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Coding and Payment Guide for Anesthesia Services

An essential coding, billing, and payment resource for anesthesiology and pain management Introduction

Introduction

Coding systems and claim forms are the realities of modern the ICD-9-CM diagnosis code when fourth and fifth digits health care. Of the multiple systems and forms available, are available will result in invalid coding. what you use is greatly determined by the setting, the type of insurance, and your practice style. HCPCS Level I (CPT) Codes The Centers for Medicare and Medicaid Services (CMS), in This book provides a comprehensive look at the coding and conjunction with the American Medical Association (AMA), reimbursement systems used by anesthesia providers. It is the American Dental Association (ADA), and several other organized topically and numerically, and can be used as a professional groups have developed, adopted, and comprehensive coding and reimbursement resource and as implemented a three-level coding system describing services a quick-lookup resource for coding. rendered to patients. Level I is the CPT coding system. Coding Systems The most commonly used coding system to report The coding systems discussed in this coding and payment professional and outpatient services is CPT, which is guide seek to answer two questions: What was wrong with published annually and copyrighted by the AMA. CPT the patient (i.e., the diagnosis or diagnoses) and what was codes predominantly describe medical services and done to treat the patient (i.e., the procedures or services procedures, and have been adapted to provide a common rendered). billing language that providers and payers can use for payment purposes. The codes are widely used and required Coding systems grew out of the need for data collection. By for billing by both private and public insurance carriers, having a standard notation for the procedures performed managed care companies, and workers’ compensation and for the diseases, injuries, and illnesses diagnosed, programs. statisticians could identify effective treatments as well as broad practice patterns. Before long, these early coding The AMA’s CPT Editorial Panel reviews the coding system systems emerged as the basis to pay claims. annually and adds, revises, and deletes codes and descriptions. New codes go into effect January 1 of each Under the aegis of the federal government, a three-tiered year. The panel accepts information and feedback from coding system has emerged for physician offices and providers about new codes and revisions to existing codes outpatient facilities. Physicians’ Current Procedural that could better reflect the services or procedures. Terminology (CPT) codes report procedures and physician services. A second level, known informally as HCPCS, HCPCS Level II Codes comprises the second level and the codes largely report HCPCS Level II codes are commonly referred to as national supplies, non-physician services, and pharmaceuticals. A codes or by the acronym HCPCS (Healthcare Common third level of codes is used on a local or regional basis and Procedure Coding System—pronounced hik-piks). HCPCS is of diminishing importance. Dovetailing with each of the codes are used to bill Medicare and Medicaid patients and levels is the International Classification of Diseases, Ninth have also been adopted by some third-party payers. Revision, Clinical Modification (ICD-9-CM) classification that HCPCS Level II codes, periodically updated and published reports the diagnosis of illnesses, diseases, and injuries. (A annually by CMS, are intended to supplement the CPT portion of ICD-9-CM also lists codes for inpatient coding system by including codes for non-physician procedures and is used exclusively by inpatient facilities.) services, durable medical equipment (DME), and office ICD-9-CM Codes supplies. These Level II codes consist of one alphabetic The ICD-9-CM classification system is a method of character (A through V) followed by four numbers. translating medical terminology into codes. Codes within Non-Medicare acceptance of HCPCS Level II codes is the system are either numeric or alphanumeric and are idiosyncratic. Providers should check with the payer before composed of three, four, or five characters. A decimal point billing these codes. follows all three-character codes when fourth and fifth characters are needed. “Coding” involves using a numeric HCPCS Level III (Local) Codes or alphanumeric code to describe a disease or injury. For All HCPCS local codes have been phased out, a process that example, cholelithiasis with acute cholecystitis without began in 2002. As the first step, effective October 16, 2002, mention of obstruction is classified to code 574.00. carriers were required to eliminate all local codes and modifiers that had not been approved by CMS. Carriers had Generally, the reason the patient seeks treatment should be to identify those codes and modifiers in use, crosswalk sequenced first when multiple diagnoses are listed. Claim them to national codes, and delete any that were not forms require that the appropriate ICD-9-CM code be approved. If carriers felt that an unapproved code should be reported rather than a description of the functional deficits. retained for use, they had to submit a request for a Health care providers need to be aware of the necessity for temporary national code for that service/supply, with an specific diagnosis coding. Using only the first three digits of

explanation as to why the code should be retained. These settings that include rehabilitation centers, certified requests were due to the regional offices by April 1, 2002. outpatient rehabilitation facilities, skilled nursing facilities, and hospitals. Outpatient and partial hospitalization Introduction The next phase was the elimination of the official HCPCS facility claims might be submitted on either a CMS-1500 or Level III local codes and modifiers by December 31, 2003. UB-92, depending on the payer. Again, carriers were required to review all local codes in their systems, crosswalk them to appropriate national For professional component billing, most claims are filed codes, and submit requests for replacement temporary using ICD-9-CM diagnosis codes, CPT procedure codes, and national codes by April 1, 2003. Temporary national codes CMS-1500 forms. that are requested and approved will be implemented While discussing claim forms, it is important to note that January 1, 2004. due to the administrative simplification provisions of the Local codes had been used to denote new procedures or Health Insurance Portability and Protection Act of 1996 specific supplies for which there was no national code. For (HIPAA), all health care plans, clearinghouses, and Medicare, these five-digit alphanumeric codes used the providers who transmit health care information in letters W through Z. Each carrier created local codes as the electronic form will be subject to the electronic data need dictated. However, carriers were required to obtain interchange (EDI) standards for certain types of approval from CMS's central office before implementing information exchanges. All health care providers using them. The Medicare carrier was responsible for providing electronic transmittals are required to use a uniform set of you with these codes. EDI standards for billing and other health care transactions, and all health plans will be required to accept these As a result of the Consolidated Appropriations Act of 2001, standard electronic claims. The vast majority of inpatient and as part of the National Code Data Sets implemented claims are already submitted in this format, as well as the under the Health Insurance Portability Accountability Act, largest percent of provider claims. Providers submitting the Secretary of Health and Human Services was instructed information by paper will not be affected by these rules, to maintain and continue the use of HCPCS level III codes but privacy compliance must always be maintained. through December 31, 2003. The advantages of electronic claim submission over paper Program Memorandum (PM) AB-01-45 instructed carriers claim submission are many. Clean electronic claims are to take the following steps to implement the law on April paid in about half the time of clean paper claims, Errors 29, 2001: can be minimized due to built-in edit signals that prevent • Maintain and accept current level III HCPCS codes and common errors and omission of required data field modifiers until December 31, 2003. However, carriers were information. You receive transmission and validation not allowed to create any new HCPCS Level III codes or reports electronically that notify you of successful file modifiers. transfers, as well as an “Error/Acceptance” report within 24 •Carriers were to reinstate any HCPCS Level III codes and hours that tells you how many claims were accepted and modifiers they may have eliminated after August 16, 2000. how many were rejected due to invalid or missing information. •Carriers were to publish on their Web sites any HCPCS Level III codes and modifiers with their descriptors that were in Check with your local Medicare carrier about free billing effect August 16, 2000. software available for those who are interested in filing their claims electronically. Medicare carriers who wished to establish a temporary national code were required to submit the request to their A step-by-step guide for completing the CMS-1500 and regional office. The regional office then submitted that UB-92 claim forms and an explanation of the claims filing recommendation to the central office for approval. process can be found in the Claims Processing section. Claims Forms Contents and Format of This Guide Institutional (facility) providers use the UB-92 claim form, Coding and Payment Guide for Anesthesia Services contains also known as the CMS-1450, to file a Medicare Part A chapters that address reimbursement, definitions and claim to Medicare Fiscal Intermediaries. Non-institutional guidelines for the ICD-9-CM, CPT, and HCPCS Level II providers and suppliers (private practice or other health coding systems, indexes, official Medicare regulatory care providers’ offices) utilize the CMS-1500 form to information, and a glossary. submit to Medicare Carriers for Medicare Part B covered services. Medicare Part A coverage includes inpatient Reimbursement hospital, skilled nursing facilities, hospice, and home The first section of the guide provides comprehensive health. Medicare Part B coverage provides payment for information about the coding and reimbursement process. medical supplies, physician, and outpatient services. It has three chapters: The Reimbursement Process, Documentation—An Overview, and Claims Processing. Not all services rendered by a facility are inpatient services. While these chapters are predominantly narrative in nature, Providers working in facilities routinely render services on the Claims Processing chapter does provide a step-by-step an outpatient basis. Outpatient services are provided in

Receiving appropriate reimbursement for health care services Medicaid, and TRICARE. Private payers range from fee-for- can sometimes be difficult because of the myriad of rules services plans to health maintenance organizations. Reimbursement and paperwork involved. The following recommendations will help you understand the various requirements for Medicare getting the claim paid promptly and correctly. Administered by the federal government, Medicare provides health insurance benefits to those 65 years of age and older, Coverage Issues and individuals of any age who are entitled to disability First, you need to know what services are covered. Covered benefits under Social Security or Railroad Retirement programs. services are services payable by the insurer in accordance In addition, individuals with end-stage renal disease that with the terms of the benefit-plan contract. Such services require hemodialysis or kidney transplants are also eligible for must be documented and medically necessary for payment Medicare benefits. Consisting of two parts, Medicare Part A (for to be made. Typically, payers define medically necessary which all persons over 65 are qualified) covers hospitalization services or supplies as: and related care while Part B (which is optional) covers physician and other related health services. Fees for Medicare • Services that have been established as safe and effective services are based on the Medicare fee schedule. • Services that are consistent with the symptoms or diagnosis In addition, the Medicare+Choice plan, created in 1997 as • Services that are necessary and consistent with generally part of the Balanced Budget Act (BBA), allows managed care accepted medical standards plans, such as health maintenance organizations (HMOs) • Services that are furnished at the most appropriate, safe, and preferred provider organizations (PPOs), to join the and effective level Medicare system. Access to these various options depend on where the beneficiary lives and the availability of plans in Documentation must be provided to support the medical their community. necessity of a service, procedure, and/or other item. This documentation should show: Medicaid Medicaid is administered by the state governments under •What service or procedure was rendered federal guidelines to provide health insurance for low- •To what extent the service or procedure was rendered income or otherwise needy individuals. In addition to the •Why the service, procedure, or other item(s) was broad guidelines established by the federal government, medically warranted each state has the responsibility to administer its own program including: Services, procedures, and/or other items that may not be considered medically necessary are: • Establishing eligibility standards • Services that are not typically accepted as safe and • Determining the type, amount, duration, and scope of effective in the setting where they are provided services • Services that are not generally accepted as safe and • Setting payment rates for services effective for the condition being treated • Program administration • Services that are not proven to be safe and effective TRICARE based on peer review or scientific literature Formerly called CHAMPUS, TRICARE provides health • Experimental or investigational services insurance to active and retired military personnel and • Services that are furnished at a duration, intensity, or dependents. frequency that is not medically appropriate Blue Cross and Blue Shield • Services that are not furnished in accordance with Blue Cross (hospital services) and Blue Shield (physician accepted standards of medical practice services) were the first pre-paid health plan in the country. • Services that are not furnished in a setting appropriate Although all “Blues” plans are independent, they are united to the patient’s medical needs and condition by membership in the national Blue Cross and Blue Shield Association (BCBSA). The Blue Cross and Blue Shield System Payer Types is responsible for the administration of the four million- Most providers have to deal with a number of different payers member Federal Employee Program (FEP), comprising all and plans, each with its own specific policies and methods of federal government employees, retirees, and dependents. reimbursement. For that reason, it is important to become familiar with the guidelines for each payer your practice has Health Maintenance Organizations (HMOs) contact with. Some insurance plans are administered by either The most common form of managed care is the HMO. This the federal or state government, including Medicare, type of plan has several variations, but basically, the

subscriber pays a monthly fee for services, regardless of the several years, there have been major changes to provider type or amount of services provided. The primary care payment systems. The following will discuss the many physician (PCP) acts as a gatekeeper to coordinate the varieties of payment methodologies used by Medicare and individual’s care and to make decisions regarding specialty other third-party payers for outpatient and inpatient claims. referral and care. In a “group model” HMO, referrals for care outside of the large independent physician group must Diagnosis-related Groups (DRGs) be arranged, care for emergency services must be DRGs apply to inpatient acute hospital/facility settings preauthorized, and information about care provided in a only, grouping multiple diagnoses together. Reimbursement life-threatening situation must be communicated to the plan is based on this grouping rather than on the actual services. within a specified period of time. On the other hand, the Inpatient stays typically use revenue codes to describe the managed choice model HMO allows individuals to access care treatments or procedures rendered. Reimbursement via the PCP or to go outside of the network to receive care Usual, Customary, and Reasonable without permission of the PCP, but at a lower level of benefits. Fee-for-service reimbursement based on reasonable and Preferred Provider Organizations customary charges has been the typical payment method to Preferred provider organizations (PPOs), are generally reimburse providers over most of Medicare’s history (as contracted by an employer group or other plans to provide well as private payers). Medicare’s previous “customary, hospital and physician services at reduced rates. Although prevailing, and reasonable” (CPR) payment methodology coverage is higher for preferred or participating providers, was similar to the private sector’s charge system of “usual, individuals have the option to seek services provided by customary, and reasonable” (UCR). non-participating providers. A variation of the PPO is the This payment system is designed to pay providers based on exclusive provider organization (EPO,) where enrollees their actual fees. The provider is paid the lowest charge must receive care within the network and must assume among the actual fee for the service, the provider’s responsibility for all out-of-network costs. customary charge (the median of that individual’s charges Point-of-Service Plans (POS) for the service over a defined time), or the prevailing usual charge of all providers within the area. There was no Point-of-service plans permit covered individuals to receive attempt to reimburse services based on the work required. services from participating or nonparticipating providers, Owing to the diversity in fees charged for the same services, but with a higher level of benefits when participating this system allowed for a wide variance in payment for the providers are used. same service. As health care costs exploded in the 1970s Independent Practice Association (IPA) and 80s, cost containment efforts led policy makers to This type of organization comprises physicians that evaluate alternative reimbursement methodologies. maintain separate practices and participate in the IPA as a Capitation Plans means to contract with HMOs or other health plans. The Capitation places a cap on the dollars spent on health care. physicians also generally treat patients who are not Capitation contracts emphasize high volume practices members of the HMO or other plans. and/or primary care, generally where one provider is the Indemnity Plans gatekeeper for the patient’s overall management. Payment Under indemnity plans, the payer provides payment is based on a certain amount of dollars per member and directly to the provider of service when benefits have been the amount does not vary according to the actual number assigned by the patient. Many carriers now include PPO of patients in the member population seen by the provider. attributes to help reduce costs. Subsequently, health care in a capitated system depends on shared risk, or the ability to successfully manage a practice Third-Party Administrators (TPAs) and or a specialty clinic according to fees paid on a “per capita” Administrative Services Organizations (ASOs) basis. This varies significantly from fee-for-service (FFS) Although neither insurers or health plans, TPAs and ASOs health plans. Under capitation, incentive depends upon manage and pay claims for clients such as self-insured providing quality care in the most appropriate and lowest groups. The self-insured group then assumes the risk of cost setting, whereas incentives in a FFS system depend on providing the services and may contract directly with volume and the number of procedures actually performed. providers or use the services of a PPO. Terms important to capitation contracts include the following: Physician Hospital Organization (PHO) • Risk Pool—a portion of the capitated payment set aside to cover certain expenses, such as the portion a primary Hospitals and physician organizations may create a PHO to care physician may set aside to pay for laboratory assist in managed care contracting on behalf of the parties. diagnostic services Degrees of management, common ownership, and oversight vary depending on the model of the arrangement. • Stop-Loss Provision—a member’s age, sex, copayment, use patterns, and the scope of services covered Payment Methodologies by the plan are factors influencing the dollar amount in Once covered services are known, the next issue to resolve a capitated contract. The provider’s financial risk is how you will be paid for those services. Over the last increases with the number of services offered in the

