were no complications 5694 during delivery or during admission. See 6.10.4.1.1.3 for Day 1 guidance. 5695 Responsible ICD-9 E&M CPT Clinic OB with Delete normal DAY 1 Pregnancy rounds OB delivery DAY 2 Delivery codes N/A 59XXX OB DAY 3 Post-partum aftercare N/A 99024 OB Discharge Per discharge summary/progress note N/A 99024 OB 5696 5697 Surgery Example: 5698 Orthopedist sees patient in clinic and decision is made to admit patient for reduction of fracture. 5699 Responsible ICD-9 E&M CPT Clinic Day 1 Fracture code w/ E code 992xx-57 Reduction of Fracture Ortho Traumatic Day 2 Aftercare N/A 99024 Ortho Fracture Day 3 Aftercare N/A 99024 Ortho Discharge Fracture code w/ E code N/A 99024 Ortho 5700 5701 Illness with No Complication Example: 5702 Patient admitted from clinic with a diagnosis of gastritis. On day two, patient developed 5703 hyponatremia. No surgical procedure was performed during this stay. 5704 ICD-9 E&M CPT Responsible Clinic Admission Gastritis 99221–99223 ~~ Gastro Gastritis DAY 2 Gastritis w/ hyponatremia 99231–99233 ~~ Gastro DAY 3 Gastritis 99231–99233 ~~ Gastro Discharge Gastritis w/ hyponatremia 99238–99239 ~~ Gastro 5705 5706 9.6. Inpatient Consults 5707 5708 9.6.1. Outpatient Appointment Type 5709 Follow current procedures for capturing consults to inpatients, using the outpatient appointment 5710 type walk-in. When prompted, “Is this clinic visit related to the inpatient stay?” answer No. This 5711 will ensure credit is given to the appropriate B MEPRS code for services rendered. 5712 5713 Inpatient consults are collected using the appropriate E&M code along with the appropriate 5714 diagnoses and procedure codes. Example: Dr Orthopedics, an orthopedic surgeon, requests a 5715 pulmonary consult on a high-risk surgical patient. In this case, Dr. Pulmonary did not 5716 recommend the patient be transferred to his service. The inpatient consult performed by Dr. 5717 Pulmonary, the consulting physician, will be entered in CHCS under the B MEPRS code along 5718 with the appropriate diagnosis and procedures. 9-9 MHS Professional Services Coding Guidelines March 2013 ______

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5719 9.7. Subsequent Hospital Care 5720 Use the 99231–99233, 99294, 99296, 99298–99299 codes when an initial consult is completed 5721 and the consultant assumes some (both attending and consultant responsible for different aspects 5722 of care) or all (patient transferred to consultant) inpatient care. 5723 5724 9.7.1. Same Specialty: Additional Provider 5725 A request for a consult from a physician or provider in the same specialty would be listed as an 5726 additional provider on the attending’s inpatient E&M encounter. 5727 5728 Example: An internist seeing another internist’s patient would be listed as the additional 5729 provider. 5730 5731 Example: A cardiologist seeing an internal medicine patient will generate a separate 5732 inpatient consultation (B MEPRS). The document will be maintained in the inpatient 5733 record and not the clinic. 5734 5735 9.8. Observation Status 5736 This is an outpatient status. Patients may not be discharged from inpatient status to observation 5737 status. Patients may be admitted directly from observation. Once admitted, all E&M services, 5738 both the observation and inpatient, for a specific condition provided that calendar day (for clinic 5739 or observation status) shall be collected in the E&M code for inpatient services. (See also 5740 Appendix H for Coding for Observation) 5741 5742 9.8.1. Inpatient Record 5743 All professional services given to the patient are documented in the inpatient record. 5744 Ambulatory clinic services for the inpatient are also recorded in the inpatient record. 5745 5746 9.9. Newborn Early Hearing Detection and Intervention (EHDI) 5747 EHDI while the newborn is in the hospital should be documented in the RNDS if done by the 5748 attending provider. 5749 5750 NEWBORN EARLY HEARING DETECTION AND INTERVENTION Encounter Type ICD-9-CM CPT CPT Diagnosis E&M Procedure Codes Codes Codes Newborn hearing screening with no abnormalities V72.1** If applicable, 92586 or performed in newborn nursery or neonatal ICU (Inpatient 992XX* 92587 rounds CAPER) 5751 5752 If a newborn hearing test is performed by the pediatrician, then the service is reported as a 5753 "Rounds" encounters. 5754 5755 If a newborn hearing test is performed by the audiologist (a consult), then report to the 5756 appropriate "B" MEPRS.

9-10 MHS Professional Services Coding Guidelines March 2013