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Index

A for photodynamic therapy, 286 Abdomen, peritoneum, and omentum for placement of adjustable suture during sub-section of surgery, 151–152 strabismus surgery, 203 Abortion, 179 plus symbol (+) to designate, 14, 74 Accessory sinuses, endoscopies of, 112 for previous eye surgery, 203 Accounts receivable (A/R) management, for qualifying circumstances for 384–386 anesthesia, 291 aged accounts receivable and claims for surgery, 73–74 follow-up for, 384–385 for veins harvested for bypass grafts, 128 appeals process in, 385–386 for vertebral levels in rhizotomy, 191 definition of, 384 Additional codes denial management as part of, 385 for additional tissue block from same tracking amounts using days in accounts specimen, 252 receivable for, 384–385 for application of stereotactic headframe, Accreditation Association for Ambulatory 185 Health Care (AAAHC), 3 for arthrodesis, 100 standards for basic elements of health for audiometric tests, 271 records set by, 8–9 for breast procedures, 88 Accreditation organizations and standards, 3 for cardiac catheterization, 273 Accredited Standards Committee (ASC) X12 for cardiovascular myocardial perfusion Electronic Data Interchange (ASC X12) and cardiac blood pool imaging transaction and code set standards, 379 studies, 231 Acellular dermal grafts, 85 for injections, 265, 266, 283–286 Acellular xenogeneic implant, 85 for intracardiac during Acupuncture, 289 therapeutic/diagnostic intervention, 273 ADA Dental Claim Form, 303 for multiple vessels in procedure, 275 Add-on codes for operating microscope for surgical for anesthesia, 40 services, 203 for angioscopy during therapeutic for physician standby services, 342 intervention, 131 for reconstruction procedures on ear, 203 for computer-assisted, image-guided for skin grafts in addition to primary navigation, 113 procedures, 85 for coronary artery blocked vessels, 275 for spinal instrumentation, 101 for critical care services, 336 when to use, 29–30 for electrode arrays, 185 Additional procedures, separate codes for, 74 for iliac artery angioplasty, 135 Adenoidectomy, 146–147 for , 276 Adjacent tissue transfer or rearrangement, 84 for , 225–226 Administration of contrast materials, 234

523 Index

Administrative law judge (ALJ) hearing for medical direction of, Medicare and reimbursement decision, 386 Medicaid coverage of, 44–45 Advance beneficiary notice (ABN), 374 qualifying circumstances for, 42, 291 modifiers for, 374, 376 regional, as separate from surgical Aged accounts receivable, 384–385 package, 171 AHA Coding Clinic for ICD-10-CM, 10 steps in coding, 42–43 ALJ hearing. See Administrative law judge team approach for providing, 44 (ALJ) hearing for reimbursement decision time charges for, 43–44 Allergen immunotherapy, 281 Anesthesia types included and not included Allergy and clinical immunology, 280–281 in surgical package, 71 Allergy testing, 280–281 Anesthesiologist assistant (AA), 38–39 Allograft (human skin), 85 time charges for, 43 corneal endothelial, 196 Aneurysm, 137 definition of, 85 abdominal aortic, 131 tissue cultured, 85 , 224 Ambulatory coding guidelines for ICD-10-CM, Angioplasty 27–30 balloon, 275 accessing and downloading current, 27 iliac artery, 135 Ambulatory surgery, diagnosis for, 30 transluminal, 120, 275 American Academy of Professional Coders Angioscopy, 131 (AAPC), 32 Antepartum and/or postpartum care only, American Dental Association, Current Dental 177–178 Terminology (CDT) of, 146, 303 Anterior segment of eye, 195, 196–198 American Health Information Management Anus, surgery on, 149 Association (AHIMA) Appendectomy, 148 certifications by, 32 Aqueous shunt to extraocular reservoir, 196 ICD-10 resources of, 10 Arterial catheterizations, 131–132 American Medical Association (AMA) Arteriogram, 137 CPT code book first developed by, 10 Arteriovenous fistulas, 134 E/M service documentation guidelines by Arthrodesis codes, 100 CMS (HCFA) and, 310 Arthroscopies, diagnostic and surgical, revisions of CPT code book by, 10 105–106 American Society of Anesthesiologists (ASA) Atherectomy, 275–276 ranking system of, 40 Attorney–client privilege, 424–425 time units and relative values system of, 43 Audiologic function tests, 203, 271 Amount and/or complexity of data to review Audiometry, 203 for medical decision making, 317 Audit Anastomosis to analyze coding information, 419 arteriovenous, 134 attorney–client privilege for completing, of multiple-vein segments, 131 424–425 preparation of artery for, 131 baseline, physician office, 433 in stomach, 147 conducting, 311, 425–427 Anatomic pathology determining size of sample for, 426 consultations for, 247, 251–252 factors that trigger, 424 physician services for, 249 following up, 426–427 Anesthesia, general, ophthalmological identifying need for, 424 examination performed under, 270 preparing for, 424–425 Anesthesia section, 18, 37–52 steps in performing, 425–426 codes used in reporting qualifying steps in performing internal, 425–426 circumstances in, 42 time required to complete, 426 format and arrangement of codes in, 38 Audit tool to assess quality of coding, 419 modifiers for, 39–41 based on 1995 guidelines, 419, 421–422 Anesthesia services based on 1997 guidelines, 419, 423 anesthesia package for, 39–40 Auditory system subsection of surgery, fees for, calculating, 43–44 199–203

524 Index

Autograft (autologous) skin graft Bone marrow biopsy codes, 97, 248 definition of, 84 Bone scans, 231 tissue cultured skin in, 85 Bones of foot, diagram of, 103 Brachytherapy B clinical, 229–231 Bad debt write-off, 384 definition of, 228 Balanced Budget Act of 1997 (BBA), 376 for radiation oncology, 228–230 Bariatric surgery, laparoscopic, 147–148 Breast procedures, 88–90 Bell curve graph, 400 Bronchial valves, 113–114 Benign lesions, 80–81 Bronchoscopies, 113–114, 286 Biliary tract, 141, 149–150 Bullet (•) in CPT code book to designate Biller, teamwork of coder and, 409–410 new code, 13, 302 Billing abuse Bundling of services, improper, 405 as audit trigger, 424 Bunion repairs, 103–104 avoiding allegations of, 311. See also errors in coding, 428 Fraud and abuse Burch procedure, 173 inflated medical billing as, 431 Burns Billing, component, 282, 376 debridement of, 80 Billing database, physician, 394 local treatment of, 87–88 Biofeedback, 268 Bypass graft, veins and arteries harvested Biopsies for, 124–128 bladder/urethra, 160 bone, 97 C bone marrow, 97, 248 C codes as inappropriate for billing breast, 88–89, 136 professional services, 303 digestive system, 143 Capitation payment arrangement, 365 excisional versus incisional, 88 Cardiac anomalies, complex, 127–128 female genital system, 171 Cardiac catheterizations, 120, 136, 272–275 hysteroscopic, 175 Cardiac procedures, HCPCS codes for, 294 lung and pleura, 114 Cardiac scans, 231 lymph node, 136 Cardiac valves, 124 male genital system, 170 Cardiography and cardiovascular monitoring mediastinum, 137 services, 272 miscoding, 428 Cardiopulmonary resuscitation, 278 prostate, 170, 251 Cardiovascular device monitoring, 272 sentinel node, 136 Cardiovascular, hemic and lymphatic systems ureter, 161 of surgery, 120–138 Birthday rule for primary and secondary Cardiovascular monitoring services, 272 payers, 381 Cardiovascular subsection of medicine, 271–275 Birthing room attendance, 348 Cardiovascular system subsection of surgery, Bladder, 161–163 120–138 Blood draws (venipuncture), 244–245 miscellaneous guidelines for, 136–137 Blood flow to and from heart, diagram of, Care plan oversight services, 343 120–124 Case management services, 343 Blood gases and information data stored in Casts and strapping, 96, 104 computers, 339 Cataract extraction Blood or blood component transfusion, 376 common errors in coding, 429 Blood transfusions and provision of blood ECCE and ICCE, 197 products, 255 implant procedures in, 197 Body size, measuring, 85 procedures included in, 197 Boldface for main terms in CPT code book terminology for, 197 index, 17 Catheters Bone density study, 235 arterial, 39 Bone flaps, 182 bronchoscopic placement of, 113 Bone grafts, 98, 100, 189 cardiac, 120, 136, 272–275