The role played by medical documentation has always been not liable to pay for such services if the service is performed a supportive one. As the practice of medicine became more without prior notification from the physician. Medical sophisticated and complex, the need to record specific necessity requires items and services to be: clinical data grew in importance. What certainly began as a • Consistent with symptoms or diagnosis of disease or simple written mechanism to jog the memory of a treating injury physician evolved into a more refined system to service others assisting in patient care. Tracking patient history • Necessary and consistent with generally accepted emerged as a fundamental element in planning a course of professional medical standards (e.g., not experimental treatment. When medical specialties evolved early in the or investigational) last century, the patient record offered a means to provide • Furnished at the most appropriate level that can be Documentation pertinent data for referrals and consultations. provided safely and effectively to the patient Still, until about 35 years ago, no clear standards existed for Computer conversion of the review process in the 1980s recording patient information. Medical documentation was added a new twist: speed and a degree of accuracy. Claims seen, maintained, and used almost exclusively by adjudication, data analysis, and physician profiling revealed physicians and medical staff. Patient care information was incongruities. A significant number of physicians and never submitted to insurance companies or to government hospitals were found to have billed for services that were payers; only rarely did medical documentation become the not provided or found to be medically unnecessary. focus of malpractice suits. Projected total estimates in the millions of dollars were Developments in the mid-1970s, however, irrevocably publicized by CMS as findings of fraud and abuse. These affected the role of documentation in medicine. A dramatic findings led to the creation of the federal Fraud and Abuse national increase in medical malpractice claims and awards program coordinated by several federal organizations, abruptly altered the strictly clinical nature of including the Department of Health and Human Services documentation. The patient medical record was swept into (HHS), and its agencies, CMS, and the Office of Inspector the broad realm of civil law. Since most medical liability General (OIG). In 1997, CMS reported a possible $23 suits approach resolution years after the contested care, the billion in questionable Medicare payments due to medical record provides a main source of information documentation problems in the hospital and outpatient about what happened. The patient record became a legal settings. document, a basis to reconstruct the quality and quantity of Commercial insurance companies were quick to follow suit. health care services. In many instances, it also serves as a Similar to CMS, private payers monitor claims to uncover physician’s only defense against charges of malpractice. coding mistakes and to verify that the documentation Marked change in the Medicare program also served to supports the claims submitted. Although there are no broaden the influence of medical documentation during national guidelines for proper documentation, the the 1970s. For example, the Centers for Medicare and guidelines this chapter provides should ensure better Medicaid Services (CMS), Medicare’s federal administrator, quality of care and increase the chances of full and fair authorizes the program’s regional carriers to review paid reimbursement. claims to determine whether the care was medically necessary, as mandated under the Social Security Act of 1996. Methods of Documentation The problem-oriented medical record (POMR) is one This type of review checks processed and paid claims documentation method. The provider identifies problems against the documentation recorded at the time of service. individually and arranges them for resolution. The POMR The aim is to ensure that Medicare dollars are administered has four elements: (1) database, (2) problem list, (3) initial correctly and, once again, medical documentation must plans, and (4) progress notes. support the medical necessity of the service, to what extent the service was rendered, and why it was medically At minimum, the data portion of the POMR includes justified. For example, based on findings from a routine information such as chief complaint, present illness, past, x-ray exam, a radiologist may believe further studies are present, family, and social history, review of systems, warranted. Documentation must indicate the medical physical examination, and baseline ancillary data. necessity for the added studies. In such a situation, the The problem list consists of any problem that requires radiologist is not required to check with the ordering management or diagnostic workup. It may be a symptom, physician before proceeding. However, the service may an abnormal finding, a physiological finding, or a specific require prior authorization from the payer, depending on diagnosis. The provider adds or changes the list as payer guidelines. problems are identified and resolved. Medicare does not pay for services that are “medically unnecessary,” according to Medicare standards. Patients are

The third portion, initial plans, states what the provider Principles of Documentation plans to do to learn more about the problem, to treat it, To provide a basis for maintaining adequate medical record and to educate the patient about the problem. information, follow the principles of medical record Progress notes are the final element of the POMR. Each documentation listed. The principles below have been problem is documented with regard to the following: developed by representatives of the following (S)ubjective findings (symptoms); (O)bjective findings organizations: (measurable, observable); (A)ssessment (interpretation or • American Health Information Management Association impression of the current condition); and (P)lan (treatment). (AHIMA) This process is often referred to by the acronym “SOAP.” • American Hospital Association (AHA) The integrated medical record is another method of •American Managed Care and Review Association documentation that is strictly chronological without section (AMCRA) divisions by the source of care. This keeps the episode of care documented in one continuous flow by date; but may • American Medical Association (AMA) make it more difficult to compare information from the • American Medical Peer Review Association (AMPRA) same source, such as laboratory data. Because of this • Blue Cross and Blue Shield Association disadvantage, some chart order arrangements may integrate certain types of forms while maintaining others, such as • Health Insurance Association of America (HIAA) radiology reports, together chronologically. Medical Record Documentation Documentation No specific format for documentation is recommended. It • The medical record should be complete and legible. depends on the provider. But it is important that anyone • The documentation of each patient encounter should reading the medical record be able to understand from the include the date, the reason for the encounter, documentation the service rendered and the reason for the appropriate history and physical exam, review of lab service. and x-ray data, and other ancillary services (where appropriate), an assessment, and a care plan (including General Guidelines for Documentation discharge plan, if appropriate). Documentation is the recording of pertinent facts and observations about a patient’s health history, including past •Past and present diagnoses should be accessible to the and present illnesses, tests, treatments, and outcomes. The treating or consulting health care professional. medical record documents the care of the patient to: • The reasons for and results of x-rays, lab tests, and other ancillary services should be documented and included • Enable a physician or other health care professionals to in the medical record. plan and evaluate the patient’s treatment •Relevant health risk factors should be identified. • Enhance communication and promote continuity of care among physicians and other health care • The patient’s progress, including response to treatment, professionals involved in the patient’s care change in treatment, change in diagnosis, and patient noncompliance, should be documented. •Facilitate claims review and payment • The written plan for care should include treatments and • Assist in utilization review and quality of care medications—specifying frequency and dosage, any evaluations referrals and consultations, patient and family •Reduce hassles related to medical review education, and specific instructions for follow-up. • Provide clinical data for research and education • The documentation should support the intensity of the • Serve as a legal document to verify the care provided patient evaluation and the treatment, including thought (e.g., as defense in the case of a professional liability processes and the complexity of medical decision claim) making. Payers want to know that their health care dollars are well • All entries to the medical record should be dated and spent. Because they have a contractual obligation to authenticated. beneficiaries, they look for the documentation to validate • The codes reported on the health insurance claim form that services are: or billing statement should reflect the documentation • Appropriate for treating the patient’s condition in the medical record. • Medically necessary for the diagnosis Documentation to Code and Bill • Coded correctly Many insurers rely on written evidence of the evaluation of the patient, care plan, and goals for improvement to To ensure the appropriate reimbursement for services, the determine and approve the medical necessity of care. Initial provider should use documentation to demonstrate evaluation findings documenting the medical diagnosis compliance with any third-party payer utilization form the basis for judging the reasonableness and necessity guidelines. of care that was subsequently provided. Consequently, the

The most important document for correct reimbursement is birthday is March 1, 1962, the wife is primary for their the insurance claim, whether submitted electronically or on dependents because her birthday is first during the year a standard claim form. Other information, such as (year of birth is ignored). operative reports, chart notes, and cover letters may establish medical necessity, but the claim “sets the stage.” Assignment of Benefits and Release of Information The term “claims processing” describes the course of Consider adding an assignment of benefits statement to the submitting a claim to the payer and subsequent patient information form. It should state that the patient adjudication. Understanding how this process works allows has agreed to have insurance payments sent directly to the physicians and staff members to file claims properly and physician and that medical information can be released to leads to maximum and timely reimbursement. In addition, the patient’s insurance company. A signed copy of this this knowledge will allow the physician’s office to serve as a assignment submitted with a claim helps ensure at least resource to patients in understanding the process. partial payment from most commercial insurers. With commercial insurance companies, submit the claim Assignments also reduce collection expenses. An alternative, directly to the payer or provide the patient with the lifetime assignment of benefits should nearly eliminate the necessary information to submit the claim. If there is a need to obtain a signature after each date of service; signed agreement with Blue Cross and Blue Shield or with however, there are payers that require a current signature an HMO or PPO, the office may be required to send the with each claim. claim directly to the insurer. Medicare requires that the If the office participates with Medicare, an assignment of Processing Claims office submit all Medicare claims directly to the carrier, benefits and release of billing are necessary. whether participating or not in the Medicare program. Determining Coverage If patients pay at the time of service, the office may want to provide an itemized statement or a superbill attached to a A patient’s insurance coverage should be verified before any claim form that can be submitted to the patient’s insurance service is rendered with the common sense exception of company. This arrangement works well for office services, emergency treatment. This policy should not apply but surgical services are usually more accurately reimbursed exclusively to new patients. Established patients may have if the office bills the hospital and surgical services directly changed employers, married or divorced, or no longer be to the payer. covered by the same policy that was in effect during the last visit. The law requires Medicaid patients to provide current For paper claims, use the standard claim forms (CMS-1500 proof of eligibility with each visit. and the UB-92 described in this chapter) when submitting charges, and be sure to complete the forms completely and Preauthorization accurately. Determining in advance the benefits and allowables provides the physician’s office with reimbursement figures What to Include on Claims before the patient’s visit. Under most circumstances, the office should be able to discuss the deductible, copayment, Patient Information and balance over and above the allowable with the patient Before filing any claim, obtain clear, accurate information prior to providing costly surgical services. Asking a few from the patient, and update the information regularly. pointed questions of the patient and insurer will provide Most offices verify the information at each visit. A uniform additional information regarding deductibles, for example: policy for multiple physician offices or clinics makes everyone accountable for current and correct patient data. •How much is the deductible and has it been met for the current year? Primary vs. Secondary Coverage •What are the allowables for the quoted procedures? Households with dual incomes often have more than one insurer. Determine which is the primary and which is the • What percentage of the allowables will be paid? secondary insurance company. For commercial plans, the subscriber’s or insured’s insurance company is always Clean Claims primary for the subscriber. In other words, the husband’s Claims submitted with all of the information necessary for insurance company is primary for him and the wife’s processing are referred to as “clean” and are usually paid in insurance company is primary for her. However, the a timely manner. Paying careful attention to what should primary insurance company for any dependents is appear on the claim form helps produce these clean claims. determined by the insureds’ birthdays, the primary insured Common errors include the following: being the individual whose birthday is first during the year. •Failure to pay attention to communications from This is often referred to as the “birthday rule.” For example, carriers (including Medicare and Medicaid transmittals) if the husband’s birthday is October 14, 1960 and the wife’s • An incorrect patient identification number

•Patients’ names and addresses that differ from the be required to accept these standard electronic claims, and insurers’ records all health care providers using electronic transmittals will •Physician tax identification numbers, provider numbers, be required to use the EDI standards. Providers that submit or Social Security numbers that are incorrect or missing information by paper will not be affected by the rules. However, the health plans they bill are not prohibited from • No or insufficient information regarding primary or independently requiring the EDI standards for paper secondary coverage transactions as well. • Missing authorized signatures—patient and/or Guidelines specify that transactions involving the following physician types of information exchanges between health care plans, • Dates of service that are incorrect or don’t coincide to clearinghouses, and providers are subject to EDI standards: the claims information sent by other providers (such as hospitals or nursing homes) • Health care claims and equivalent encounter information • Dates that lack the correct number of digits • Health care payment and remittance advices •A fee column that is blank or not itemized and totaled • Coordination of benefits • Incomplete patient information • Health care claim status • Invalid CPT and ICD-9 codes, or diagnostic codes that are not linked to the correct services or procedures • Enrollment or disenrollment in a health plan • An illegible claim • Eligibility for a health plan •Referral certification and authorization The Health Insurance Portability and • Health insurance plan premiums Accountability Act (HIPAA) The deadline for compliance with the electronic The Health Insurance Portability and Accountability Act of transactions rule was October 16, 2002, with the exception 1996 (Public Law 104-191) is a complex, multi-faceted law of small health plans (defined as those with less than $5

Claims containing a number of provisions and amendments. It was

Processing million in gross receipts) that had until October 2003. passed as a means of improving the portability and However, with passage of the Administrative Simplification availability of health insurance coverage for individuals and Compliance Act (ASCA) in December 2001, Congress groups. While insurance reform (Title 1) is an important authorized a one-year extension for entities that are aspect of the law, it is the anti-fraud and abuse provisions required to comply as long as they submitted a compliance that have the greatest impact on physician practices and plan on or before October 15, 2002 that outlines how they daily operational activities. Other provisions promote the will reach their goal of compliance within the year. The use of medical savings accounts, improving access to long- plan is required to include the following: term care services and coverage, and simplification of health insurance administration. •Strategy, work plan, budget, and schedule for compliance implementation Possibly the best approach is to be certain that your practice keeps abreast of the rapid changes taking place as • The entity's current compliance level and reasons why the different provisions of HIPAA are implemented. One of compliance could not be accomplished by the date of the best sources of information is the CMS web site, which the original deadline provides not only background information, but also keeps • Entity's plans with regards to obtaining outside help you up to date with current rules and CMS requirements. from a vendor or contractor That address is http://www.cms.hhs.gov/hipaa •A schedule for testing that began prior to April 16, 2003 Administrative Simplification Provisions Providers and other covered entities may use the model The Administrative Simplification provisions of HIPAA compliance plan that is available on CMS web site at (Title II) requires the Department of Health and Human http://www.cms.hhs.gov/hipaa Services (HHS) to establish national standards for electronic health care transactions and national identifiers Providers with no capability for electronic claim for providers, health plans, and employers. It also addresses submission and those with less than 25 full-time the security and privacy of health data. Implementation of employees (facilities) and 10 full-time employees these standards and encouraging the use of electronic data (physician practices) are exempt from the requirement to interchange (EDI) in health care will improve the efficiency submit claims electronically. of the nation's health care system, reduce the A health care provider electing to use direct data entry administrative burden on providers and health care plans, transactions approved by a health plan is required to use and save over $30 billion more than the next decade. the EDI standards but is not required to use the EDI format Under HIPAA, every health care provider will be able to use requirements. EDI standards for billing and other health care transactions, such as referrals and diagnosis reports. All health plans will

Physicians’ Current Procedural Terminology, (CPT), Fourth CPT Coding Conventions Edition, has been developed by the American Medical To code properly, you must understand and follow the CPT Association (AMA) and is published annually under conventions developed by the AMA. copyright. CPT codes predominantly describe medical services and procedures performed by physicians and non- Symbols physician professionals. The codes are classified as Level I There are several symbols used in the CPT manual. of the HCPCS coding system. •A bullet (●) before the code means that the code is new In general, whenever possible, providers should consider to the CPT coding system in the current year using CPT codes to describe their services for several ▲ reasons. Foremost, providers can evaluate patient care by •A triangle ( ) before the code means that the code reviewing coded services and procedures. Secondly, narrative has been revised in the current year procedural coding is a language understood in the provider • Codes with a (+) symbol indicate an “add-on” code. and payer communities. Consequently, accurate coding can Procedures described by “add-on” codes are always also help an insurer determine coverage eligibility for performed in addition to the primary procedure and services provided. should never be reported alone. This concept applies only to procedures or services performed by the same Accurate coding consists of choosing the most appropriate physician to describe any additional intra-service work, code available for the service provided to the patient. such as a procedure on additional digits or lesions, However, the existence of a CPT or HCPCS code does not associated with the primary procedure guarantee that a third-party payer will accept the code or that the service described by the code is covered. • This symbol (w x) indicates new or revised text other than that contained in the code descriptors. Investigate codes that are denied or downcoded on a claim * by the third-party payer, and resubmit with the correct • The symbol ( ) designates a code that is exempt from codes if necessary. the use of modifier 51; they have not been designated as “add-on” codes in CPT CPT Definitions Structure of CPT • Prior to 2004, the CPT book also contained a starred The CPT coding system has an introduction, six main sections, procedure designation (indicated by an asterisk after the five appendices and an index. code) that signified a surgical procedure considered by the American Medical Association (AMA) to be a minor Category I Codes surgical procedure that did not include pre- or The sections considered Category I are: postoperative services. This designation, which was not recognized for Medicare purposes, was eliminated in •Evaluation and Management CPT 2004. Check with individual payers to determine • Anesthesia their specific billing guidelines. • Surgery Unlisted Procedures •Radiology, Nuclear Medicine, and Diagnostic Ultrasound Not all medical services or procedures are assigned CPT •Pathology and Laboratory codes. The code book does not contain codes for •Medicine infrequently used, new, or experimental procedures. Each code section contains codes set aside specifically for Category II Codes reporting unlisted procedures. Category II codes, which are published January 1 and July 1 of Before choosing an unlisted procedure code, carefully each year, are supplemental tracking codes that are to be used review the CPT code list to ensure that a more specific code for performance measurement only. They describe is not available. Also, check HCPCS Level II if these codes components usually included in an evaluation and are acceptable to the third-party payer. These codes are management service or test results that are part of a laboratory found at the end of the section or subsection of codes and test. Use of these codes is voluntary. However, they are not to most often end in “99.” For example: be used in lieu of Category I codes. 01999 Unlisted anesthesia procedure(s) Category III Codes Whenever an unlisted code is reported, it is necessary to Category III codes, which are considered temporary, have been include a descriptive narrative of the procedure performed added for reporting the use of new technologies that are not in item 19 of the CMS-1500 claim form, as long as it can available to report in the existing Category I CPT code set. be adequately explained in the space provided. Payers generally require additional documentation (e.g., progress notes, operative notes, consultation report, or history and

CPT only ©2003 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association ©2003 Ingenix, Inc. + Add-On Code * Modifier 51 Exempt ● New Codes ▲ Changed Codes 69 Coding and Payment Guide for Anesthesia Services

physical) before considering claims with unlisted procedure and/or service was provided. As such, different codes. diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be Modifiers reported by adding modifier 25 to the appropriate The CPT coding system also includes modifiers that can be level of E/M service. added to codes to describe extenuating or special 26 Professional Component: Certain procedures are a circumstances or to provide additional information about a combination of a physician component and a procedure that was performed, or a service or supply that technical component. When the physician was provided. Addition of the modifier does not alter the component is reported separately, the service may be basic description for the service; it merely qualifies the identified by adding modifier 26 to the usual circumstances under which the service was provided. Some procedure. third-party payers, such as Medicare, require providers to 50 Bilateral Procedure: Unless otherwise identified in use modifiers in some circumstances. Circumstances that the listings, bilateral procedures that are performed modify a service include the following: at the same operative session should be identified by • Procedures have both a technical and professional adding modifier 50 to the appropriate five digit code. component 51 Multiple Procedures: When multiple procedures, • More than one individual or setting was involved in the other than Evaluation and Management Services, are service performed on the same day or at the same session by • Only part of a service was performed the same provider, the primary procedure or service may be reported as listed. The additional procedure •The service was delivered to more than one patient or service may be identified by appending modifier •Adjunctive, complex or bilateral procedures were 51 to the additional procedure or service code. performed NOTE: This modifier should not be appended to The following modifiers are used most often in designated “add-on” codes. anesthesiology services: 52 Reduced Services: Under certain circumstances a 21 Prolonged Evaluation and Management Services: service or procedure is partially reduced or When the face-to-face or floor/unit service provided eliminated at the physician’s discretion. Under these is prolonged or otherwise greater than that usually circumstances, the service provided can be identified required for the highest level of evaluation and by its usual procedure number and the addition of management service within a given category, it may modifier 52, signifying that the service is reduced. be identified by adding modifier 21 to the evaluation This provides a means of reporting reduced services and management code number. A report may also be without disturbing the identification of the basic appropriate. service. CPT Definitions 22 Unusual Procedural Services: When the service NOTE: For hospital outpatient reporting of a provided is greater than that usually required for the previously scheduled procedure/service that is listed procedure, it may be identified by adding partially reduced or cancelled as a result of modifier 22 to the usual procedure. A report may extenuating circumstances or those that threaten the also be appropriate. well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 24 Unrelated Evaluation and Management Service by 74 (see modifiers approved for ASC hospital the Same Physician During a Postoperative Period: outpatient use). The physician may need to indicate that an evaluation and management service was performed 53 Discontinued Procedure: Under certain during a postoperative period for a reason unrelated circumstances, the physician may elect to terminate a to the original procedure. This circumstance may be surgical or diagnostic procedure. Due to extenuating reported by adding modifier 24 to the appropriate circumstances or those that threaten the well being of level of E/M service. the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but 25 Significant, Separately Identifiable Evaluation and discontinued. This circumstance may be reported by Management Service by the Same Physician on the adding modifier 53 to the code reported by the Same Day of the Procedure or Other Service: The physician for the discontinued procedure. physician may need to indicate that on the day a procedure or service identified by a CPT code was NOTE: This modifier is not used to report the performed, the patient’s condition required a elective cancellation of a procedure prior to the significant, separately identifiable E/M service above patient's anesthesia induction and/or surgical and beyond the usual preoperative and postoperative preparation in the operating suite. For outpatient care associated with the procedure that was hospital/ambulatory surgery center (ASC) reporting performed. The E/M service may be prompted by the of a previously scheduled procedure/service that is symptom or condition for which the procedure partially reduced or cancelled as a result of extenuating circumstances or those that threaten the

Ablation Anesthesia — continued Bone tumor, 20982 Anus, 00902 Acromioclavicular Joint Arm Arthrocentesis, 20605 Lower, 00400, 01810-01860 Arteries, 01842 Adhesion, Adhesions Bones, Closed, 01820 Epidural, 62263 Bones, Open, 01830 Administration Cast Application, 01860 Injection Cast Removal, 01860 Intramuscular Antibiotic, 90788 Embolectomy, 01842 Therapeutic, Diagnostic, Prophylactic, Nerves, Muscle, Tendons, 01810 Intra-arterial, 90783 Phleborrhaphy, 01852 Intramuscular, 90782 Shunt Revision, 01844 Intravenous, 90784 Skin, 00400 Subcutaneous, 90782 Total Wrist, 01832 Veins, 01850 Advanced Life Support Upper Arm, and Elbow, 00400 Emergency Department Services, 99281-99288 Nerves, Muscles, Tendons, 01710 Physician Direction, 99288 Tenodesis, 01716 After Hours Medical Services, 99050-99054 Tenoplasty, 01714 Tenotomy, 01712 Allergy Services/Procedures Skin, 00400 Education and Counseling, 99201-99215 Arrhythmias, 00410 ALS, 99288 Arteriograms, 01916 Arteriography, 01916 Analgesia, 99141 Arteriovenous (AV) Fistula, 01432 Analysis Arthroplasty Electronic Hip, 01214-01215 Drug Infusion Pump, 62367 Knee, 01402 Arthroscopic Procedures Anesthesia Ankle, 01464 Abbe-Estlander Procedure, 00102 Elbow, 01732 Abdomen Foot, 01464 Abdominal Wall, 00700-00730, 00800 Hip, 01202 Halsted Repair, 00750-00756 Knee, 01382, 01464 Blood Vessels, 00770, 01930 Shoulder, 01622-01630 Inferior Vena Cava Ligation, 00882 Wrist, 01829-01830 Transvenous Umbrella Insertion, 01930 Axilla, 00400, 01610-01656, 01680-01682 Endoscopy, 00740 Back Skin, 00300 Extraperitoneal, 00860, 00866-00870 Batch-Spittler-McFaddin Operation, 01404 Hernia Repair, 00830-00834 Biopsy Diaphragmatic, 00756 Anorectal, 00902 Halsted Repair, 00750-00756 Clavicle, 00454 Omphalocele, 00754 External ear, 00120 Intraperitoneal, 00790-00797, 00840 Inner ear, 00120 Laparoscopy, 00790 Intraoral, 00170 CPT Index Liver Transplant, 00796 Liver, 00702 Pancreatectomy, 00794 Middle ear, 00120 Renal Transplant, 00868 Nose, 00164 Abdominoperineal Resection, 00844 Parotid gland, 00100 Abortion Salivary gland, 00100 Induced, 01964 Sinuses, accessory, 00164 Achilles Tendon Repair, 01472 Sublingual gland, 00100 Acromioclavicular Joint, 01620 Submandibular gland, 00100 Adrenalectomy, 00866 Bladder, 00870, 00912 Amniocentesis, 00842 Blepharoplasty, 00103 Amputation Brain, 00210-00214, 00216-00222 Femur, 01232 Breast, 00402-00406 Forequarter, 01636 Augmentation Mammoplasty, 00402 Interthoracoscapular, 01636 Breast Reduction, 00402 Penis Muscle Flaps, 00402 Complete, 00932 Bronchi, 00542 Radical with Bilateral Inguinal and Iliac Intrathoracic Repair of Trauma, 00548 Lymphadenectomy 00936 Reconstruction, 00539 Radical with Bilateral Inguinal Lymphadenectomy, 00934 Bronchoscopy, 00520 Aneurysm Burns Axillary-Brachial, 01652 Debridement and/or Excision, 01951-01953 Knee, 01444 Burr Hole, 00214 Popliteal Artery, 01444 Bypass Graft Angiography, 01920 Coronary Artery without Pump Oxygenator, 00566 Angioplasty, 01924-01926 Leg Ankle, 00400, 01462-01480, 01484, 01490-01520 Lower, 01500 Achilles Tendon, 01472 Upper, 01270 Nerves, Muscles, Tendons, 01470 Shoulder, Axillary, 01654 Skin, 00400 Cardiac Catheterization, 01920 Anorectal Procedure, 00902 Cardioverter, 00534

Anesthesia — continued Anesthesia — continued Cast Excision Application Adrenal gland, 00866 Body Cast, 01130 Bladder Forearm, 01860 Total, 00864 Hand, 01860 Gland Knee joint, 01420 Adrenal, 00866 Lower leg, 01490 Iris, 00147 Pelvis, 01130 Prostate, 00865 Shoulder Spica, 01682 Retropharyngeal tumor, 00174 Shoulder, 01680 Testes Wrist, 01860 Abdominal, 00928 Removal Inguinal, 00926 Forearm, 01860 Uterus Hand, 01860 Vaginal, 00944 Knee joint, 01420 Vulva, 00906 Lower leg, 01490 External Cephalic Version, 01958 Shoulder Spica, 01682 Eye Shoulder, 01680 Corneal Transplant, 00144 Repair Iridectomy, 00147 Forearm, 01860 Iris, 00147 Hand, 01860 Lens Surgery, 00142 Knee joint, 01420 Ophthalmoscopy, 00148 Lower leg, 01490 Vitrectomy, 00145 Shoulder Spica, 01682 Eyelid, 00103 Shoulder, 01680 Facial Bones, 00190 Central Venous Circulation, 00532 Mandibular, 00190 Cervical Cerclage, 00948 Midface, 00190 Cervix, 00948 Zygomatic, 00190 Cesarean Section, 01961, 01968 Femoral Artery Chemonucleolysis, 00634 Ligation, 01272 Chest Skin, 00400 Femur, 01220-01234, 01340 Chest, 00400-00410, 00470-00474, 00540-00550 Fibula, 01390-01392 Childbirth Foot, 00400, 01462-01480, 01484, 01490-01520 Cesarean Delivery, 01961, 01969 Forearm, 00400, 01810-01860 External Cephalic Version, 01958 Fowler-Stephens Orchiopexy, 00930 Vaginal Delivery, 01960 Gastrocnemius Recession, 01474 Clavicle, 00450-00454 Gastrointestinal Endoscopy, 00740 Cleft Lip Repair, 00102 Genitalia Cleft Palate Repair, 00172 Female, 00940-00952, 01958-01969 Colpectomy, 00942 Male, 00920-00938 Colporrhaphy, 00942 Great Vessels of Chest, 00560-00563 Colpotomy, 00942 Hand, 00400, 01810-01860 Conscious Sedation, 99141 Harrington Rod Technique, 00670 Corneal Transplant, 00144 Head, 00222-00300 Culdoscopy, 00950 Muscles, 00300 Cystectomy, 00864 Nerves, 00300 Cystolithotomy, 00870 Heart, 00560-00580 Decortication, 00542 Coronary Artery Bypass Grafting, 00566 Defibrillator, 00534 Electrophysiology/Ablation, 00537 Diaphragm, 00540 Transplant, 00580 Disarticulation Hepatectomy Hip, 01212 Partial, 00792 Knee, 01404 Hernia Repair Shoulder, 01634 Abdomen