525 Index

codes for placement of, 131, 132, 272 Chemistry, 247–248 epidural, 47–48 Chemotherapy, 229 hyperalimentation or hemodialysis, 120 administration of, 285–286 inserted by physician rather than nurse, 132 Chest x-rays, 224, 339 intra-arterial, 39 Chief complaint used for coding, 27 nonselective and selective, in definition of, 314 interventional , 227 in history component of E/M service, 314 in pelvic organs and/or genitalia, 170 Childbirth and parenting classes, 179 removal of, 132 Chiropractic manipulative treatment (CMT), suprapubic, 172 289–290 ureteral, 161–162 Chronic diseases, coding, 29 venous, 132–133 Circumcision, 169–170 Cell washings and brushings, 113 Claim adjustment reason codes, Washington Centers for Medicare and Medicaid Services Publishing Company tables of, 409 (CMS) Claim denial ambulatory coding guidelines by NCHS C codes on CMS-1500 form resulting in, 303 and, 27 caused by failure to perform steps in claim form for billing. See CMS-1500 claims process, 383 claim form denial management for, 385 CPT code book included in Healthcare diagnosis codes as cause of, 404 Common Procedure Coding System by, NCCI edits signaling, 377–378 10–11 noncoding reasons for, 409 National Codes updated by, 302 nonspecific diagnosis code causing, 398 National Correct Coding Initiative preventing, 385 developed by, 377 speeding Medicare, 374 payment for consultation codes eliminated Claim history, patient, 394 by, 334 Claims process statistics for comparative graph available appeals process for Medicare in, 385 from, 400–401 steps in, 383–386 website of, 62, 246, 302, 304, 366, 374, submission of CMS-1500 form in, 378–381 377, 378, 400 Clean claims Central line catheter placement, 132 goal of submitting, 378 Central nervous system assessments/tests, percentage of, as key indicator, 410 282–283 Clinic/office setting for charges, 19 Central venous access procedures, 132–133 Clinical brachytherapy, 230 Central venous lines (CVLs), 39 Clinical Laboratory Improvement Certified Coding Associate (CCA), 32 Amendments of 1988 (CLIA), Certified Coding Specialist (CCS), 32 245–246 Certified Coding Specialist–Physician-Based Clustering of service codes, 403 (CCS–P), 32 CMS-1500 claim form Certified Professional Coder (CPC), 32 billing professional services on, 303 Certified Registered Nurse Anesthetist claims process for, 383–386 (CRNA), 38, 39, 41 code edits for missing information on, fees for services of, 43 407–409 modifiers for services of, 41 completing, 381 time charges for, 43 date of accident or injury on, 30 Cervical cerclage, 177 electronic format of, 380, 383 Cervical or vaginal cancer screening; pelvic HIPAA transaction and code set for, 379 and clinical breast examination, 376 internal fee schedule for, 381–382, 406 Cervix uteri, 172 linking diagnoses to procedures or Charge summary report, 394, 397 services on, 268, 381 Charge ticket reporting allergy tests performed on, 280 items included on, 21 reporting units on, 97 submission for payment of, 418 submission of paper or electronic, 380, 383 used in audit, 425 used in audit, 425

526 Index

Codable diagnostic statements, identifying, Compliance regulations, 429–433 26–31 Complications, surgical package as not Codable physician office documentation including encounters for, 71 statements, identifying, 31–32 Component billing, 282, 376 Codable procedural statements, identifying, Comprehensive history in E/M service level, 22–26 313 Coders. See also Certified Coding Associate Computed (CT), 224–225 (CCA); Certified Coding Specialist performed with stereotactic biopsy, 184 (CCS); Certified Coding Specialist– spinal, 189 Physician-based (CCS–P); Certified ultrafast or cine, 234 Professional Coder (CPC) Computerized corneal topography (CCT), 270 and billers as team, 409–410 Computerized internal fee schedule reports, as validating code selection, 311 381–382, 406 Coding Concurrent care, appropriate ICD-10-CM anesthesia, 37–52 code for each service provided in, 312 audit of, 419, 421–427, 432 Confirmatory consultations, 336 basics of, introduction to, 1–35 Conization of cervix, 172 diagnostic, 10 Conscious sedation, 291 evaluation and management, 309–361 Consultations, 334–336 main body of CPT code books used for anatomic pathology, 247, 251–252 assigning, 18, 22 clinical pathology, 247 medicine, 263–294 definition of, 334 operative report used for, 25–26 documentation of, 19 pathology and laboratory, 244–255 inpatient, 335–336 radiology, 223–235 for minor diagnoses, audits triggered by, 424 surgery, 69–222 modifiers for, 336 Coding credentials earned from AHIMA and outpatient, 335 AAPC, 32 Consulting physicians, guidelines for roles of, 334 Coding errors Contact lens service, 270 common CPT, 427–429 Contact lenses, HCPCS codes for, 293 identified through reports, 403–406 Contrast materials payer remittance report revealing, administration of, 234 406–410 for diagnostic radiology, 224–225, 234 Coding fraud. See Fraud and abuse HCPCS codes for, 234 Coding quality, evaluation of, 417–433 Contributing components of E/M services, 313 Coexisting conditions, coding, 29 Coordination of care as contributing E/M Colonoscopy component, 313 coding, 145, 428 Coronary arteries with potential blockages, distinguished from proctosigmoidoscopy diagram of, 124 and sigmoidoscopy, 145 Coronary artery bypass grafting (CABG), Colposcopy/vaginoscopy, 172 124–128 Combination code, 273 Coronary thrombolysis, 278 Communication tools Corpus uteri, 172–175 complex, 420 Corrected claim, 383, 385 simple, 418 Counseling Comparative study for service distribution as contributing E/M component, 313 report to promote health and prevent illness or creating, 400–401 injury, 346 purpose of, 398 CPT Assistant Complete blood counts (CBCs), 248 allergy tests and treatments in, 280–281 Complex repair of wounds, 82 AMA as publisher, 10 Compliance, definition of, 429 aspiration and trigger point injection codes Compliance programs for physician practices, in, 97 432–433 bilateral codes for tonsillectomy and OIG work plans for, 433 adenoidectomy in, 146–147

527 Index

biopsy and excision of lesions in, 89, 145 sections of, 18 breast procedures in, 88–89 structure and conventions of, 11–18 circumcision, in newborn, 169–170 subheadings in, 18 electrodiagnostic medicine (EDX) testing subsections of, 18 in, 282 symbols in, 13–14 history and physical performed on used in audit, 426 newborn in, 348 vascular families described in appendix L interventional radiology defined in, 226–228 of, 227 multiple gestation vaginal deliveries in, 178 CPT codes narcosynthesis in, 267–268 add-on, plus sign (+) to designate, 14, 17 orchiopexy with hernia repair in, 153 Category I of, 11, 12 Pap smear results in, 249–250 Category II service and/or test, 12 reporting open and laparoscopic Category III new and emerging procedures in, 148, 161, 163 technology, 11, 12 separate coding for lysis of adhesions for catheter insertions by physicians, 132 in, 148 code assignment hierarchy for National surgical laparoscopy in, removal of Codes and, 302–303 adnexal structures during, 175 deleted, 16 surgical margins of lesions in, attention to, development of new HCPCS codes to 88–91 replace, 376 uses of urodynamics in, 161–162 examples of, 11 CPT code book format of, 13–14 add-on codes in appendix D of, 14, 17 general instructions for using, 22 alphabetic index of, 244 for internal fee schedule, 381–382 appendices of, 13, 16–17 new and revised text in coding notes for, assignment of codes for services from, 10 facing triangles (▶◀) to indicate, 14 clinical examples for E/M coding in new, filled-in dot (d) in CPT code book to appendix C of, 16, 313 designate, 13 code formats in, 13–14 non-add on, exempt from using –51 code organization in, 18 modifier, null zero () to designate, 14 codes assigned from main body rather out of numerical sequence, 14, 17 than index of, 18, 26 revised, triangle (▲) in CPT code book to codes exempt from use of –51 modifier in designate, 13, 302 appendix E of, 14, 17 for unlisted procedures, 16 codes exempt from use of –63 modifier in CPT Editorial Panel (AMA), 11 appendix F of, 17 Craniectomy, 182 coding notes and instructions in, 16 Craniotomy, 17, 182 criteria for inclusion of procedures in, Critical care services, 338–339 12–13 care settings for, 338 crosswalk to deleted CPT codes in, 17 neonatal and pediatric inpatient, 338, HCPCS Level I as, 10–11 348–350 headings in, 18 Crosswalk to deleted CPT codes in Appendix index of, 17–18, 25–26 M of CPT code book, 17 main entry in, semicolon (;) to designate Current Dental Terminology (CDT) coding common portion of indented portions system, 146, 303 of, 14–16 Current Procedural Terminology, Fourth modifiers list in appendix A of, 16, 54 Edition, 10. See also CPT code book modifiers to use with genetic testing codes Custom reports for assessing coding quality, in appendix I of, 17 401–403 new, revised terminology, and deleted Cystectomy, 161 codes in appendix B of, 16 Cystometrogram, simple and complex, 162 non-add-on codes exempt from use of –51 Cystoscopy, 160, 162 modifier in appendix E of, 14, 17 Cystourethroscopy, 162, 163 professional edition of, 104, 199 Cytogenetic studies, 251 revisions by AMA of, 11 Cytopathology, 249–251