CPT Index Diskography, 01905 Lower, 00830-00834 Donor Upper, 00750-00752 Nephrectomy, 00862 Hip, 01200-01215 Drug Administration Humerus, 01620, 01730, 01758 Epidural or Subarachnoid, 01996 Hysterectomy, 01962 Ear, 00120-00126 Cesarean, 01963, 01969 ECT, 00104 Vaginal, 00944 Elbow, 00400, 01710-01782 Hysterosalpingography, 00952 Electrocoagulation Hysteroscopy, 00952 Intracranial Nerve, 00222 Induced Abortion, 01964 Electroconvulsive Therapy (ECT), 00104 Inferior Vena Cava Ligation, 00882 Embolectomy Injection procedures Arm, Upper, 01772 Diskography Femoral Artery, 01274 Cervical, 01905 Femoral, 01274 Lumbar, 01905 Forearm, Wrist and Hand, 01842 Myelography Leg, Lower, 01502 Cervical, 01905 Endoscopy Lumbar, 01905 Arm, Lower, 01830 Posterior Fossa, 01905 Gastrointestinal, 00740 Nerve Blocks, 01991 Intestines, 00810 Pneumoencephalography, 01905 Uterus, 00952 Integumentary System Vaginal, 00950 Anterior Chest, 00400 Esophagoscopy, 00520 Anterior Pelvis, 00400 Esophagus, 00320 Arm, Upper, 00400 Axilla, 00400

The International Classification of Diseases, Ninth Revision, The Structure of ICD-9-CM Clinical Modification (ICD-9-CM), is a classification system The ICD-9-CM system contains two classifications, one for in which diseases and injuries are arranged in groups of diseases and the other for procedures. It consists of three related cases for statistical purposes. Based on the World volumes: Health Organization’s (WHO) International Classification of Diseases, the ICD system has been revised periodically to • Volume 1, Diseases: Tabular List meet the needs of statistical data usage. In the United • Volume 2, Diseases: Alphabetic Index States, the system has been expanded and modified (-CM) • Volume 3, Procedures: Tabular List and Alphabetic to meet unique clinical purposes. Clinical uses include Index indexing medical records, facilitating medical care reviews, and completing reimbursement claims. Volume 3, Procedures, is used primarily for inpatient coding. The physician office, outpatient clinics, or The responsibility for maintenance of the classification ambulatory surgery centers coding staff should use the CPT system is shared between the National Center for Health system for coding procedures. Therefore, only Volume 1 Statistics (NCHS) and the Centers for Medicare and (Tabular List) and Volume 2 (Alphabetic Index) of Medicaid Services (CMS). These two organizations co-chair ICD-9-CM are used in the physician office for assigning the ICD-9-CM Coordination and Maintenance Committee, diagnosis codes. which meets twice a year in a public forum to discuss revisions to the classification system. Final decisions The Structure of the Alphabetic Index concerning any revisions to the system are made by the The Alphabetic Index of ICD-9-CM, commonly referred to director of NCHS and the administrator of CMS. Once as the Index, is used in the first step in assigning a code. determined, the final decisions are published in the Federal The Index is divided into three sections: the “Alphabetic Register and become effective October 1 of each year. Index to Disease and Injury,” the “Table of Drugs and The ICD-9-CM coding system is a method of translating Chemicals,” and the “Alphabetic Index to External Causes medical terminology for diseases and procedures into of Injury and Poisoning.” For this book, only anesthesia codes. Codes within the system are either numeric or related index entries are listed. alphanumeric and are made up of three, four, or five characters. A decimal point follows all three-character codes Alphabetic Index to Diseases and Injuries when fourth and fifth digits are required. “Coding” involves Included in this section is an alphabetic list of diseases, using a numeric or alphanumeric code to describe a disease injuries, symptoms, and other reasons for contact with the or injury. For example, pneumonia, organism unspecified, physician. This section also contains two tables that classify is translated into code 486. hypertension and neoplasms. Although hospitals and other health care facilities have Table of Drugs and Chemicals used ICD-9-CM codes for many years, health care provider The drugs and chemicals that are the external causes of offices are also required to use ICD-9-CM codes for all poisoning and other adverse effects are organized in table Medicare billings. Thus, it is essential that coding staff, format. Specific drugs and chemical substances that the regardless of setting, become more knowledgeable, patient may have taken, or been given, are listed proficient, and accurate in their use of the ICD-9-CM alphabetically. Each of these substances is assigned a code diagnosis coding system. By improving coding skills, to identify the drug as a poisoning agent, resulting from Definitions appropriate reimbursement, and efficient claims processing, incorrect substances given, incorrect dosages taken, ICD-9-CM coders limit audit liability and decrease the number of overdose, or intoxication. The five columns titled, “External denied claims and requests for additional information. Cause,” list E codes for external causes depending upon if the circumstances involved in the use of the drug were This chapter provides information on the structure of accidental, for therapeutic use, a suicide attempt, an assault, ICD-9-CM. We have also identified coding tips and or undetermined. guidelines for the ICD-9-CM chapters that are pertinent to the anesthesia provider. Alphabetic Index to External Causes of Injury and Poisoning (E Codes) Coding Tip This section is an alphabetic list of environmental events, Be sure that your ICD-9-CM coding system contains circumstances, and other conditions that can cause injury the most up-to-date information available. Changes and adverse effects. take place October 1 of every year, and your code book must be current to ensure accurate coding. The Structure of the Tabular List The Tabular List contains codes and their narrative descriptions. There are three sections: the Classification of

Disease and Injuries, Supplementary Classifications, and are referred to as “subcategory codes” and take precedence the Appendices. over three-digit category codes. Section 1: Classification of Diseases and Subclassification—Five-digit codes. Greater specificity has Injuries been added to the ICD-9-CM system with the expansion of The Tabular List contains 17 chapters. Ten chapters are four-digit subcategories to the fifth-digit subclassification devoted to major body systems. The other seven chapters level. Five-digit codes are the most precise subdivisions in describe specific types of conditions that affect the entire the ICD-9-CM system. body. This classification contains only numeric codes, from Section 2: Supplementary Classifications (V 001.0 to 999.9. Codes and E Codes) Category Classification of Factors Influencing Health Status and Chapter Chapter Title Code Range Contact with Health Services (V Codes). The codes in this 1. Infectious and Parasitic Diseases 001–139 classification, otherwise known as V codes, are alphanumeric and begin with the letter “V.” These codes are 2. Neoplasms 140–239 used to describe circumstances, other than a disease or 3. Endocrine, Nutritional and Metabolic injury, that are the reason for an encounter with the health Diseases, and Immunity Disorders 240–279 care delivery system or that have an influence on the 4. Diseases of the Blood and Blood patient’s current condition. forming Organs 280–289 Example 5. Mental Disorders 290–319 V70.0 Routine general medical examination at a 6. Diseases of the Nervous System health care facility and Sense Organs 320–389 V codes are sequenced depending on the circumstance or 7. Diseases of the Circulatory System 390–459 problem being coded. Some V codes are sequenced first to 8. Diseases of the Respiratory System 460–519 describe the reason for the encounter, while others are 9. Diseases of the Digestive System 520–579 sequenced second because they identify a circumstance that 10. Diseases of the Genitourinary System 580–629 affects the patient’s health status but is not in itself a current illness. Assignment of V codes will be discussed in 11. Complications of Pregnancy, depth in a separate section. Childbirth and the Puerperium 630–677 12. Diseases of the Skin and Classification of External Causes of Injury and Poisoning Subcutaneous Tissue 680–709 (E Codes). These codes are also alphanumeric and begin with the letter “E.” They are used to describe circumstances 13. Diseases of the Musculoskeletal and conditions that cause injury, poisoning, or other System and Connective Tissue 710–739 adverse side effects. They may be used in addition to codes 14. Congenital Anomalies 740–759 in the main classification (001–999) to identify the external 15. Certain Conditions Originating in cause of an injury or condition. They may never be used the Perinatal Period 760–779 alone and may never be listed as the first diagnosis. 16. Symptoms, Signs and Example Conditions 780–799 821.01 Right femur shaft fracture 17. Injury and Poisoning 800–999 E814.7 Pedestrian struck by motorcycle Each of the 17 chapters in the Classification of Diseases and Injuries is divided into the following: Section 3: Appendices Appendix A: Morphology of Neoplasms. This appendix is Subchapters. Subchapters are a group of closely related an adaptation of the International Classification of Diseases conditions. Separate titles describe the contents of each for Oncology (ICD-O), a coded nomenclature of the ICD-9-CM Definitions subchapter. morphology of neoplasms. These codes are alphanumeric Category—Three-digit codes. Three-digit codes and their and begin with the letter “M.” An example is code titles are called “category codes.” Some three-digit codes are M8000/0, Neoplasm, benign. very specific and are not subdivided. These three-digit codes Appendix B: Glossary of Mental Disorders. This glossary can stand alone to describe the condition being coded. consists of psychiatric terms that are used in ICD-9-CM Subcategory—Four-digit codes. Most three-digit categories chapter 5, titled “Mental Disorders.” This glossary can be have been further subdivided with the addition of a used to ensure that their terminology is consistent with the decimal point followed by another digit. The fourth digit ICD-9-CM coding system. provides specificity or more information regarding such Appendix C: Classification of Drugs by American Hospital things as etiology, site, and manifestation. Four-digit codes Formulary Service List Number and Their ICD-9-CM Equivalents. The ICD-9-CM classification of adverse effects

The ICD-9-CM chapter contains comprehensive coding process only if they are specified in the physician’s information about the most frequently diagnosed diagnosis. conditions that are coded by anesthesia services. This book In the following example, “anterior,” “meatal,” “organic,” is based on official Centers for Medicare and Medicaid “posterior,” and “spasmodic” are nonessential modifiers, Services (CMS) material and uses the most up-to-date and “urethra” is an essential modifier. diagnosis coding information available. Stricture (see also Stenosis) This chapter is meant only as a quick reference for urethra (anterior) (meatal) (organic) (posterior) (spasmodic) 598.9 2 anesthesia services. It does not replace Ingenix ICD-9-CM code books. Cross-References Cross-references make locating a code easier. Two types of Physicians and hospitals are required by law to submit cross-references are used in this book: see and see also. diagnosis codes for Medicare reimbursement. A passage in the Medicare Catastrophic Coverage Act of 1988 requires The “see” cross-reference directs the coder to look for health care provider offices to include appropriate another term elsewhere in the book. For example: diagnosis codes when billing for services provided to Tumor Medicare beneficiaries on or after April 1, 1989. The repeal dermois — see Neoplasm, by site, benign of the Act has not changed this requirement. CMS The “see also” cross-reference provides the coder with an designated ICD-9-CM as the coding system physicians must alternative main term if the appropriate description is not use. found under the initial main term, such as:

This chapter concentrates on the most common diagnoses Stricture (see also Stenosis) that are utilized by anesthesia services. Easy to use, it urethra (anterior) (meatal) (organic) (posterior) (spasmodic) 598.9 2 contains an alphabetic list of diagnoses, and has symbols Abbreviations (see symbol key) to identify common coding principles. Understanding these principles will increase the efficiency NEC — “Not elsewhere classifiable.” Not every condition and promptness of claim submission for Medicare and has its own ICD-9-CM code. The NEC abbreviation is used other third-party payers. with those categories of codes for which a more specific code is not available. The NEC code describes all other Codes effective October 1, 2003 to September 30, 2004 specified forms of a condition. For example:

Disorder (see also Disease) ICD-9-CM Coding Conventions bone NEC 733.90 2 The ICD-9-CM coding conventions, or rules, used in this book are outlined below. All ICD-9-CM coding rules can be NOS — “Not otherwise specified.” Coders should use an found in the front of any ICD-9-CM code book. NOS code only when they lack the information necessary for assigning a more specific code. The symbol j is used to indicate when a fifth-digit subclassification is required to complete a code. This Coding Neoplasms symbol refers the coder to corresponding boxed The index contains a neoplasm table in which the codes for information that defines the appropriate fifth digits. each particular type of neoplasm are listed for the body Modifiers part, system, or tissue type affected. The columns divide the codes into neoplasm type: malignant, benign, uncertain The physician’s diagnostic statement usually contains behavior, and unspecified with three distinct columns several medical terms. To translate the terms into diagnosis appearing under the malignant heading for primary, codes, choose only the condition as the main term. The secondary, and carcinoma in situ. other terms may be considered modifiers. Malignant neoplasms are uncontrolled new tissue growths There are two types of modifiers, nonessential and essential: or tumors that can progressively invade tissue in other parts Nonessential modifiers are shown in parentheses after the

of the body by spreading or metastasizing the disease ICD-9-CM Index term that they modify. Nonessential modifiers may be producing cells from the initial site of malignancy. Primary either present or absent in the diagnostic or procedure defines the body site or tissue where the malignancy first statement without affecting the code selection. These began to grow and spread from there to other areas. modifiers do not affect the code selection. Secondary malignancies are those sites that have been Essential modifiers are indented under the main term. invaded by the cancer cells coming from another part of the When there is only one essential modifier, it is listed next body and are now exhibiting cancerous growth. Carcinoma to the main term after a comma. Essential modifiers affect in situ is confined to the epithelium of the vessels, glands, code assignment; therefore, they should be used in the organs, or tissues in the body area where it originated and has not crossed the basement membrane to spread to the neighboring tissues.

Benign neoplasms are those found not to be cancerous in Though the conventions and general guidelines apply to all nature. The dividing cells adhere to each other in the tumor settings, coding guidelines for outpatient and physician and remain a circumscribed lesion. Neoplasms of uncertain reporting of diagnoses will vary in a number of instances behavior are those whose subsequent behaviour cannot from those for inpatient diagnoses, recognizing that: 1) the currently be predicted from the present appearance of the Uniform Hospital Discharge Data Set (UHDDS) definition tumor and will require further study. Unspecified indicates of principal diagnosis applies only to inpatients in acute, simply a lack of documentation to support the selection of short-term, general hospitals, and 2) coding guidelines for any more specific code. inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to Manifestation Codes outpatients. When two codes are required to indicate etiology and manifestation, the manifestation code appears in italics and A. Selection of first-listed condition brackets. The manifestation code is never a principal/ In the outpatient setting, the term “first-listed diagnosis” primary diagnosis. Etiology is always sequenced first. is used in lieu of principal diagnosis. Arthritis, arthritic (acute) (chronic) due to or associated In determining the first-listed diagnosis, the coding with enteritis NEC 009.1 [711.3] conventions of ICD-9-CM, as well as the general and disease-specific guidelines, take precedence over the Official ICD-9-CM Guidelines for outpatient guidelines. Diagnoses often are not Coding and Reporting established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is The Public Health Service and CMS of the U.S. Department confirmed. of Health and Human Services (DHHS) present the following guidelines for coding and reporting using The most critical rule involves beginning the search for ICD-9-CM. These guidelines should be used as a companion the correct code assignment through the Alphabetic document to the official versions of the ICD-9-CM. Index. Never begin searching initially in the Tabular List These guidelines for coding and reporting have been as this will lead to coding errors. developed and approved by the cooperating parties for ICD- B. The appropriate code or codes from 001.0 through 9-CM: American Hospital Association, American Health V83.89 must be used to identify diagnoses, symptoms, Information Management Association, and the National conditions, problems, complaints, or other reason(s) for Center for Health Statistics. These guidelines appear in the the encounter/visit. second quarter 2002 Coding Clinic for ICD-9-CM, published by the American Hospital Association, where they are C. For accurate reporting of ICD-9-CM diagnosis codes, the updated regularly. documentation should describe the patient's condition, using terminology which includes specific diagnoses as These guidelines have been developed to assist the user in well as symptoms, problems, or reasons for the coding and reporting in situations where the ICD-9-CM encounter. There are ICD-9-CM codes to describe all of book does not provide direction. Coding and sequencing these. instruction in the three ICD-9-CM volumes take precedence over any guidelines. D. The selection of codes 001.0 through 999.9 will frequently be used to describe the reason for the These guidelines are not exhaustive. The cooperating parties encounter. These codes are from the section of ICD-9-CM are continuing to conduct review of these guidelines and to for the classification of diseases and injuries (e.g., develop new guidelines as needed. Users of ICD-9-CM infectious and parasitic diseases; neoplasms; symptoms, should be aware that only guidelines approved by the signs, and ill-defined conditions, etc.). cooperating parties are official. Revisions of these guidelines and new guidelines will be published by the DHHS when E. Codes that describe symptoms and signs, as opposed to they are approved by the cooperating parties. diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the Diagnostic Coding and Reporting Guidelines physician. Chapter 16 of ICD-9-CM, Symptoms, Signs, for Outpatient Services (Hospital-Based and and Ill-defined Conditions (codes 780.0–799.9) Physician Office) contains many, but not all, codes for symptoms. These coding guidelines for outpatient diagnoses have been F. ICD-9-CM provides codes to deal with encounters for approved for use by hospitals and physicians in coding and circumstances other than a disease or injury. The reporting hospital-based outpatient services and physician Supplementary Classification of Factors Influencing office visits. Health Status and Contact with Health Services The terms “encounter” and “visit” are often used (V01.0–V83.89) is provided to deal with occasions ICD-9-CM Index interchangeably in describing outpatient service contacts when circumstances other than a disease or injury are and, therefore, appear together in these guidelines without recorded as diagnosis or problems. distinguishing one from the other.

Introduction CMS. Carriers had to identify those codes and modifiers in One of the keys to gaining accurate reimbursement lies in use, crosswalk them to national codes and delete any that understanding the multiple coding systems that are used to were not approved. If carriers felt that an unapproved code identify services and supplies. To be well versed in should be retained for use, they had to submit a request for reimbursement practices, coders should be familiar not a temporary national code for that service/supply, with an only with the CPT coding system (HCPCS Level I) but also explanation as to why the code should be kept. These with HCPCS Level II codes which are becoming requests were due to their regional office by April 1, 2002. increasingly important to reimbursement as they are The next phase was the elimination of the official HCPCS extended to a wider array of medical services. Level III local codes and modifiers by December 31, 2003. Again, carriers were required to review all local codes in Level II National Codes their systems, crosswalk them to appropriate national codes HCPCS Level II codes commonly are referred to as national and submit requests for replacement temporary national codes or by the acronym HCPCS, which stands for the codes by April 1, 2003. Temporary national codes that are Healthcare Common Procedure Coding System requested and approved will be implemented January 1, (pronounced “hik-piks”). HCPCS codes are used for billing 2004. Medicare and Medicaid patients and have been adopted by most third-party payers. Local codes had been used to denote new procedures or specific supplies for which there was no national code. For These codes, updated and published annually by the Medicare, these five-digit alphanumeric codes use the letters Centers for Medicare and Medicaid Services (CMS), are W through Z. Each carrier may create local codes as the intended to supplement the CPT coding system (Level I) by need dictates. However, carriers were required to obtain including codes for nonphysician services, administration approval from CMS's central office before implementing of injectable drugs, durable medical equipment, and office them. The Medicare carrier was responsible for providing supplies. you with these codes. When using HCPCS Level II codes, keep the following in Due to the Consolidated Appropriations Act of 2001, and mind: as part of the National Code Data Sets implemented under • CMS does not use consistent terminology for unlisted the Health Insurance Portability Accountability Act, the services or procedures. The code descriptions may Secretary of Health and Human Services was instructed to include any one of the following terms: unlisted, not maintain and continue the use of HCPCS level III codes otherwise classified (NOC), unspecified, unclassified, through December 31, 2003. other, and miscellaneous. Program Memorandum (PM) AB-01-45 instructed Carriers • If billing for specific supplies and materials, avoid CPT to take the following steps to implement the law on April code 99070 (general supplies) and be as specific as 29th, 2001: possible unless the local carrier directs otherwise. • Maintain and accept current level III HCPCS codes and • Coding and billing should be based on the service or modifiers until December 31, 2003. However, provided. Documentation should describe the patient’s Carriers were not allowed to create any new HCPCS problems and the service provided to enable the payer Level III codes and or modifiers. to determine reasonableness and necessity of care. •Carriers were to reinstate any HCPCS level III codes •Refer to Medicare coverage references (Coverage Issues and/or modifiers they may have eliminated after August Manual and Medicare Coverage Manual) to determine 16, 2000. whether the care provided is a covered service. •Carriers were to publish on their websites any HCPCS •When both a CPT and HCPCS Level II code share nearly level III and modifiers with their descriptors that were identical narratives, apply the CPT code. If the narratives in effect August 16, 2000. are not identical, select the code with the narrative that Medicare carriers who wished to establish a temporary better describes the service. Generally, the HCPCS Level national code had to submit the request to their regional II code is more specific and takes precedence over the office. The regional office then submitted that CPT code. recommendation to the central office for approval. Level III Local Codes All HCPCS level III local codes have been recently phased out, a process that began in 2002. As the first step, effective October 16, 2002, carriers were required to eliminate all local codes and modifiers that had not been approved by Definitions HCPCS

Structure and Use of HCPCS Level II L codes L0100–L9999 Orthotic and Prosthetic Procedures, Devices Codes M codes M0064–M9999 Medical Services The Index P codes P2028–P9999 Pathology and Laboratory Services The main terms are in boldface type in the index. Main Q codes Q0035–Q9999 Miscellaneous Services term entries include tests, services, supplies, orthotics, (Temporary Codes) prostheses, medical equipment, drugs, therapies, and some R codes R0070–R9999 Radiology Services medical and surgical procedures. Where possible, entries are T codes T1000–T9999 Medical Services listed under a ”common” main term. In some instances, the S codes S0009–S9999 Commercial Payers (Temporary common term is a noun; in others, the main term is a Codes) descriptor. V codes V2020–V9999 Vision, Hearing and Speech- Language Pathology Services Searching the Index Section Guidelines The steps to follow for searching the index are: Examine the instructions found at the beginning of each of 1. Analyze the statement or description provided that the 17 sections. Instructions include the guidelines, notes, designates the item to be coded. unlisted procedures, special reports, and the modifiers that 2. Identify the main term. pertain to each section. 3. Locate the main term in the index. Use the alphabetic index to initially locate a code by looking for the type of service or procedure performed. The 4. Check for relevant subterms under the main term. Verify same rule applies: never code directly from the index. the meaning of any unfamiliar abbreviations. Always check the specific code in the appropriate section. 5. Note the codes found after the selected main term or subterm. The Conventions: Symbols and 6. Locate the code in the alphanumeric list to ensure the Modifiers specificity of the code. If a code range is provided, locate the code range and review all code narratives in Symbols that code range for specificity. Symbols used in the HCPCS Level II system may be presented in various ways, depending on the vendor. St. In some cases, an entry may be listed under more than one Anthony/Medicode follows the pattern established by the main term. AMA in the CPT code books. For example, bullets and Never code directly from the index. Always verify the code triangles signify new and revised codes, respectively. choice in the alphanumeric list and the index. When a code is new to the HCPCS Level II system, a bullet HCPCS Level II codes: Sections A–V (●) appears to the left of the code. This symbol is Level II codes consist of one alphabetic character (letters A consistent with the CPT symbol for new codes. The bullet through V) and four numbers. Similar to CPT codes, they represents a code never before seen in the HCPCS coding also can have modifiers, which can be alphanumeric or two system. letters. National modifiers can be used with all levels of Example HCPCS codes. ● J0595 Injection, butorphanol tartrate, 1 mg The HCPCS coding system is arranged in 17 sections: A triangle (▲) is used (as in the CPT system) to indicate A codes A0021–A9999 Transportation Services, Including that a change in the narrative of a code has been made Ambulance, Chiropractic Services, from the previous year’s edition. The change made may be Medical and Surgical Supplies and Miscellaneous and slight or significant, but it usually changes the application Investigational of the code. B codes B4034–B9999 Enteral and Parenteral Therapy Example C codes C1000–C9999 Temporary Codes for use with Outpatient PPS ▲ C9009 Baclofen intrathecal refill kit, per 2000 D codes D0120–D9999 Dental Procedures mcg E codes E0100–E9999 Durable Medical Equipment Modifiers G codes G0001–G9999 Temporary Procedures/ In certain circumstances, modifiers must be used to report Professional Services the alteration of a procedure or service. In HCPCS Level I H codes H0001–H9999 Alcohol and Drug Abuse (CPT), modifiers are two-digit suffixes that usually directly Treatment Services follow the five-digit procedure or service code. J codes J0120–J9999 Drugs Administered Including Oral and Chemotherapy Drugs K codes K0001–K9999 Durable Medical Equipment Prosthetics, Orthotics, Supplies and Dressings (DMEPOS) HCPCS Definitions

HCPCS Level II Index

A-methaPred, J2920 Compazine, J0780 Access system, A4301 Conductive ACTH, J0800 garment (for TENS), E0731 Acthar, J0800 Corticotropin, J0800 AdvantaJet, A4210 Cotranzine, J0780 Aimsco Ultra Thin syringe, 1 cc or 1/2 cc, each, A4206 D.H.E. 45, J1110 Amitriptyline HCI, J1320 Dalalone, J1100 Amobarbital, J0300 Dalfopristin, J2270 Amytal, J0300 Decadron Phosphate, J1100 Anectine, J0330 Decadron, J1100 Anergan (25, 50), J2550 Decaject, J1100 Antispas, J0500 Dehydroergotamine mesylate, J1110 Aqueous Demerol HCl, J2175 sterile, J7051 Derata injection device, A4210 Aramine, J0380 Dexacen-4, J1100 Arrestin, J3250 Dexamethasone Astramorph, J2275 sodium phosphate, J1100 Ativan, J2060 Dexasone, J1100 Azithromycin Dexone, J1100 injection, Dextran, J7100 intrathecal refill kit, C9008-C9009 Dextrose, intrathecal screening kit, C9007 saline (normal), J7042 B-D disposable insulin syringes, up to 1cc, per syringe, A4206 water, J7060-J7070 Baclofen, J0475 Di-Spaz, J0500 Baclofin Diabetes supplies refill kit, C9009 injection device, needle-free, A4210 Battery, syringe, disposable infusion pump, A4632 each, A4206 TENS, A4630 Diazepam, J3360 Ben-Allergin-50, J1200 Dibent, J0500 Bena-D (10, 50), J1200 Dihydrex, J1200 Benadryl, J1200 Dihydroergotamine mesylate, J1110 Benahist (10, 50), J1200 Dilaudid, J1170 Benoject (-10, -50), J1200 Dilomine, J0500 Bentyl, J0500 Diphenacen-50, J1200 Betameth, J0704 Diphenhydramine HCl, J1200 Betamethasone Dolophine HCl, J1230 acetate and betamethasone sodium phosphate, J0702 Drugs sodium phosphate, J0704 disposable delivery system, 5 ml or less per hour, A4306 Biofeedback device, E0746 disposable delivery system, 50 ml or greater per hour, A4305 Bupivicaine, S0020 infusion supplies, A4221 injections (see also drug name), J0300-J0330, J0380, J0475- Buprenorphine hydrochloride, J0592 J0500, J0583, J0592-J0595, J0670, J0702-J0704, Butorphanol tartrate, J0595 J0745, J0780-J0800, J1100-J1110, J1170, J1200, J1230, J1320, J1700, J1885, J1990, J2010, J2060, Butorphanolt tartrate nasal spray, S0012 J2175-J2180, J2250, J2270, J2275, J2300-J2310, Carbocaine with Neo-Cobefrin, J0670 J2515, J2550, J2650, J2765, J2780, J2920-J2930, J3030-J3070, J3250, J3360, J3410, J3490, J7030- Catheter, A4301-A4306 J7100, J7120 implantable access, A4301 not otherwise classiﬁed, J3490 implantable intraspinal, E0785 Durable medical equipment (DME), E0720-E0731, E0744, Cel-U-Jec, J0704 E0746-E0754, E0756, E0758-E0760, E0765, E0779-E0783, Celestone phosphate, J0704 E0785-E0786 Chemotherapy Duramorph, J2275 home infusion, continous, S9325-S9328 E-ZJect disposable insulin syringes, up to 1cc, per syringe, Chlordiazepoxide HCl, J1990 A4206 Cimetidine hydrochloride, S0023 Elavil, J1320 Codeine phosphate, J0745 Electric stimulator supplies, A4595 Compa-Z, J0780 EMG, E0746