528 Index

D for laboratory- or radiology-only D codes of HCPCS comprising Current appointment, 26 Dental Terminology (CDT), 303 in physician’s notes, 26 Data collection form for each place of Diagnostic ultrasound service, 21 coding guidelines for, 226 Data elements of computerized internal fee HCPCS codes for, 234 schedule, 381–385 types of, 227 Data evaluation, qualitative and quantitative, Dialysis, 268–269 394–406 Diaphragmatic hernia, 153 Database Dictation matched to handwritten notation, 419 billing, physician, 394 Digestive system subsection of surgery, in problem-oriented medical record, 4 141–154 reports based on encounter history, common coding errors for, 428–429 401–402 modifiers for, 145, 147 of services using CPT and HCPCS codes Dilatation and curettage (D&C), 172–173 and fee schedule, 381–382, 406 Discharge services, nursing facility, 339, 340 Days in accounts receivable, 384 Discounted charges for medical services, 364 Days or units information, 382 Dislocation treatment codes, 98–99 Debridement and decontamination of Documentation guidelines (DGs) wounds, 83, 105 for E/M services, 310–311, 314, 316 Debridement and removal of granulations or for physicians, 24 avulsion in skin grafts, 85 Documentation sources that generate Debridement of burns, 80 physician codes and charges, 19–21 Debridement of mastoid cavity, 202 Documentation that supports charges and Debridement of multiple wounds, 80 diagnoses of physician, 311, 405 Decubitus (pressure) ulcers, 87 communication tools to request, 418–419 Deleted codes in HCPCS, strike-through to Domiciliary, rest home, or custodial care indicate, 302 services, 340–341 Delivery services, 177–179, 349 Domiciliary, rest home, or home care Denial management for claims, 385 oversight services, 341 Dental-related services, billing for, 303 Donor site of skin flaps or skin grafts, 85–86 Dentoalveolar structures, 146 Dressing changes, 87 Detailed history in E/M service level, Drug testing, 246–247 314–316 codes for drug names and classes in, Developmental screening, 283 246–247 Diabetes, HCPCS codes for, 294 Drugs and associated testing codes for Diagnoses pathology and laboratory section, falsifying, 430 246–247 note to code under ICD-10-CM, 28–29 Duplex scan, 279 Diagnosis distribution report, 397–398 Durable medical equipment (DME) Diagnosis/procedure mismatch, 406 HCPCS codes used for, 106–107, 304 Diagnostic coronary angiography, codes and for Medicare beneficiaries, 304 injection codes, 275 provider number for, 106, 293, 304 Diagnostic imaging. See Diagnostic radiology Durable medical equipment Medicare Diagnostic scans, 231 administrative contractors (DME Diagnostic procedures, reports of, 8 MACs), 304 Diagnostic radiology, 224–225 contrast materials for, 224–225 E HCPCS codes for, 234 E codes for external causes of injury, 30–31 Diagnostic services, sequencing, 29 Echocardiography, 272 Diagnostic statement Education and training for patient self assignment of code number to describe management, 290 physician’s, 10 Electrocardiograms (ECGs or EKGs), 272 definition of, 10 screening, 344 identifying codable, 26–31 Electroencephalography (EEG), 282

529 Index

Electromyography (EMG), 282 categories that identify new versus of muscle activity during voiding, 162 established patient for, 311–312, 269 surface, 294 coding for, 70, 268, 309–361 Electronic claims for CMS-1500 documentation guidelines for, 310–311 claim submission using, 380 format of service codes for, 38 signatures for, 380 modifiers for, 322–324, 336, 343, 347 submission error management for, 380 1995 guidelines for, 310, 316, 317, 419 time savings using, 380 1997 guidelines for, 270, 310, 316, 317, 419 Electrophysiologic (EP) procedures, 124, 279 Evaluation and management (E/M) services Emergency department services, 336–337 code, psychotherapy with, 267 modifiers for, 337 levels of, 269, 312–322 Emergency department setting for charges, other, 353 20–21 special, 347 End-stage renal disease (ESRD), 268 terms used in reporting, 311–312 Endarterectomy, 131 Evaluation of coding quality, 417–433 Endocrinology, 281 Evocative/suppression testing, 247 Endomicroscopy, optical, 144 Examination Endoscopy. See also Laparoscopies four types of, 317–319 bladder, 162 as key E/M component, 316–317, 324, 325, diagnostic endoscopy as included in 419 surgical procedure, 113 Excision-debridement of skin, 80 digestive system, 141–154, 428–429 Excision inferior turbinate, 112 genitourinary, 162 Excisional biopsies, 88 larynx, 112–113 Expanded problem focused history in E/M posterior segment, 197 service level, 313 renal, 160 Explanation of benefits (EOB), 383, 407, 409 sinus, 112 codes and code edits for, 407–409 ureteral, 162 payer information about, 407 Endoscopy/arthroscopy, 105–106 External causes of injury (E codes), 30–31 Endovascular repair of abdominal aortic External fixation of fracture, 98 aneurysm, 137 Extracapsular cataract extraction (ECCE), 197 Endovascular revascularization, 134–135 Extracranial nerves, peripheral nerves, and Errors, reports for identifying autonomic nervous system, 190–191 claim history and charge summary Extraction of lens, extracapsular and qualitative analysis, 394 intracapsular, 197 comparative, 398, 400–401 Extraspinal regions, 289 computerized internal fee schedule, 406 Eye and ocular adnexa subsection of surgery, diagnosis distribution and service distribution 195–203 quantitative analysis, 397–401 common coding errors for, 429 status, 380 modifiers for, 199 types of errors revealed by, 402, 403–406 Eyeball, 196 Esophageal motility studies, 269 Esophagogastric fundoplasty, 147 F Esophagoscopy, 144, 286 F wave test, 282 Established patient defined for E/M services, Facing triangles (▶◀) to indicate new and 311–312 revised text in coding notes, 14 for domiciliary, rest home, or custodial Fallopian tubes (oviducts), 175 care services, 340–341 False Claims Act (FCA), Federal, criminal for home services, 341–342 penalties for fraud under, 431 for office or other outpatient services, Federal Register 325–326 listing of global surgical days in, 426 Evaluation and management (E/M) section, Medicare conversion factors published 16, 18, 177, 178, 229, 247, 280, 285, 289 annually in, 365 categories and subcategories for, 311–312, National Physician Fee Schedule Relative 324–353 Value File as electronic, 366