Enovil, J1320 Micro-Fine External disposable insulin syringes, up to 1cc, per syringe, A4206 ambulatory infusion pump, E0781 Midazolam HCl, J2250 HCPCS Index Famotidine, S0028 Miscellaneous, A9150 Gentran, J7100 Monoject disposable insulin syringes, up to 1cc, per syringe, Hexadrol phosphate, J1100 A4206 Home health care Morphine sulfate, J2270, S0093 re-certification, G0179-G0180 sterile, preservative-free, J2275 Home health Nalbuphine HCl, J2300 infusion therapy, S9325-S9328 Naloxone HCl, J2310 Hydrocortisone Narcan, J2310 acetate, J1700 Needle, A4215 Hydrocortone non-coring, A4212 acetate, J1700 with syringe, A4206-A4209 Hydromorphone, J1170 Nembutal sodium solution, J2515 Hydroxyzine HCl, J3410 Neoquess, J0500 Hyrexin-50, J1200 Neuro-Pulse, E0720 Hyzine-50, J3410 Neurostimulator Imitrex, J3030 implantable pulse generator, E0756 Implant access system, A4301 Nonprescription drug, A9150 infusion pump, E0782 Nordryl, J1200 osteogenesis stimulator, E0749 Not otherwise classiﬁed drug, J3490 percutaneous access system, A4301 Nubain, J2300 Infusion, pump Or-Tyl, J0500 ambulatory, with administrative equipment, E0781 Osteogenic stimulator, E0747-E0749 implantable, E0782 implantable, refill kit, A4220 Pentazocine HCl, J3070 mechanical, reusable, E0779 Pentobarbital sodium, J2515 supplies, A4221-A4222 Percutaneous Injection (see also drug name), J0300-J0330, J0380, J0475- access system, A4301 J0500, J0583, J0592-J0595, J0670, J0702-J0704, J0745, J0780-J0800, J1100-J1110, J1170, J1200, J1230, J1320, Pharmaplast disposable insulin syringes, per syringe, A4206 J1700, J1885, J1990, J2010, J2060, J2175-J2180, J2250, Phenazine (25, 50), J2550 J2270, J2275, J2300-J2310, J2515, J2550, J2650, J2765, J2780, J2920-J2930, J3030-J3070, J3250, J3360, J3410, Phenergan, J2550 J3490, J7030-J7100, J7120 Polocaine, J0670 Isocaine HCl, J0670 Predalone-50, J2650 Ketorolac thomethamine, J1885 Predcor (-25, -50), J2650 Key-Pred Predicort-50, J2650 -25,-50, J2650 Prednisolone Kits acetate, J2650 surgical dressing (tray), A4550 Predoject-50, J2650 Lactated Ringer’s infusion, J7120 Prescription drug, J3490 Librium, J1990 Prochlorperazine, J0780 Lincocin, J2010 Promethazine and meperdine, J2180 Lincomycin HCl, J2010 Promethazine HCl, J2550 Lioresal, J0475 Prorex (-25, -50), J2550 LMD, 10%, J7100 Pump Lorazepam, J2060 ambulatory infusion, E0781 Medi-Jector injection device, A4210 implantable infusion, E0782 implantable infusion, refill kit, A4220 Medical and surgical supplies, A4206-A4210, A4212-A4222, A4290, A4301-A4306, A4550, A4595, A4630-A4632 Quelicin, J0330 Medical conference, S0220-S0221 Radiofrequency transmitter, sacral root neurostimulator, replacement, E0759 Mepergan (injection), J2180 Reglan, J2765 Meperidine, J2175 and promethazine, J2180 Replacement battery, A4630 Mepivacaine HCl, J0670 Ringer’s lactate infusion, J7120 Metaraminol bitartrate, J0380 Sacral nerve stimulation test Methadone HCl, J1230 lead, each, A4290 Methylprednisolone Saline, A4216-A4217 sodium succinate, J2920 solution, J7030-J7051 Metoclopramide HCl, J2765 Selestoject, J0704

Revisions to the CMS Manual System Publication # Title The Centers for Medicare and Medicaid Services (CMS) Pub. 100-7 Medicare State Operations (The new References MCM/CIM initiated its long awaited transition from a paper-based manual is under development. manual system to a Web-based system on October 1, 2003, Please continue to use the paper- which updates and restructures all manual instructions. The based manual.) new system, called the online CMS Manual system, Pub. 100-8 Medicare Program Integrity combines all of the various program instructions into an Pub. 100-9 Medicare Contractor Beneficiary electronic manual, which can be found at and Provider Communications http://www.cms.hhs.gov/manuals. Pub. 100-10 Medicare Quality Improvement Organization Effective September 30, 2003, the former method of Pub. 100-11 Reserved publishing program memoranda (PMs) to communicate Pub. 100-12 State Medicaid (The new manual is program instructions was replaced by the following four under development. Please templates: continue to use the paper-based • One-time notification manual.) • Manual revisions Pub. 100-13 Medicaid State Children's Health Insurance Program • Business requirement (Under development) • Confidential requirements Pub. 100-14 Medicare End Stage Renal Disease Network The Office of Strategic Operations and Regulatory Affairs Pub. 100-15 Medicare State Buy-In (OSORA), Division of Issuances, will continue to Pub. 100-16 Medicare Managed Care communicate advanced program instructions to the regions Pub. 100-17 Medicare Business Partners Systems and contractor community every Friday as it currently does. Security These instructions will also contain a transmittal sheet to Pub. 100-18 Medicare Business Partners identify changes pertaining to a specific manual, Security Oversight requirement, or notification. Pub. 100-19 Demonstrations The Web-based system has been organized by functional Pub. 100-20 One-Time Notification area (e.g., eligibility, entitlement, claims processing, benefit Table of Contents policy, program integrity) in an effort to eliminate redundancy within the manuals, simplify the updating The table below shows the paper-based manuals used to process, and make CMS program instructions available in a construct the Web-based system. Although this is just an more timely manner. The initial release will include Pub. overview, CMS is in the process of developing detailed 100, Pub. 100-02, Pub. 100-03, Pub. 100-04, Pub. 100-05, crosswalks to guide you from a specific section of the old Pub. 100-09, Pub. 100-15, and Pub. 100-20. manuals to the appropriate area of the new manual, as well as to show how the information in each section was The Web-based system contains the functional areas derived. included in the table below: Paper-Based Manuals Internet-Only Manuals Publication # Title Pub. 06–Medicare Coverage Pub. 100-01–Medicare General Pub. 100 Introduction Issues Information, Eligibility, and Pub. 100-1 Medicare General Information, Entitlement Eligibility, and Entitlement Pub. 09–Medicare Outpatient Pub. 100-2 Medicare Benefit Policy (basic Physical Therapy coverage rules) Pub. 10–Medicare Hospital Pub. 100-02–Medicare Benefit Policy Pub. 100-3 Medicare National Coverage Pub. 11–Medicare Home Pub. 100-03–Medicare National Determinations (national Health Agency Coverage Determinations coverage decisions) Pub. 12–Medicare Skilled Pub. 100-4 Medicare Claims Processing Nursing Facility (includes appeals, contractor Pub. 13–Medicare Intermediary Pub. 100-04–Medicare Claims interface with CWF, and MSN) Manual, Parts 1, 2, 3, and 4 Processing Pub. 100-5 Medicare Secondary Payer Pub. 14–Medicare Carriers Pub. 100-05–Medicare Secondary Pub. 100-6 Medicare Financial Management Manual, Parts 1, 2, 3, and 4 Payer (includes Intermediary Desk Review and Audit)

*Medicare Carriers Manual (MCM) and Coverage Issues Manual (CIM) sections are printed verbatim from these manuals and current at the time of printing of this publication. These references may be changed by CMS at any time thoughout the year.

Paper-Based Manuals Internet-Only Manuals category. A revision transmittal sheet will identify any new Pub. 21–Medicare Hospice Pub. 100-06–Medicare Financial material and recap the changes as well as provide an Management effective date for the change and any background Pub. 27–Medicare Rural Pub. 100-08–Medicare Program information. At any time, one can refer to a transmittal Health Clinic and Federally Integrity indicated on the page of the manual to view this Qualified Health Center information. Pub. 29–Medicare Renal Pub. 100-09–Medicare Contractor By the time it is complete, the book will contain two Dialysis Facility chapters. Chapter 1 includes a description of national coverage determinations that have been made by CMS. Beneficiary and Provider Communications MCM/CIM References When available, chapter 2 will contain a list of HCPCS Paper-Based Manuals Internet-Only Manuals codes related to each coverage determination. To make the Pub. 19–Medicare Peer Pub. 100-10–Medicare Quality manual easier to use, it is organized in accordance with Review Organization Improvement Organization CPT category sequences. Where there is no national Pub. 07–Medicare State Pub. 100-07–Medicare State coverage determination that affects a particular CPT Operations Operations category, the category is listed as reserved in the table of Pub. 45–State Medicaid Pub. 100-12–State Medicaid contents. Pub. 100-13–Medicaid State Children’s Health Insurance Medicare Benefit Policy Manual Program The Medicare Benefit Policy Manual replaces current Pub. 81–Medicare End Stage Pub. 100-14–Medicare End Stage Medicare general coverage instructions that are not national Renal Disease Renal Disease Network Organizations coverage determinations. As a general rule, in the past these Network Organizations instructions have been found in chapter II of the Medicare Pub. 24–Medicare State Buy-In Pub. 100-15–Medicare State Buy-In Carriers Manual, the Medicare Intermediary Manual, other Pub. 75–Health Maintenance Pub. 100-16–Medicare Managed provider manuals, and program memoranda. New Organization/Competitive Care instructions will be published in this manual. As new Medical Plan transmittals are included they will be identified. Pub. 76–Health Maintenance On the CMS Web site, a crosswalk from the new manual to Organization/Competitive the source manual is provided with each chapter and may Medical Plan (PM) be accessed from the chapter table of contents. In addition, Pub. 77–Manual for Federally the crosswalk for each section is shown immediately under Qualified Health Maintenance the section heading. Organizations Pub. 13–Medicare Pub. 100-17–Business Partners The list below is the table of contents for the Medicare Intermediaries Manual, Part 2 Systems Security Benefit Policy Manual: Pub. 14–Medicare Carriers Chapter Title Manual, Part 2 Pub. 13–Medicare Pub. 100-18–Business Partners One Inpatient Hospital Services Intermediaries Manual, Part 2 Security Oversight Two Inpatient Psychiatric Hospital Services Pub. 14–Medicare Carriers Three Duration of Covered Inpatient Services Manual, Part 2 Demonstrations (PMs) Pub 100-19–Demonstrations Four Inpatient Psychiatric Benefit Days Program instructions that Pub 100-20–One-Time Notification Reduction and Lifetime Limitation impact multiple manuals Five Lifetime Reserve Days or have no manual impact. Program Memoranda Six Hospital Services Covered Under Part B Pub. 60A–Intermediaries Seven Home Health Services Pub. 60B–Carriers Pub. 60AB–Intermediaries/Carriers Eight Coverage of Extended Care (SNF) NOTE: Information derived from Pub. 06 to Pub. 60AB was used to Services Under Hospital Insurance develop Pub. 100-01 to Pub. 100-09 for the Internet-only manual. Nine Coverage of Hospice Services Under National Coverage Determinations Hospital Insurance Manual Ten Ambulance Services The National Coverage Determinations Manual (NCD), Eleven End Stage Renal Disease (ESRD) which is the electronic replacement for the Coverage Issues Twelve Comprehensive Outpatient Manual (CIM), is organized according to categories such as Rehabilitation Facility (CORF) Coverage diagnostic services, supplies, and medical procedures. The table of contents lists each category and subject within that

Ablation. Removal or destruction of tissue either by cutting, benefits to a group account to allow for greater frequency electrical energy, chemical substances, or excessive heat of use by participants. application. Administrative service only (ASO). A contract stipulation Abstractor. A person who selects and extracts specific data between a self-funded plan and an insurance company in from the medical record and enters the information into which the insurance company assumes no risk and computer files. The data and coded diagnoses track provides administrative services only. morbidity and mortality, infectious disease, and index Admission date. Date that the patient was admitted to the disease. Information may be gathered to track data for health care facility for inpatient care, outpatient service, or departments such as quality assurance and utilization the start of care. This date is reported in UB-92 FL 17. review within the facility. Age restriction. Limitation of benefits when a patient Glossary Abuse. As defined by Medicare, an incident that is reaches a certain age. inconsistent with accepted sound medical, business, or fiscal practices and directly or indirectly results in Age/sex rating. Structuring capitation payments based on unnecessary costs to the Medicare program, improper members' ages and genders. reimbursement, or reimbursement for services that do not Aggregate amount. The maximum for which a member is meet professionally recognized standards of care or which insured for any single event. are medically unnecessary. Examples of abuse include excessive charges, improper billing practices, billing AHA. American Hospital Association. Medicare as the primary insurance instead of other third- AHIMA. American Health Information Management party payers that are primary, and increasing charges for Association. Medicare beneficiaries, but not to other patients. Allergen. An antigenic substance capable of producing Accredited Record Technician (ART). A former certification immediate-type hypersensitivity (allergy) when exposed to title awarded to medical records practitioners; now known it. An example would be a pollen, which is any protein as a Registered Health Information Technician (RHIT). antigen of weed, tree, or grass pollens capable of causing Acquired. A condition, which is not genetic, that is allergic asthma or rhinitis. produced by outside influences. Alloplastic. Inert material (foreign body), such as plastic or Acromioplasty. Repair of the part of the shoulder blade that metal, implanted into tissues for the purpose of connects to the deltoid muscles and clavicle. construction, augmentation, or reconstruction. Actual charge. Under Medicare, the charge a physician or Allowable charge (also called approved charge). Fee supplier bills for a service rendered or a supply item. schedule amount for a medical service under Medicare Part B. The allowable charge is based on relative value units Acute care facility. Health care facility that provides multiplied by a conversion factor and geographical cost continuous professional medical care to patients who are in index and adjusted according to Medicare's transition rules. an acute phase of illness. Alternative delivery system (ADS). A phrase indicating any Add-on codes. A procedure performed in addition to the health care delivery system other than traditional fee-for- primary procedure and designated with a + in CPT. Add-on service. codes are never reported as stand-alone services. They are reported secondarily in addition to the primary procedure. Ambulatory surgery center (ASC). Any distinct entity that operates exclusively for the purpose of providing surgical Adjudication. The process of hearing and settling a case services to patients not requiring hospitalization. To receive through an objective, judicial procedure. In claims reimbursement for treatment of Medicare patients, an ASC processing, the process of judging claims as payable, must have an agreement with the Centers for Medicare and partially payable, or rejected. Medicaid Services (CMS) and meet certain required Adjusted average per capita cost (AAPCC). The estimated conditions. average cost of Medicare benefits for an individual, based Ambulatory surgery. A surgical procedure in which the on the following criteria: age, sex, institutional status, patient is admitted, treated, and released on the same day. Medicaid, disability, and end stage renal failure. The Centers for Medicare and Medicaid Services (CMS) uses American Academy of Professional Coders (AAPC). AAPCC as a guide to make monthly payments to risk and 1) From the website, “AAPC (American Academy of cost contractors. Professional Coders) membership spans all 50 states and several foreign countries as well. It is supported by a Adjusted community rate (ACR). A calculation of what National Advisory Board made up of certified members premium the plan charges to provide Medicare-covered representing clinics, facilities, payers, and consulting firms.

The AAPC National Advisory Board offers direct input into Appeal. A specific request (reconsideration) to reverse a the certification programs, educational curricula, and denial or adverse coverage or payment decision and membership services offered by the Academy. AAPC is also potential restriction of benefit reimbursement. An appeal is supported by a National Physician Advisory Board with a special kind of formal complaint to let the carrier know physicians from many different specialties.” that you disagree with any decision about health care 2) Supports membership in issues relating to coding and services. This complaint is made directly to the health plan reimbursement and offers coder certification. by following a specific process set up by the health plan. The insured or the health care provider can initiate appeals American Medical Association (AMA). A physician when the insured and the plan disagree with a plan's organization, advocate group, and publisher. The AMA decision to deny or limit care. publishes a variety of medical and medical coding books including Current Procedural Terminology (CPT), which is Appropriateness of care. Term often used to denote proper a standardized coding system used to document and report setting of medical care that best meets the patient's medical procedures and other services performed by diagnosis. physician and non-physician providers. ASC payment group rate. Facility payment received by an American Society of Anesthesiologists (ASA). Publishes ASC when a covered surgical procedure is performed on a the Relative Value Guide with guidelines on anesthesia Medicare beneficiary. This rate is adjusted for geo-economic coding. variation. Covered ASC surgical procedures are grouped Glossary into nine payment categories for reimbursement purposes. ANA. American Nursing Association. ASC surgical procedure. Procedure performed on an Analgesia. Absence of a normal sense of pain without loss outpatient basis in an ambulatory surgical center. The of consciousness. Medicare Hospital Manual, Addendum F, lists all Medicare- Analgesic. An agent that relieves pain without causing loss covered ASC surgical procedures. This listing covers services of consciousness. pertaining to incision, excision, repair, suture, destruction, Ancillary services. Services, other than routine room and introduction, fractures, manipulation, dislocations, board charges, that are incidental to the hospital stay. These amputation, and endoscopy. services include operating room; anesthesia; blood Assigned claim. A claim from a physician or supplier who administration; pharmacy; radiology; laboratory; medical, has agreed to accept the Medicare allowable amount as surgical, and central supplies; physical, occupational, payment in full for the services rendered. Payment for an speech pathology, and inhalation therapies; and other assigned claim is made directly to the provider or supplier diagnostic services. of the item or service. Under the terms of assignment, the Anesthesia. A loss of feeling or sensation, usually induced physician or supplier may not collect from the beneficiary to permit the performance of surgery or other painful or another insurer the difference between the Medicare procedures. allowable and the physician's actual charge for the item or service (excluding the beneficiary's 20 percent coinsurance Anesthesia formula. See Standard anesthesia formula. and deductible). Anterior. The front area or toward the front area of the Assignment of benefits. Payment of benefits directly to the body; an anatomical reference point used to show the provider of the services rather than to the member who position and relationship of one body structure to another received the benefits. body structure. Attained age. The age of the member as of the last birthday. Anterolateral. Situated in the front part and off to one side. Auditing and monitoring. A system to audit and monitor Anteromedial. Situated in the front part and off to the an organization's practices. The auditing process involves a medial side. regular review of the organization's claim development and Anteroposterior (AP). Front to back. submission process from the point where a service for a patient is initiated to the submission of a claim for Anti-Kickback Act. Prohibits knowing or willful solicitation payment. The monitoring process involves a system of or receipt of remuneration in return for referring, checks and controls, as well as a method of reporting, over recommending, or arranging for the purchase, lease, or all areas of compliance, including regulations and audits. ordering of items or services for which payment will be The audit process should be used to establish a baseline in made from any federal or state health care program, initiating a compliance plan, periodically assess the including Medicare, Medicaid, Federal Employee Health effectiveness of the organization, monitor the work of new Benefit Programs, TRICARE/CHAMPUS, federal block grant employees, and respond to complaints. Since the programs, or other health care programs funded with government initiated comprehensive audits three years ago, federal funds. The Balanced Budget Act of 1997 provides improper Medicare payments to hospitals, doctors, and penalties of up to $50,000 for each violation and other health care providers declined in 1998 to the lowest additional punitive damages of up to three times the total error rate since 1995. The error rate for fiscal year (FY) amount of remuneration offered or received. 1998, about 7.1 percent, represented estimated improper

478 ©2003 Ingenix, Inc. Correct Coding Initiative v Indicates a mutually exclusive edit 82273, 90780-90788, 90865, 91000, 91055, 91105, 92511-92520, 92543, 92950-92961, 93000-93010, 0001F No CCI edits apply for this code. 93015-93018, 93040-93042, 93303-93318, 93501, 0001T 0002Tv, 34800v-34804v, 36000, 36410, 90780 93701, 93922-93981, 94200, 94250, 94640, 94656, 94660-94662, 94680-94690, 94760- 0002F No CCI edits apply for this code. 94770, 95812-95822, 95829, 95955-95957, 0003F No CCI edits apply for this code. 99201-99233, 99238, 99241-99285, 99293-99313, 99321-99343, 99347-99349, 99354-99357, 0003T No CCI edits apply for this code. G0272 0004F No CCI edits apply for this code. 00103 01995-01996, 31505, 31515, 31527, 31622, 31645, 0005F No CCI edits apply for this code. 36000, 36005-36015, 36400-36410, 36420-36440, 36600, 36640, 61026, 61055, 62280-62284, 0005T 35201-35206, 35226, 35261-35266, 35286, 62310-62319, 64400-64470, 64475, 64479, 36000, 36410, 36620-36625, 37202, 37205v, 64483, 64505-64560, 64565, 67500, 76986, 69990, 76000, 76003, 76360, 76393, 76942, 81000, 81002-81005, 81015, 82013, 82205, 82270- 90780 82273, 90780-90788, 90865, 91000, 91055, 91105, 0006F No CCI edits apply for this code. 92511-92520, 92543, 92950-92961, 93000-93010, 93015-93018, 93040-93042, 93303-93318, 93501, 0006T No CCI edits apply for this code. 93701, 93922-93981, 94200, 94250, 94640, 0007F No CCI edits apply for this code. 94656, 94660-94662, 94680-94690, 94760- 0007T 35201-35206, 35226, 35261-35266, 35286, 94770, 95812-95822, 95829, 95955-95957, 36000, 36410, 37202, 76360v, 90780 99201-99233, 99238, 99241-99285, 99293-99313, 99321-99343, 99347-99349, 99354-99357, 0008F No CCI edits apply for this code. G0272 0008T 00740, 00810, 36000, 36410, 43200, 43202- 00104 01995-01996, 31505, 31515, 31527, 31622, 31645, 43235, 43255, 69990, 89130, 90780-90784, 36000, 36005-36015, 36400-36410, 36420-36440, 91105, 94760-94761 36600, 36640, 61026, 61055, 62280-62284, CCI 0009F No CCI edits apply for this code. 62310-62319, 64400-64470, 64475, 64479, 64483, 64505-64560, 64565, 67500, 76986, 0009T 36000, 36410, 57100, 57180, 57400-57410, 57452, 81000, 81002-81005, 81015, 82013, 82205, 82270- v 57500, 57530, 57800, 58100-58120, 58353 , 82273, 90780-90788, 90865, 91000, 91055, 91105, v 58558, 58563 , 64435, 69990, 76362, 76394, 92511-92520, 92543, 92950-92961, 93000-93010, 76490, 76942, 76986, 90780 93015-93018, 93040-93042, 93303-93318, 93501, 00100 31505, 31515, 31527, 31622, 31645, 36000, 93701, 93922-93981, 94200, 94250, 94640, 36005-36015, 36400-36410, 36420-36440, 36600, 94656, 94660-94662, 94680-94690, 94760- 36640, 61026, 61055, 62280-62284, 62310-62319, 94770, 95812-95822, 95829, 95955-95957, 64400-64470, 64475, 64479, 64483, 64505- 99201-99233, 99238, 99241-99285, 99293-99313, 64560, 64565, 67500, 76986, 81000, 81002- 99321-99343, 99347-99349, 99354-99357, 81005, 81015, 82013, 82205, 82270-82273, 90780- G0272 90788, 90865, 91000, 91055, 91105, 92511-92520, 0010F No CCI edits apply for this code. 92543, 92950-92961, 93000-93010, 93015-93018, 93040-93042, 93303-93318, 93501, 93701, 0010T No CCI edits apply for this code. 93922-93981, 94200, 94250, 94640, 94656, 0011F No CCI edits apply for this code. 94660-94662, 94680-94690, 94760-94770, 95812-95822, 95829, 95955-95957, 99201- 00120 01995-01996, 31505, 31515, 31622, 31645, 36000, 99233, 99238, 99241-99285, 99293-99313, 36005-36015, 36400-36410, 36420-36440, 36600, 99321-99343, 99347-99349, 99354-99357, 36640, 61026, 61055, 62280-62284, 62310-62319, G0272 64400-64470, 64475, 64479, 64483, 64505- 64560, 64565, 67500, 76986, 81000, 81002- 00102 01995-01996, 31505, 31515, 31527, 31622, 31645, 81005, 81015, 82013, 82205, 82270-82273, 90780- 36000, 36005-36015, 36400-36410, 36420-36440, 90788, 90865, 91000, 91055, 91105, 92511-92520, 36600, 36640, 61026, 61055, 62280-62284, 92543, 92950-92961, 93000-93010, 93015-93018, 62310-62319, 64400-64470, 64475, 64479, 93040-93042, 93303-93318, 93501, 93701, 64483, 64505-64560, 64565, 67500, 76986, 93922-93981, 94200, 94250, 94640, 94656, 81000, 81002-81005, 81015, 82013, 82205, 82270-

94660-94662, 94680-94690, 94760-94770, 99293-99313, 99321-99343, 99347-99349, 95812-95822, 95829, 95955-95957, 99201- 99354-99357, G0272 99233, 99238, 99241-99285, 99293-99313, 00142 01995-01996, 31505, 31515, 31527, 31622, 31645, 99321-99343, 99347-99349, 99354-99357, 36000, 36005-36015, 36400-36410, 36420-36440, G0272 36600, 36640, 61026, 61055, 62280-62284, 00124 01995-01996, 31505, 31515, 31527, 31622, 31645, 62310-62319, 64402-64430, 64445-64470, 64475, 36000, 36005-36015, 36400-36410, 36420-36440, 64479, 64483, 64505-64560, 64565, 67500, 36600, 36640, 61026, 61055, 62280-62284, 76986, 81000, 81002-81005, 81015, 82013, 82205, 62310-62319, 64400-64470, 64475, 64479, 82270-82273, 90780-90788, 90865, 91000, 91055, 64483, 64505-64560, 64565, 67500, 76986, 91105, 92100, 92511-92520, 92543, 92950-92961, 81000, 81002-81005, 81015, 82013, 82205, 82270- 93000-93010, 93015-93018, 93040-93042, 93303- 82273, 90780-90788, 90865, 91000, 91055, 91105, 93318, 93501-, 93701, 93922-93981, 94200, 92511-92520, 92543, 92950-92961, 93000-93010, 94250, 94640, 94656, 94660-94662, 94680- 93015-93018, 93040-93042, 93303-93318, 93501, 94690, 94760-94770, 95812-95822, 95829, 93701, 93922-93981, 94200, 94250, 94640, 95955-95957, 99201-99233, 99238, 99241- 94656, 94660-94662, 94680-94690, 94760- 99285, 99293-99313, 99321-99343, 99347-99349, 94770, 95812-95822, 95829, 95955-95957, 99354-99357, G0272 99201-99233, 99238, 99241-99285, 99293-99313, 00144 01995-01996, 31505, 31515, 31527, 31622, 31645, 99321-99343, 99347-99349, 99354-99357, 36000, 36005-36015, 36400-36410, 36420-36440, G0272 36600, 36640, 61026, 61055, 62280-62284, 00126 01995-01996, 31505, 31515, 31527, 31622, 31645, 62310-62319, 64400-64470, 64475, 64479, 36000, 36005-36015, 36400-36410, 36420-36440, 64483, 64505-64560, 64565, 67500, 76986, 36600, 36640, 61026, 61055, 62280-62284, 81000, 81002-81005, 81015, 82013, 82205, 82270- 62310-62319, 64400-64470, 64475, 64479, 82273, 90780-90788, 90865, 91000, 91055, 91105, 64483, 64505-64560, 64565, 67500, 76986, 92511-92520, 92543, 92950-92961, 93000-93010, 81000, 81002-81005, 81015, 82013, 82205, 82270- 93015-93018, 93040-93042, 93303-93318, 93501, 82273, 90780-90788, 90865, 91000, 91055, 91105, 93701, 93922-93981, 94200, 94250, 94640, 92511-92520, 92543, 92950-92961, 93000-93010, 94656, 94660-94662, 94680-94690, 94760- 93015-93018, 93040-93042, 93303-93318, 93501, 94770, 95812-95822, 95829, 95955-95957, 93701, 93922-93981, 94200, 94250, 94640, 99201-99233, 99238, 99241-99285, 99293-99313, 94656, 94660-94662, 94680-94690, 94760- 99321-99343, 99347-99349, 99354-99357, 94770, 95812-95822, 95829, 95955-95957, G0272