530 Index

Fee problem log, 370 Genital system. See Female genital system Fee schedule management, 369–371 subsection of surgery; Male genital computerized reports for, 406 system subsection of surgery Fee schedule management worksheet, Geographic practice cost index (GPCI) for 369–371 Medicare payments, 366 Fee schedule, negotiated, 363 Gestational diabetes, 178 Fee survey report, national, 370–371 Glaucoma screening, 270 Female genital system subsection of surgery, Glaucoma, surgical treatment of, 196 171–179 Global surgical days listed in Federal Fertilization services, 179 Register, 426 Fetal repairs, HCPCS codes for, 179 Global surgical procedure. See Surgical Filled-in dot (•) in CPT code book to package designate new code, 13 Gonioscopy with medical diagnostic Fine needle aspiration of prostate, 170 evaluation, 270 First-listed diagnosis in outpatient setting, 28 Goniotomy, 196 Fistulectomy, 149 GPCI. See Geographic practice cost index Fistulization of sclera, 197 (GPCI) for Medicare payments Flaps Grafts. See Bone grafts; Coronary artery donor site for, 87 bypass grafting (CABG); Skin grafts procedures included in reporting use Growth factor preparation, 92 of, 92 types of, 86–87 H Follow-up care Hammertoe, errors in coding, 428 for diagnostic and therapeutic surgical HCPCS codes procedures, 72 assignment of, 10–11 postoperative, 72, 73 C outpatient, 303 Food and Drug Administration (FDA), symbol D Current Dental Terminology, 303 for approval of vaccines by, 14, 266 durable medical equipment, 304 Foreign bodies, removal of effect of HIPAA on, 303 from external ear, 203 J medication. See J codes, HCPCS from eye, 196 Level I of. See CPT code book from wound, 83, 96 Level II of, 376. See also National Codes Fracture treatment codes, 96, 98–99, 106 symbols used with, 302 Fraud and abuse temporary, 303–304 changing or manipulating codes as used in audit, 426 constituting, 410 website to obtain, 302 civil monetary penalty for, 431 HCPCS coding system. See Healthcare HIPAA provisions to address, 430–431 Common Procedure Coding System reducing risk of allegation of, 374 (HCPCS) submission of undocumented code as Health and behavior assessment/intervention, constituting, 311 283 unsubstantiated charges as constituting, 2 Health Care Fraud and Abuse Control Freedom of Information Unit, 371 Program created under HIPAA, 430 Full-thickness skin graft, 85 Health Insurance Portability and Accountability Act (HIPAA) (Public G Law 74–177) Gastrectomy, 147 code sets for use for third-party payers Gastric and duodenal intubation and under, final rule for, 430 aspiration, 147 effect on HCPCS of, 303 Gastric bands, bariatric surgery using, 147 fraud and abuse provisions of, 430 Gastric intubation, 269, 339 Health Care Fraud and Abuse Control Gastroenterology, 269 Program created under, 430 Gastrointestinal (GI) subsection endoscopies, 143 major provisions of, 430 Gastrostomy (feeding) tube (PEG), 147 Transaction and Code Sets (TCS) of, Genetic testing codes, modifiers used with, 17 379, 430

531 Index

Health record Home infusion procedures, 291 addendum to, 9 Home services, 341–342 administrative data in, 4–5 Home visit hemodialysis, 269 assignment of benefits form and Medicare Home visit setting for charges, 20 signature on file in, 4 Hospital discharge services, 331 changes to, 9 Hospital inpatient services, 330–334 clinical data in, 5–8 modifiers for, 332–334 content of, 3, 4–8 Hospital observation services, 329 documentation elements of accrediting Hospital outpatient prospective payment agencies for, 8–9 system (OPPS) reimbursement, 303 formats of, 4 H-reflex test, 282 fraud and abuse involving, 311, 409, 430 Hybrid format of health record, 4 integrated, 4 Hyperthermia, 229–330 primary functions of, 2 Hysterectomy purposes of, 2 abdominal, 173 registration record within, 4–5 vaginal, 173 Healthcare Common Procedure Coding Hysteroscopy, 173–175 System (HCPCS) for contrast material, 225 I CPT codes included in, 12 ICD-10-CM. See International Classification for diagnostic radiology, 234 of Diseases, Tenth Edition, Clinical for diagnostic ultrasound, 234 Modifications (ICD-10-CM) for female genital system, 179 ICD-10-CM code book for integumentary system, 92 annual update of, 10 master list of services by CPT codes Index to External Causes in, 30–31 and, 381 ICD-10-CM codes for medicine, 290–291 assigned to highest level of specificity, 29, modifiers in, 12, 380–381. See also 311, 408 Modifiers, HCPCS coding reason for encounter using, 28 for musculoskeletal system, 96, 106–107 linking CPT/HCPCS codes to, 376, 383–384 for nervous system, 191 physician office uses for, 8 for ophthalmology, 270 role in billing and receiving payment for for pathology and laboratory, 254–255 concurrent care services of, 312 for radiology services, 235 ICD-10-CM diagnostic codes, 10 requests for new codes in, 376 ICD-10-PCS procedure coding system, 10 for supplies in internal fee schedule, 382 Immune globulins, serum or recombinant Hematology and coagulation, 248 products, 264–265 Hemic and lymphatic systems, 136 Immunization administration for vaccines/ Hemilaminectomy, 186 toxoids, 265–266 Hemodialysis, 268–269 Immunization against disease, 264–266 Hemodialysis access, intervascular Immunization pending FDA approval, symbol cannulation for extracorporeal in CPT code book to note, 14, 266 circulation or shunt insertion, 133–134 Immunization services, HCPCS codes for, 293 Hemorrhoidectomy, 141 Immunology, 248 Hepatobiliary (HIDA) scans, 232 Immunotherapy, allergen, 280–281 Hernia repair, 152–154 Implant, removal of, 98 Hiatal hernia, 147, 153 Implanted material in eye, removal of, 195 History “Incident to” services and supplies, billing, 424 as key E/M component, 313, 314–317, 419 Incision and drainage of skin, simple and psychiatric, 266–268 complicated, 79 History of present illness (HPI) in history Incisional biopsies, 88 component of E/M service, 314 Index of CPT code book, avoiding assigning Home health agencies, physician supervision codes from, 16–18, 25–26 of patients for, 343 Index to External Causes in ICD-10-CM Home health procedures/services, 291 code book, 30–31

532 Index

Induction dilution studies, 273 Intersex surgery, 170 Infants, critical care services for, 338, 348, 350 Interventional radiology, 226–228 Information analysis, 419. See also Audit Intestines, 148–149 Information collection, charge ticket for, 418 Intracapsular cataract extraction (ICCE), 197 Information correction, tools for, 418–423 Intracardiac electrophysiologic procedures/ Infusion pumps, 120, 132 studies, 278–279 Infusions, therapeutic, prophylactic, or Intraocular lens prosthesis (IOL), 197 diagnostic, 283–286 Intravascular cannulization or shunt, 132 Inhalation bronchial challenge testing, 280 Intravascular ultrasound (IVUS), 276 Initial hospital care, 19, 330 Intravenous (IV) infusion, 283–285 to neonate of 28 or fewer days, 350 Inventory discrepancies on service Initial observation care, 329 distribution report, 396, 398 Initial plan in problem-oriented medical Iridotomy/iridectomy by surgery, 197 record, 4 Initial preventive physical examination J (IPPE) for Medicare patients, 344–346 J codes, HCPCS Injections for evocative/suppression testing, 247 anesthetic agent, 47, 169, 171 for medications, 97, 280, 284, 304 hydration, therapeutic, prophylactic, and for nebulizer treatment, 280 diagnostic, 283–286 Joint, aspiration or injection of medication into, 97 joint, 189, 190 Joint Commission, 3 of medication into joint or ganglion cyst, 97 medication list required to be included in neurolytic, 189 health record by, 5 nonneurolytic, 189 problem list required for continuing spinal, 186, 189 ambulatory services by, 5 trigger point, 97 standards for basic elements of health Injury, E codes for external causes of, 30–31 records set by, 8–9 Inpatient consultations, 335–336 Joint scans, 231 Inpatient hospital setting for charges, 19 Inpatient neonatal and pediatric critical care, K 348–350 Keratoplasty (corneal transplant), 196 Insurance company appeals process, 385–386 Key components of E/M services Insurance company claim processing, 383 for consultation codes, 335 Insurance company fact sheet, 371 for domiciliary, rest home, or custodial Integrated health record, 4 care services, 340–341 Integumentary system subsection of surgery, for home services, 341–342 77–92, 112 for nursing facility services, 339, 340 HCPCS codes for, 92 in selecting level of E/M service, 312–322, Intermediate repair of wounds, 82 324 Internal elective electrical cardioversion of Kidney, 160–161 arrhythmia, 278 Internal fee schedule L computerized reports for, 406 Laboratory-only appointments, diagnosis for, 26 data elements of computerized, 381–382 Laboratory reports in health record, 8 Internal fixation of fracture, 98 Laboratory tests International Classification of Diseases, evocative/suppression testing in, 247 Tenth Edition, Clinical Modifications kit or transportable instrument for, 60 (ICD-10-CM) medical necessity of, 374 ambulatory coding guidelines for, 27–30 repetition of, audits triggered by, 424 benign versus malignant neoplasms in, 81 Laminectomy, laminotomy, codable using, 26–31 hemilaminectomy, 186, 189 code book for, index and tabular sections Laparoscopic surgical approach, 73 of, physician offices’ use of, 10 Laparoscopies understanding which diagnostic statements, 26 digestive system, 141, 143, 147–148 used in audit, 426 female genital system, 171–173