CCI 99201-99233, 99238, 99241-99285, 99293-99313, 00145 01995-01996, 31505, 31515, 31527, 31622, 31645, 99321-99343, 99347-99349, 99354-99357, 36000, 36005-36015, 36400-36410, 36420-36440, G0272 36600, 36640, 61026, 61055, 62280-62284, 0012T 29870-29871, 29874-29875, 29877-29879, 62310-62319, 64400-64470, 64475, 64479, 29884, 29886-29887, 36000, 36410, 37202, 64483, 64505-64560, 64565, 67500, 76986, 62318-62319, 64415-64417, 64450-64470, 64475, 90780-90788, 90865, 91000, 91055, 91105, 92511- 90780 92520, 92543, 92950-92961, 93000-93010, 93015-93018, 93040-93042, 93303-93318, 93501, 0013T 0012Tv, 29870-29871, 29874-29875, 29877- 93701, 93922-93981, 94200, 94250, 94640, 29879, 29884, 29886-29887, 36000, 36410, 94656, 94660-94662, 94680-94690, 94760- 37202, 62318-62319, 64415-64417, 64450-64470, 94770, 95812-95822, 95829, 95955-95957, 64475, 90780 99201-99233, 99238, 99241-99285, 99293-99313, 00140 01995-01996, 31505, 31515, 31527, 31622, 31645, 99321-99343, 99347-99349, 99354-99357, 36000, 36005-36015, 36400-36410, 36420-36440, G0272 36600, 36640, 61026, 61055, 62280-62284, 00147 01995-01996, 31505, 31515, 31527, 31622, 31645, 62310-62319, 64400-64470, 64475, 64479, 36000, 36005-36015, 36400-36410, 36420-36440, 64483, 64505-64560, 64565, 67500, 76986, 36600, 36640, 61026, 61055, 62280-62284, 81000, 81002-81005, 81015, 82013, 82205, 82270- 62310-62319, 64400-64470, 64475, 64479, 82273, 90780-90788, 90865, 91000, 91055, 91105, 64483, 64505-64560, 64565, 67500, 76986, 92100, 92511-92520, 92543, 92950-92961, 93000- 90780-90788, 90865, 91000, 91055, 91105, 92511- 93010, 93015-93018, 93040-93042, 93303-93318, 92520, 92543, 92950-92961, 93000-93010, 93501, 93701, 93922-93981, 94200, 94250, 93015-93018, 93040-93042, 93303-93318, 93501, 94640, 94656, 94660-94662, 94680-94690, 93701, 93922-93981, 94200, 94250, 94640, 94760-94770, 95812-95822, 95829, 95955- 94656, 94660-94662, 94680-94690, 94760- 95957, 99201-99233, 99238, 99241-99285, 94770, 95812-95822, 95829-, 95955-95957,

ABN, 20-21, 24-25 Calculating costs, 15 Abortion, 105, 147-148, 160, 179-180, 204-206, 215, 224- Capitation, 6-7, 50, 65, 452, 465, 477, 479, 486 225, 229, 232, 239, 252, 266, 278-280, 283-284, 294, Cast, 100, 102-104, 106, 147-148, 150, 213-214, 229, 239, 299-300, 311-313, 315-317, 319, 322-323, 327, 332, 335, 290, 359, 456-457, 474-475 339, 341, 347-348, 350, 354, 357, 361-362, 364-365, CCI, 17, 19-20, 482, 493-532 380-381, 383, 386-387, 389 Cellulitis, 173, 175, 182-183, 205, 238-239, 293, 327, 348 Abuse, 33, 37-39, 42, 49, 63-64, 176, 192, 198, 209, 365, Centers for Medicare and Medicaid Services, 1, 33, 48, 66, 382, 428, 477, 479, 482, 484, 488, 490 157, 201, 427, 432, 441, 477, 479-485, 487-490 Action Plan, 40 Cerebrovascular disease, 166, 170, 172, 257, 356, 392 Acupuncture, 21 Certified Registered Nurse Anesthetist, 8, 72, 430, 466-467, Add-on code, 69-145 469, 483 Adjudication, 33, 41, 45, 50, 52, 61, 477, 484, 488 Chief complaint, 33, 124-125, 480 Administration, 5, 9-11, 14-15, 18, 42-43, 48, 52, 70-73, Claims, 1-2, 6, 8, 10, 14-15, 17, 20-21, 27-31, 33-34, 37-68, 106, 113, 115-116, 120, 123, 140, 145, 147-148, 151-153, 70-71, 105, 119, 122, 124, 157, 193, 430, 441, 448, 450- 155, 182, 427, 433, 453-454, 457, 469-470, 475, 478- 452, 454, 462, 464-470, 477, 480-490, 492 479, 483, 485, 487 Claims processing, 2, 17, 39, 41-68, 157, 441, 467-470, Administrative simplification provisions, 2, 42 477, 481, 487, 492 Advance beneficiary notice, 21, 24 Clean claims, 41 AIDS, 24, 119, 160, 215 CMS, 1-2, 7, 10-14, 16-17, 19-20, 24-25, 27-28, 33, 37, 39, Alzheimer’s disease, 168 42-43, 45, 48-49, 52-53, 60, 66, 124, 126-127, 157, 201- Anemia, 167, 185, 188, 210, 217, 230, 233, 240, 253, 262, 202, 427, 432, 441-443, 477, 479-485, 487-490 283, 293, 298-299, 303, 308, 320, 338-339, 353, 365, CMS-1500, 2-3, 11, 41, 43, 53, 57, 59-60, 69, 119, 481, 486 375, 389 Code selection, 8, 132, 201, 458, 483 Anesthesia, reimbursement, 8 Codeine, 434, 437 Anesthetic agent, 106, 114-117, 457, 475, 484-485 Coding systems, 1-2, 427 Appeals, 20, 31, 45, 47-48, 441, 478, 484 Collection policies, 46 Appendicitis, 176, 205-206, 224, 313-314, 347-349, 372, Colonoscopy, 468 385 Complexity of Medical Decision Making, 34, 130-131 Application, 37, 51, 100, 102-104, 106, 141, 147-148, 183, Compliance, 2, 28, 34, 37, 39, 42-45, 303, 327, 472, 478, 428, 456-457, 462, 466-467, 471-472, 474-475, 477, 481-482, 485 484-485 Consultation, 10, 50, 65, 69, 71, 131, 134-135, 137-139, Arthritis, 165, 184-186, 194, 202, 206, 226-227, 229, 240, 142, 152, 154, 197, 246, 458-466, 482, 487, 489 249, 268, 284, 296, 307, 314, 329, 334, 352, 360, 370, Contusion, 190, 239, 247, 298-299, 316, 324 375, 378, 384, 386 COPD, 173-175, 233, 265

ARU, 52 Correct Coding Initiative, 3, 17, 20, 482, 493, 495, 497, Index ASA, 10-11, 36, 470, 478 499, 501, 503, 505, 507, 509, 511, 513, 515, 517, 519, Aspiration, 100, 107, 117-119, 151, 154, 174, 189, 227, 231, 521, 523, 525, 527, 529, 531 233, 267, 272, 288, 330, 333, 351-352, 373, 376 Cortisol, 306, 309, 344, 375 Assignment of benefits, 41, 478 Counseling or Coordination of Care, 124, 132, 458 Asthma, 173-175, 194, 227, 242, 260, 297, 322, 329, 332, Coverage issues, 3, 5, 118, 427, 441-442, 448, 482, 488 353, 358, 362, 364, 370, 389, 477 Coverage Issues Manual, 3, 427, 441-442, 448, 482, 488 Audit, 39-40, 71, 123, 157, 298, 441, 478, 492 CPT , Anesthesia Code List, 73, 93 Autogenous epidural blood graft, 449 CPT, modifiers, 9, 428, 460, 482 Automated, 52, 483 CPT, definitions and guidelines, 3, 69, 71, 73, 75, 77, 79, 81, 83, 85, 87, 89, 91, 93, 95, 97, 99, 101, 103, 105, 107, Base units, 8, 10-11, 59, 105-106, 453, 470-472 109, 111, 113, 115, 117, 119, 121, 123, 125, 127, 129, 131, Base units, 8, 10-11, 59, 105-106, 453, 470-472 133, 135, 137, 139, 141, 143, 145 Beneficiary late filing, 48 CPT, index, 3, 147-156 Biopsy, 93-96, 98-100, 112, 119, 147, 149-150, 153-154, CPT, modifiers, 9, 428, 460, 482 161, 454-456, 461, 468, 472-474 Critical Care, 62, 107, 121, 140-141, 152, 154, 451, 453, Blood transfusions, 109 459-460, 462-463 Blue Cross and Blue Shield, 5, 34, 41 CRNA, 8, 14-15, 58, 71-72, 429-430, 453, 466-467, 469- Bundled services, 11, 72 470, 472, 483 Burn, 105, 150, 175, 183, 190-191, 234-235, 312, 318, 324, Culture, 159, 205-207, 226, 237-238, 249, 267, 285-286, 371, 463 296-297, 313, 319-320, 322, 326, 334, 348, 353, 355, 357, 363, 366, 383, 386-387

Cyst, 103, 152, 178-179, 186-187, 220, 224, 228, 230, 240- Fraud, 33, 37-39, 49, 479, 482, 485, 488, 490-491 241, 245, 249-251, 257, 259-260, 274, 285, 288, 294, 300, 304, 310-312, 330, 332, 340, 349, 355, 362, 365, Gallstones, 177 379, 381-382, 457, 475 General anesthesia, 11, 14, 36, 73, 115-116, 449, 453-454, Cystitis, 178, 252 470, 485 Cytomegalovirus, 161, 312 Global surgery package, 10, 19, 71, 483

Dementia, 168, 215-216, 229, 231, 248, 258-259, 262-266, HCPCS, Level II Codes, 1, 3, 122, 143, 427-428, 430, 486, 298, 321, 341, 350, 354-356, 363, 368, 374-375, 386 491 Denial, 19, 21, 24, 45, 47, 49-51, 53, 193, 478, 483 HCPCS, Level III Codes, 2, 43, 427 Dependence, 192, 195, 198, 210, 259, 356 Health Maintenance Organization, 479, 481, 485-486 Depression, 177, 224, 259, 356, 358, 368 Hematoma, 190, 231, 235, 243, 245, 298-299, 316, 361 Dermatitis, 260, 293, 368, 387-388 Hematuria, 178, 232, 285, 299, 387 Diabetes, 8-9, 163-166, 169, 178, 226, 233, 241, 261, 263, Hemoglobin, 167, 217, 226, 253, 275, 285, 299, 303, 327, 267-268, 271, 293, 295-296, 298, 336-338, 343, 352, 375 374-375, 378, 383, 385, 437, 461, 465 Hemorrhage, 98-99, 149, 163, 165, 167, 169, 173, 177, Diabetic, 65, 164-166, 169, 188-189, 218-219, 226-228, 180-182, 187, 193, 196, 204, 216-219, 224, 231, 242- 238-239, 261, 267, 277-278, 293-294, 299, 301, 320, 245, 248, 261-262, 267, 274-275, 279, 284, 286, 288, 326, 331-332, 336-338, 352, 359, 376, 385, 461 294-295, 298-301, 308, 319, 336, 350, 361, 375, 383, Diaphragm, 97, 114, 148, 152, 204, 208, 212, 214, 219-220, 385, 389, 481 222, 253-254, 278, 280, 282, 286, 302-303, 307, 315, Hepatitis B, 25, 160 342, 344, 346, 362, 366, 383, 402, 404, 455, 473 HIPAA, 2, 42, 44-45, 53, 61, 480, 484 Dislocation, 190, 220-221, 230, 259-260, 268-270, 272, History of, 124-125, 145, 163, 169, 172, 177, 183, 193- 276, 289, 294-295, 312, 324, 327-328, 372 195, 197, 450 Documentation, 2, 5, 9-10, 14-15, 18, 20, 24, 33-40, 45, HIV, 144, 160, 194, 197, 258, 264, 312 47-48, 51, 69, 72, 97, 112-113, 123-128, 130, 132-133, Hypertension, 157, 159, 170-171, 175, 181, 187-189, 225, 135, 137, 162, 164, 168-172, 176-177, 187, 192-193, 227, 229-230, 232-233, 237, 239, 242-243, 252, 257- 199, 202-203, 427, 429-430, 449-450, 453, 457-461, 258, 261-264, 266-267, 275, 278, 280, 283, 295-296, 463, 465-469, 480-481, 484, 486, 488-489, 491-492 303, 306-307, 311, 318-319, 334, 336, 354, 363, 372-374, Drainage, 151-152, 154, 170, 172, 213, 238, 260, 275, 281, 380, 386, 388, 392-394, 461 324, 362, 369, 372, 377 Hyperthyroidism, 163, 264, 268, 282, 338 DRGs, 6, 483, 485, 490 Hypotension, 10, 123, 150, 173, 309, 347, 365, 377, 470 Drug, 36, 43, 56-57, 64-65, 105-107, 113-114, 120, 123, Hypothyroidism, 163, 226, 228, 235, 309, 333-334, 339, 144, 147-148, 152, 155, 157, 167-168, 172, 184, 186, 371-372 188-189, 192-193, 196-198, 209, 217, 258-259, 271, 275, 288, 313, 319, 322, 327-328, 334, 350, 356, 358, 364, ICD-9-CM, definitions and guidelines, 3, 157, 159, 161, 368, 373-374, 376, 378, 389, 428, 430-431, 433, 435, 163, 165, 167, 169, 171, 173, 175, 177, 179, 181, 183, 437-439, 457, 459, 475, 483, 485 185, 187, 189, 191, 193, 195, 197, 199 ICD-9-CM, index, 3, 184, 190, 201-426 ECG, 36, 204, 264, 285, 311, 467, 479 Immunization, 64, 193, 331

Index E code, 167-168, 172, 186, 192-193, 198, 322 Impacted cerumen, 170 EKG, 16, 25, 57, 171, 204, 285, 458-459, 462-464 Independent Practice Association, 6 Elevation, 95, 171, 253, 278, 454, 472, 479 Index, 3, 69, 147-157, 163, 170-171, 178-179, 182, 184, EOB, 30, 49, 55, 484 190, 193, 198, 201-426, 428, 437-439, 470, 477, 480, EPO, 6 482, 484 Evaluation and management, 9, 19, 69-70, 72, 121, 123, Inhalation, 19, 72-73, 123, 159, 174, 233, 246, 272, 277, 132-134, 141-143, 152, 450, 457-464, 467, 480, 484, 285, 288-289, 314, 339, 351-352, 372, 478, 485 486 Injection, 18, 21, 37, 50, 65, 72-73, 105-120, 123, 144, Excision, 10, 71, 73, 94, 102-103, 105, 147-148, 150-152, 147-156, 428, 431, 433-438, 457, 459, 475, 479-480, 170, 183, 186, 454, 456-457, 472, 474-475, 478 484-485 Explanation of benefits, 49, 55, 484 Injection anesthetic agent, 114-117 Explanation of Medicare benefits, 28, 479, 484, 490 Injury, 1, 10, 20, 30, 33, 53, 55-56, 58, 61-62, 71, 157-158, 169, 178, 183, 185, 187-191, 193-194, 196, 198-199, Fee for service, 484 202, 205, 213, 216, 218, 230-231, 238-239, 247-248, 252, Fee schedules, 7, 9, 15 259-260, 270, 272, 277, 279, 281-282, 287-289, 291-293, Focused medical review, 39, 47-48, 484 298-301, 304, 311, 314-318, 320, 323-325, 327, 329, 331, Fracture, 58, 95, 101, 106, 158, 160, 186, 189-191, 213-214, 338-339, 344-348, 352, 354, 361-362, 367, 370-372, 231, 242, 245, 272, 275, 282, 288-293, 299, 312, 315, 374-378, 380-383, 389, 431, 433, 458, 460, 462-463, 317, 324, 328-329, 332, 339, 353, 359, 365, 383, 390, 483-486, 489-490, 492 454, 472