533 Index

male genital system, 168 Managed care organizations, capitation used surgical, diagnostic laparoscopy included by, 365 in, 141, 153, 173–175 Manipulation of fracture, 98 urinary system, 158–164 Mastectomies, 89–91 Laparotomy for abdomen, peritoneum, and Mastoidectomy cavity, 199, 204 omentum, 151–152 Maternity care and delivery, 177–179 Laryngoscopies, indirect and direct, 112–113 Mechanical thrombectomy, 276 Larynx, 112–113 Mediastinoscopy, 136 LEEP procedures, 172 Mediastinum, 136 Lens extraction. See Cataract extraction Medicaid Lesions, biopsies of genital, 171 certification number for lab on file for test Lesions, breast, 88 coverage by, 245 Lesions, digestive system, 143, 145, 146 reduced reimbursement by, 45 Lesions, eyelid, 198 Medical and/or surgical complications during Lesions, penile, 169 pregnancy, 178 Lesions, skin Medical decision making as key E/M destruction of, 88, 428 component, 313, 314, 317–321, excision of, 77, 80–81, 428 324, 325 malignant versus benign, 428 factors in, 317 measurement of, 80 four types of, 317 Lesions, skull base, 182, 183 Medical history in health record, 6 Lesions, surgical margins of, 89 report in health record, 8 Lesions, tongue, 146 Medical necessity, 373–374 Lesions, vulva, 172 in office visits, 424 Levels of E/M services, 312–322 Medical nutrition therapy, 289 audits triggered by billing unsupported, 424 Medical record. See Health record components of, key and contributing, Medicare Appeals Council, 386 312–322, 324, 335 Medicare appeals process, 385–386 examples of selecting among, 321 Medicare audit, factors triggering, 424 time as factor in selecting, 322 Medicare carriers Ligation as part of wound repair, 83 anesthesiology coverage by, 38 Lips, repairs of, 146 appeals process of, 385–386 Lithotripsy to destroy urinary stones, 160 certification number for lab on file for test Local Coverage Determinations (LCDs), 373, coverage by, 245 374, 376 CMS-1500 form used for claims to. See LOOP procedures, 172 CMS-1500 claim form Lower gastrointestinal endoscopies, durable medical equipment supplies 145–146 reimbursed by, 293 Lumpectomy, breast, 89 HCPCS Level II codes required for claims Lung excision, 114 to, 302 Lung scans, 232 information on coding and payments Lungs and pleura, 114–115 from, 371 Lymph nodes National Codes used for, 302 removal during cystectomy of, 161 participating provider agreements with, 369 removal during mastectomy of, 89 point scales of, 321 Lymphadenectomies, 136 RBRVS used by, 365 reduced reimbursement by, 45 M supplies and materials provided by Magnetic resonance imaging (MRI), 224, 235 physicians reported to, 290 Main terms in CPT code book index, 17, 26 time increments recognized by, 43 Male genital system subsection of surgery, venipuncture coverage by, 245 158, 168–170 Medicare Claims Processing Manual Malignant lesions, 81 appeals process detailed in, 385–386 Mammography, screening and diagnostic, Medicare surgical package defined in, 71 225–226 NCCI edits concept in, 432

534 Index

Medicare Integrity Program, 430 for E/M services, 322–324, 326, 331–332, Medicare National Correct Coding Initiative 337, 346 (NCCI) edits. See National Correct for genetic testing codes, 17 Coding Initiative (NCCI) edits for medicine, 271, 272, 279, 282, 283, 289, Medicare Physician’s Fee Schedule Database 292–293 (Relative Value File), code status in, for pathology and laboratory, 245, 247, 302–303 249, 253–254 Medicare Prescription Drug, Improvement, for physician claims, 54–61 and Modernization Act of 2003 for radiology, 231, 232–235 (MMA), 344 for surgery, 73, 74–75, 81–82, 88, 96, Medicare signature on file form, 7, 8 97, 100–101, 105, 106, 112, 115, 143, Medicare summary notice, 407 147–149, 154, 170, 171, 173, 175, 184, 186 Medicare surgical package, 71–72 Modifiers, CRNA, 41 Medication administration. See J codes, Modifiers, HCPCS, 12, 62–63 HCPCS for anesthesia, 45 Medication list required by Joint Commission component billing, 376 in health record, 6 Level II anesthesia, 41 Medication therapy management services Level II E/M, 45, 324 (MTMS), 292 Level II radiologic, 233 Medicine section, 18, 120, 136, 177, 203, 263–294 Level II technical component (–TC), 63, anatomical modifiers for, 292–293 233, 282, 292, 376 content and structure of, 264–292 for medicine services, 293–294 HCPCS codes for, 293–294 for radiology, 230, 233, 376 modifiers for, 272, 282, 289, 292–293 for surgery, 178, 199 Meniscectomies, 105 Modifiers list Metric measurement conversions, 80 –AA, anesthesia services performed Microbiology, 248–249 personally by anesthesiologist, 41, 45, 62 Minimal service history in E/M service –AD, medical supervision by a physician: level, 313 more than four concurrent anesthesia Minimum data set (MDS) included in procedures, 41, 62 RAI, 339 –AI, principal physician of record, 62 Missed abortion, 179 –AP, determination of refractive state not Missed charges performed in the course of diagnostic definition of, 405 ophthalmological examination, 292 sample, 403 –AT, acute treatment, 292 service distribution report to reveal, –E1–E4, eyelids, 63, 75, 198, 378 398–401 –EJ, subsequent claims for defined course Moderate (conscious) sedation, 291 of treatment, 292 Modifiers, 53–66 –F1–F4, left hand digits, 63, 75, 233, 293, 378 claim form convention for separating –F5–F9, right hand digits, 63, 75, 233, 293, 378 codes from, 54 –FA, left hand thumb, 63, 75, 233, 293, 378 index of, 64–66 –FP, service provided as part of Medicaid types of, 54–65 family planning program, 324 Modifiers, anatomical –G6, ESRD patient, 292 assigned to digits, list of, 75, 293 –G8, monitored anesthesia care (MAC) for for breast procedures, 88, 89 deep complex, complicated, or markedly list of, 75 invasive surgical procedure, 41, 46, 62 for medicine, 292–293 –G9, monitored anesthesia care (MAC) for radiology, 233 for patient who has history of severe for surgery (–LT and –RT), 75, 88 cardio-pulmonary condition, 41, 46, 62 Modifiers, CPT, 54–61 –GA, waiver of liability statement on file, for ABN waiver, 254, 374 62, 254, 324, 374 for anesthesia, 41, 47 –GC, service performed in part by a in CPT code book, appendix A, 16, 54 resident under the direction of a to define service further, 382 teaching physician, 45, 62, 324

535 Index

–GE, service performed by a resident –TA, left foot, great toe, 63, 75, 233, 293, 378 without the presence of a teaching –TC, technical component, 63, 233, 282, physician under the primary care 292, 376 exception, 62, 324 –XE, separate encounter, 82, 143, 233 –GG, performance and payment of a –XP, separate practitioner, 82, 143, 233 screening mammogram and diagnostic –XS, separate structure (or organ), 82, 143, mammogram on the same patient, 233 same day, 62 –XU, unusual non-overlapping service, 82, –GH, diagnostic mammogram converted 143, 233 from screening mammogram same day, –1P, exclusion to performance measure, 12 62, 233 –2P, exclusion to performance measure, 12 –GX, notice of liability issued, voluntary –3P, 12 under payer policy, 62, 374 –8P, 12 –GY, item or service statutorily excluded –22, increased procedural services, 41, or does not meet the definition of any 54–55, 74, 148, 178, 225, 232, 253, 381 Medicare benefit, 62, 374 –23, unusual anesthesia, 41, 55, 74 –GZ, item or service expected to be denied –24, unrelated evaluation and management as not reasonable and necessary, 62, 374 service by the same physician during a –LT, left side, 63, 75, 88, 233, 292, 378 postoperative period, 55, 322, 326, 332 –P1, normal healthy patient, 40, 61 –25, significant, separately identifiable –P2, patient with mild systemic disease, evaluation and management service 40, 61 by the same physician on the day of a –P3, patient with severe systemic disease, procedure or other service, 169, 170, 40, 61 283, 289–290, 322–323, 326, 332, 336, –P4, patient with severe system disease 344, 347, 378 that is a constant threat to life, 40, 61 –26, professional component, 55–56, 74, –P5, moribund patient who is not expected 161, 232, 253, 272, 282, 292, 376 to survive without the operation, 40, 61 –27, as being reserved for facility use –P6, declared brain-dead patient whose only, 54 organs are being removed for donor –32, mandated services, 56, 253, 323, 336 purposes, 40, 61 –33, preventive services, 56 –Q5, service furnished by a substitute –47, anesthesia by surgeon, 56, 74, 169, physician under a reciprocal billing 170, 171 arrangement, 62, 324 –50, bilateral procedure, 54, 56, 74, 88, –Q6, service furnished by a locum tenens 113, 115, 135, 154, 160, 163, 190, 199 physician, 62, 324 –51, multiple procedures, 14, 17, 41, 56, –QK, medical direction of two, three, or 73, 74, 88, 100, 105, 106, 112, 126, 143, four concurrent anesthesia procedures 149, 161, 163, 184, 186, 199, 203, 279, involving qualified individuals, 41, 45, 62 282, 292 –QS, monitored anesthesia care service, –52, reduced services, 56–57, 74, 147, 170, 41, 46, 62 232, 253, 271, 292, 381 –QW, CLIA waived test, 62, 245, 254 –53, discontinued procedure, 41, 57, 74, –QX, CRNA service: with medical 145, 232, 292 direction by a physician, 42, 45, 62 –54, surgical care only, 54, 57, 74 –QY, medical direction of one certified –55, postoperative management only, 57, 74 registered nurse anesthetist (CRNA) by –56, preoperative management only, 57, 74 an anesthesiologist, 41, 62 –57, decision for surgery, 57, 74, 323, 326, –QZ, CRNA service: without medical 332, 336 direction by a physician, 42, 45, 63 –58, staged or related procedure or service –RT, right side, 63, 75, 88, 233, 292, 378 by the same physician during the –SA, nurse practitioner rendering service postoperative period, 57–58, 73, 74, 81, in collaboration with a physician, 63 163, 378 –SB, nurse midwife, 63 –59, distinct procedural service, 39, 41, 47, –T1–T4, left foot digits, 63, 75, 233, 293, 378 48, 58, 73, 74, 82, 135, 143, 232–233, –T5–T9, right foot digits, 63, 75, 233, 293, 378 253, 292, 378

536 Index

–62, two surgeons, 58, 74, 230 N –63, procedure performed on infants less Narcosynthesis, 267–268 than 4 kg, 17, 58, 74 Nasal polyps, 110. See also Polypectomies –66, surgical team, 59, 74, 231 National Codes, 301–304 –73, discontinued outpatient hospital/ for intravenous drug and supplies ambulatory surgery center (ASC) furnished by physician, 303 procedure prior to the administration as Level II of HCPCS, 11 of anesthesia, 54, 232 process for assigning, 302–303 –74, discontinued outpatient hospital/ required for Medicare claims, 302 ambulatory surgery center (ASC) sections of, 302 procedure after administration of to specify radiopharmaceutical agent, 231 anesthesia, 54, 232 National Committee for Quality Assurance –76, repeat procedure or service by same (NCQA), 3 physician or other qualified health care standards for basic elements of health professional, 59, 73, 74, 292 records set by, 3, 8–9 –77, repeat procedure by another National Correct Coding Initiative (NCCI) edits physician or other qualified health care in claims-processing systems of Medicare professional, 59, 73, 74, 292 contractors, 432 –78, unplanned return to the operating/ denial messages for application of, 378 procedure room by the same physician development of, 377–378 or other qualified health care National Coverage Determinations (NCDs), 373 professional following initial procedure National Physician Fee Schedule Relative for a related procedure during the Value File postoperative period, 59, 74, 378 as electronic Federal Register, 366 –79, unrelated procedure or service example of, 366 by the same physician during the status indicators in, 374 postoperative period, 59–60, 72, 73, National provider identifier (NPI) of 74, 378 physician or provider for covered –80, assistant surgeon, 60, 74 entities, 378–379 –81, minimum assistant surgeon, 60, 74 Nature of presenting problem as contributing –82, assistant (when qualified resident E/M component, 313 surgeon not available), 60, 74 Nebulizer treatment, 280 –90, reference (outside) laboratory, 60, 253 Needle core biopsies, 88 –91, repeat clinical diagnostic laboratory Negotiated fee schedule, 365 test, 60, 247, 253, 378 Neonatal critical care, 348–350 –92, alternative laboratory platform Neonates, neonatal critical care for testing, 60, 253 inpatient, 338, 348–350 Modifiers, missing, 406 outpatient, 338, 348 Modifiers, physical status, 40, 43, 61 Neoplasms, benign and malignant, 81 Monitored anesthesia care (MAC), 46–47 Nephrectomy, 161 Monitoring coding functions and errors, laparoscopic, 161 427–429 Nephrolithotomy to remove urinary stones, 160 Multiple codes, indented information for Nerve conduction studies (NCS), 282 procedures requiring, 15 Nerve graft, 191 Multiple gestation, 178 Nervous system subsection of surgery, 181–191 Multiple surgical procedures, claims- modifier for, 184–185 generation guidelines for, 380–381 Neurology and neuromuscular procedures, Multiple wound repairs, 82 281–282 Musculoskeletal system subsection of HCPCS codes for, 294 surgery, 96–107, 112 Neurolytic injections, 189 common coding errors for, 428 Neuroplasty, 191 general codes for, 96 Neurorrhaphy, 191 HCPCS codes for, 106–107 Neurostimulators, 185–186, 282 modifiers for, 100, 105–106 New and emerging technologies, Category III Myocutaneous flap, 86–87 CPT codes for, 12

537 Index

New patient defined for E/M services, for new patient, 325 311–312 preventive medicine services distinguished for domiciliary, rest home, or custodial from, 343–344 care services, 340–341 Office service report, 401–402 for home services, 341–342 Office visit for office or other outpatient services, in addition to immunotherapy, 281 324–328 level of, 24, 424 for preventive medicine services, 344–346 Omentectomy, 177 New patient defined for ophthalmology, 269 On-site testing for pathological and Newborn care, 348–351 laboratory section, 244 Newborn resuscitation services, 348 Online digital evaluation and management, Non-face-to-face nonphysician services, 290, 346 346–347 Oophorectomy (ovariectomy), 177 Noncovered service, assigning code for, 432 Open prostatectomy, 158 Noninvasive vascular diagnostic studies, 279 Operating microscope Nonneurolytic injections, 189 for eye and ocular adnexa, and auditory Nonphysician services, billing, 19 system procedures, 198 Nose, 110–112 for larynx procedures, 113 Nuclear medicine, 231–232 in male genital system procedures, 168 applications of coding for, 231–232 in neural repair, 191 Null zero () to designate non-add-on code in posterior segment procedures, 198 exempt from using –51 modifier, 14 Operative report Number of diagnoses or management options coding from, 26 for medical decision making, 317 lesion measurement taken from, 80 Numerical sequence, CPT codes not in, 17 reviewed in assigning endoscopy/ appendix N of CPT code book listing, 17 arthroscopy codes, 105–106 symbol # indicating, 14 reviewed in assigning flap codes, 87 Nursing facilities, physician supervision of reviewed in assigning proctectomy codes, patients for, 339–340 148 Nursing facility services Ophthalmology, 269–271 discharge services as, 340 Ophthalmoscopy initial nursing facility care for, 339 extended, with retinal drawing, 270–271 subsequent care using key components in, ophthalmologic services erroneously 340 reported as, 270–271 Nursing facility setting for charges, 20 Optical endomicroscopy, 144 Orbital implant, 198 O Orchiectomy, 168 Observation area setting for charges, 20 Orchiopexy, 170 Observation or inpatient care services (including with hernia repair, 153 admission and discharge services), 331 Organ or disease-oriented panels, 246 Observer to assist with conscious sedation, 291 Organ systems documented in physical Ocular adnexa, 198–199 examination, 6–7 modifiers for, 198–199 Organizations and agencies directing health Ocular implant, 198 record content, 3 Ocular prosthesis, 271 Osteopathic and chiropractic manipulative Office of Inspector General (OIG) treatment, 289–290 audit size recommendations by, 426 modifiers for, 289–290 compliance program guidance documents Other evaluation and management services, 353 of, 432–433 Other procedures for integumentary system, 87 website of, 433 Other services and procedures for medicine, 291 Office or other outpatient consultations, 335 Outpatient hospital setting for charges, 20 Office or other outpatient services category, Outpatient services, basic coding guidelines 324–328 for, 27–30 for established patient, 325–326 Ovary, 176–177 modifiers for, 326–328 Oviduct, 176

538 Index

P Physical status modifiers for anesthesia, 40, 61 Pacemaker or pacing cardioverter- Physician office documentation defibrillator, 120, 123–124 differences between most health records Pain management services, 47–48 and, 8 Pap smears, 249–251 documentation guidelines by AMA and Participating provider agreements, 369 CMS for, 310–311 Past medical, family, and social history education about deficiencies in, 432 (PFSH) in history component of E/M identifying codable statements in, 31–32 service, 315–316 Physician office laboratories (POLs), 245–246 Pathology and laboratory section, 18, 244–255 Physician orders in health record, 7 alphabetic index main terms for, 244 Physician services, billing, 302–303 guidelines for subsections of, 246–252 modifiers for, 54–63, 378 HCPCS codes for, 253–255 Physician standby services requested by modifiers for, 245, 247, 249, 253–254 another physician, 342–343 quantitative and qualitative studies for, Pinch graft, 85 246 Place of service charges, 19–21, 382 structure and content of, 244–245 Place of service (POS) codes matched to Patient contact, face-to-face, for prolonged service, 408 services, 342 Plus symbol (+) to designate add-on codes, Patient record as audit tool, 425 14, 17, 74 Patient self-management, education and Polypectomies, 175, 428. See also Nasal polyps training for, 290 performed through colonoscope, 145–146 Patient transport, physician attendance simple versus extensive, 110, 112 during, 348 Polysomnographies, 282 Payer remittance report, 383, 406–410 Positron emission tomography (PET) coder and biller as team for, 409–410 imaging, 235 codes and code edits for, 407–409 Posterior segment of eye, 198 Payer-specific guidelines for procedures, Postoperative care included in global service, supplies, and services, 371, 373–378 71 Payers, primary and secondary, 381 Postpartum care, 177–178 PCI. See Percutaneous coronary interventions Prenatal visits, outpatient, 30 (PCI) Preoperative evaluations, sequencing, 30 Pediatric critical care services Pressure (decubitus) ulcers, 87 initial, 350–351 Preventive medicine services, 344–346 for patient transport, 338, 348 Principal diagnosis, definition of, 27–28 subsequent, 350–351 Problem focused history in E/M service level, Pedicle flap, 87, 184 313 Penis, 169–170 Problem list Per member per month (PMPM) rate, 365 for continuing ambulatory services, 5–6 Percutaneous coronary interventions (PCI), in problem-oriented medical record, 4 275–276 Problem-oriented medical record (POMR), 4 Percutaneous lysis of epidural adhesions, 186 Procedural statements, identifying codable, Percutaneous transluminal coronary 22–26 angioplasty (PTCA), 120, 271, 275 Proctectomy, 148 Peritoneal dialysis, 268 Proctosigmoidoscopy, 145 Phacoemulsification, 197 Professional services, billing, 303 Phacofragmentation, 197 modifiers for, 54–63 Pharmacologic management, 267–268 Progress notes Pharynx, adenoids, and tonsils, 146–147 content of, 7 Photochemotherapy, 286 in problem-oriented medical record, 4 Photodynamic therapy, 286 reviewed in assigning surgery codes, 70 Physical examination in health record, body Prolonged services, 342–343 areas, organ systems, and diagnosis Proprietary laboratory analyses (PLA), 252 statement components of, 6–7 Prostate, 170 Physical medicine and rehabilitation, 286–288 needle biopsy of, 170, 226

539 Index

Protecting Access to Medicare Act of 2014 Radiology reports in health record, 8 (PAMA), 252 Radiology section, 18, 223–235 Provider identification numbers for format and arrangement of, 224–232 physicians and nonphysicians, 19 HCPCS codes for, 235 Provider remittance advice (RA), 407 modifiers for, 231, 232–233 Psychiatric services, HCPCS codes for, 293 subsections of, 233 Psychiatry, 266–268 Radiopharmaceuticals Psychotherapy, 266–267 provision of, 231 with E/M service codes, 267 used in brachytherapy, descriptions Pulmonary services, HCPCS codes for, 294 of, 231 Pulmonary subsection, 279–280 Reason for accident or injury, 30 Pulse oximetry, 280, 339 Reason for encounter/visit, 29 Pyramid (▲) in CPT code book to designate Reduction of fracture, 98 revised terminology, 13 Reference lab testing for pathology and laboratory section, 244 Q Registered Health Information Qualified independent contractor (QIC), Administrators (RHIAs), 32 reconsideration of Medicare appeals Registered Health Information Technicians decision by, 385 (RHITs), 32 Qualifying circumstances for anesthesia, 42, 291 Registration record of demographic data, 4–5 Qualitative analysis, reports for, 394, 397 Reimbursement guidelines, sources of, 364, custom, 401–406 371–372 Quality and validation reviews, 311 Reimbursement modifiers for component Quality of coding, 417–433 billing and, 376 audit to analyze, 419–423 optimizing, 2 tools for correcting and verifying, 418–423 reduced Medicare or Medicaid, 45 Quantitative analysis Reimbursement process, 363–386 definition of, 394 claims in, 378–381, 383–386 diagnosis distribution report for, 397–398 fee schedule management in, 369–371, service distribution report for, 398–401 381–382 Quantitative and qualitative studies for master list of services kept for, 381 pathology and laboratory, 246 mechanisms for, 364–369 Qui tam (whistleblower) actions for fraud and payer-specific guidelines for, 373–378 abuse, 432 sources of guidelines for, 371–372 Relative value file for physician fee schedule, R 366–369 Radiation oncology, 224, 228–231 Relative Value Guide (ASA), 43 coding guidelines for, 230–231 Relative value unit (RVU) data on service consultations and treatment planning for, 229 distribution reports, 401 unlisted procedure codes for, 229 Relative value units (RVUs) specific to CPT Radiation therapy. See Brachytherapy; code, 382 Teletherapy for radiation oncology Remark codes, Washington Publishing Radiation treatment delivery, 229 Company tables of, 409 coding guidelines for, 230–231 Removal of hardware, 98 Radiation treatment management, 229 Removal of sutures, 87 coding guidelines for, 230–231 Renal scans, 232 Radiologic supervision and interpretation Renal transplantation, 161 subsection, coding guidelines in, 226 Repairs Radiological supervision and interpretation of tendons, 99 for biopsies of wounds, 82–83 of breast, 88 Reports and databases, coding and of lungs and pleura, 114 reimbursement, 393–410 Radiology, interventional, 226–228 Reproductive system procedures, 170 Radiology-only appointments, diagnosis for, Resident assessment instrument (RAI), 339 26, 29 Resident assessment protocols (RAPs), 339

540 Index

Resource-based relative value system Skin layers, 77 (RBRVS) Skin lesions. See Lesions, skin applying fee for standard charge to, 364 Skin tags removal, 80 elements of formula to compute, 366 Skin traction, 99 as national fee scale for Medicare, 365 Skull base surgery, 183–184 Resources to assign diagnostic and procedure Skull, meninges, and brain, 182–186 codes, 9–11 Sleep-testing codes, 282 Respiratory syncytial virus monoclonal SOAP progress notes, 7 antibodies, 264–265 in problem-oriented medical record, 4 Respiratory system subsection of surgery, Source-oriented health record, 4 110–117 Special dermatological procedures, 286 modifiers for, 110, 112, 113, 115 Special evaluation and management services Retinal detachment, 197, 198 category, 347 Retrograde (ureteropyelography), Special otorhinolaryngologic services, 271 159, 162 Special services, procedures, and reports, 290 Revascularization code series, procedures HCPCS codes for, 294 included in, 134–135 Specimen, blood, 133, 244–245 Revenue production report, 370 Specimen slides, 249–251 Review of systems (ROS) in history Spectacles component of E/M service, 314–315 lenses for, 293 Rhinoplasties, secondary, 112 prescription for, 270 Risk of significant complications, morbidity, Spermatic cord, 170 and/or mortality for medical decision Spinal injections/infusions, 189 making, 317 Spinal punctures and injections, Rotational flap, 84 documentation for, 186 Rotator cuff repair, 106 Spine bone graft codes for, 100–101 S modifiers for, 100 Sample for audit, 426 Spine and spinal cord, 186–189 Schedule of benefits, insurance, 364 Spirometry tests, 279 Screening cytopathology, 254–255 Split-thickness skin graft, 85 Sedation, moderate (conscious), 291 Standard charges for medical services, 364 See cross-reference, use of in CPT code book Standard fee, 382 index for other possible terms, 18 Statistical summary in audit follow-up, 427 Semicolon (;) to designate common portion of Stents indented portions for main entry, 14–16 ductal, 128 Separate procedures in surgery section, 72–73 indwelling, 162 Service distribution report, 398–401 temporary ureteral, 162–163 Service-mix report, 402–403 Stereotaxis, 184–185 Sigmoidoscopy, 145 Stomach, 147–148 Signatures Strabismus surgery, 199 for assignment of benefits form specific Submucous resection inferior turbinate, to Medicare (Medicare signature on partial or complete, any method, 112 file), 9 Subsequent hospital care, 19, 330–331, for services during patient encounter at 339, 348 time of service, 9 Subsequent nursing facility care, 339–340 Signs and symptoms Subterms in CPT code book index, 17, 26 chief complaint reflected in, 27 Surgery, ambulatory. See Ambulatory codes describing, when to use, 28 surgery, diagnosis for Simple repair of wounds, 82 Surgery center, same-day, as setting for Single nerve conduction study, 282 charges, 20 Sinusotomy, 112 Surgery section, 18, 69–218 Skin and components, diagram of, 77 add-on codes in, 73–74 Skin grafts, 84–85 common coding errors for, 428–429 extensive, 184 laparoscopic approach in, 73

541 Index

modifiers for, 88, 105–106, 110, 112–113, as contributing E/M component, 313, 322 115, 143, 145, 147, 154, 160–162, 195 for critical care services, 338 reporting more than one procedure or for hydration services, 283 service in, 73 for injections and infusions, 284 separate procedures in, 72–73 for medical nutrition therapy, 289 subsections of, 70. See also specific for patient transport, 338, 348 subsections for prolonged services, 342–343 Surgical dressings, 91 for psychiatric care provider, 267 Surgical package Tongue and floor of mouth, 146 anesthesia types included in, 39, 70, 98 Tonsillectomy, 147 Medicare, 71 Trabeculectomy ab externo, 196 surgical pathology, 251–252 Trabeculoplasty using laser, 196 surgical procedures included in, 72 Trabeculotomy ab externo, 196 Surgical procedures, multiple, 74, 380–381 Tracer claim, 410 Surgical services, documentation of, 20 Trachea and bronchi, 113–114 Surgical tray for procedures of integumentary Tracheostomy, 113 system, 92 Traction, skeletal and skin, 99 Susceptibility testing, 248 Transaction and Code Sets (TCS), HIPAA, 379 Sutures, removal of, 87 Transcatheter aortic valve implantation cerclage, 177 (TAVI) codes, 124 Swan-Ganz (pulmonary artery) catheters, 39 Transcatheter aortic valve replacement Symbols in CPT code book, 13–14, 302 (TAVR) codes, 124 Sympathectomy, 137 Transluminal dilation of aqueous outflow canal, 196 T Transport, coding time physician spends in TAVI codes. See Transcatheter aortic valve attendance during patient, 338, 348 implantation (TAVI) codes Transurethral cystoscopy with bladder/ TAVR codes. See Transcatheter aortic valve urethra biopsy, 160 replacement (TAVR) codes Transurethral procedures on prostatic tissue, 164 Team conferences, 343 Triangle (▲) in CPT code book to designate Technical component of service, –TC HCPCS revised terminology, 13, 302 modifier for, 233, 292 Trigger point injections, 97 Telephone services by physician, 290, 346 Trigger, release of, 428 Teletherapy for radiation oncology, 228–229 Tubal ligation, 176 Temporary codes of HCPCS (G, H, K, Q, S, Tumor removal and T), 303–304 benign, 80 Temporary transcutaneous pacing, 339 soft tissue and bone, 96 Tendon repair, revision, and/or Tympanostomy, 200 reconstruction, 99 Type of service categorization, 382 Testis, 170 Therapeutic procedures, follow-up care for, 72 U Therapeutic, prophylactic, or diagnostic Ultrasound injections and infusions, 284–285 diagnostic, 226, 234 Therapeutic services intravascular, 276 for cardiovascular subsection of medicine, obstetrical or pregnancy (abdominal), 226 271–279 paranasal sinus, 234 sequencing, 29 Unbundling of code packages, 73, 224, 405, 430 Third-party payer policies, 284, 336 Uniform Hospital Discharge Data Set (UHDDS), Thoracoscopy, diagnostic and surgical, 114 principal diagnosis defined in, 27 Thrombolysis, coronary, 278 Unique physician identification number (UPIN) Thyroid scans, 232 lack of, as noncoding reason for denied Time claim, 409 for anesthesia services, 43–44 NPI as replacing, 379 for cardiovascular monitoring, 272 Unique service identifier, 382 for care plan oversight services, 343 Unlisted procedure codes, 16

542 Index

Upcoding, 424 Vascular injection procedures, 131–132, 137 Upper gastrointestinal endoscopies, 144 Vascular order, 227 Ureter, 161 Venipuncture. See Blood draws Ureteral stent (venipuncture) insertion of, 162–165 Venous catheterizations, 132 removal of, 163 Ventilation-perfusion (V/Q) scans, 232 Urethra, 164 Ventilator management, 339 Urethral pressure profile (UPP), 162 Vertebral column (spine), 100 Urethral stricture or stenosis, 162 Vertebral corpectomy, arthrodesis, 189 Urethroplasty, 164 Vestibular tests, 203 Urethroscopy, 162, 163, 164 Vision services, HCPCS codes for, 293–294 Urgent care visits setting for charges, 21 Vitrectomy, 198 Urinary stones Voiding pressure studies, 162 lithotripsy to destroy, 160 Vulva, perineum, and introitus, 172 nephrolithotomy in kidney to remove, 160 Vulvectomy, 172 surgical removal of, 161 Urinary stress incontinence, 160, 172 W Urinary system subsection of surgery, 158–168 W-plasty, 84 common coding errors for, 429 Waiver, ABN, 374 laparoscopic codes for, 160 modifiers for, 254, 374 miscellaneous guidelines for, 159–160 Waiver, CLIA, 245 modifiers for, 161 Washington Publishing Company Urodynamics subgrouping of urinary system, publications, 379, 409 159, 161–162 Websites Uroflowmetry, 162 AHA, 10 US Government Printing Office, National AHIMA, 10 Codes available from, 302 AMA, 11 Usual and customary (U/C) fee profile, 364–365 CMS, 234, 246, 302, 304, 366, 374, 377, Uterine monitor, home, 179 379–380, 400 Utilization guidelines included in RAIs, 339 FDA, 245 ICD-10, 10 V NCHS, 27 V codes OIG, 433 for circumstances other than disease or Washington Publishing Company, 409 injury, 28 Weed, Lawrence L., POMR developed by, 4 for histories, 29 Wire localization biopsies, 88 for prenatal visits, 30 Work plan, OIG, 433 for preoperative evaluations, 30 Workman’s compensation payers, for reason for encounter, 29 requirements of, 38 for vision services, 294 Wound exploration codes, 83, 96 V-Y plasty, 84 Wound repairs, 82–83, 428 Vaccines/toxoids assignment of codes during approval X process for, 266 X-ray (radiology) reports in health record, 8 immunization administration for, 265, 293 X-rays, 224–225 products used in, 266 included in critical care codes, 339 Vagina, 172 transportation and setup of equipment for, Vaginal birth after cesarean (VBAC) 234 delivery, 178 Xenograft, 85, 86 Vas deferens, 170 Vascular access procedures, 339 Z Vascular family defined for interventional Z-plasty, 84 radiology, 227 Zipped files, unzipping, 366

543