Medicare Correct Coding Guide
Contents
Introduction ...... Introduction–1 Resource Based Relative Value System (RBRVS) Payment Computation ...... Introduction–1 Relative Value Units ...... Introduction–1 PE-RVU Transition ...... Introduction–1 Conversion Factor ...... Introduction–1 Geographical Practice Cost Indices ...... Introduction–1 General Formula for Calculating Payment ...... Introduction–2 Modifiers ...... Introduction–2 Surgical Modifiers ...... Introduction–2 Modifiers Affecting Correct Coding Edits ...... Introduction–2 Other Payment Indicators ...... Introduction–3 Status Indicator ...... Introduction–3 Global Period ...... Introduction–3 Physician Supervision Level ...... Introduction–3 Definitions ...... Introduction–3 Levels of Physician Supervision Diagnostic Tests...... Introduction–3 Correct Coding Initiative (CCI) ...... Introduction–4 The Commercial "Black Box" Edits...... Introduction–4 Manual Organization ...... Introduction–5 How to Use ...... Introduction–5 Step by Step Instructions ...... Introduction–5 Code Pair Additions ...... Summary of Changes–1 Code Pair Deletions ...... Summary of Changes–13 Modifier Revisions ...... Summary of Changes–15 General Correct Coding Policies ...... General–1 A. Introduction ...... General–1 B. Coding Based on Standards of Medical/Surgical Practice ...... General–1 C. Medical/Surgical Package ...... General–2 D. Evaluation and Management Services ...... General–3 E. Standard Preparation/Monitoring Service ...... General–3 F. Anesthesia Service Included in the Surgical Procedure ...... General–4 G. Coding Services Supplemental to a Principal Procedure (Add-on Codes) ...... General–4 H. Modifiers ...... General–4 I. HCPCS/CPT Procedure Code Definition ...... General–5 J. HCPCS/CPT Coding Manual Instruction/Guideline ...... General–5 K. Separate Procedures ...... General–6 L. Family of Codes ...... General–6 M. Most Extensive Procedures ...... General–6 N. Sequential Procedures ...... General–6 O. Laboratory Panels ...... General–6 P. Misuse of Column 2 Code with Column 1 Code ...... General–6 Q. Mutually Exclusive Procedures...... General–7 R. Gender-Specific Procedures (formerly Designation of Sex) ...... General–7 S. Excluded Service ...... General–7 T. Unlisted Services or Procedures ...... General–7 U. Modified, Deleted and Added Code Pairs, Edits Surgery: Integumentary System (CPT Codes 10000–19999) ...... Integumentary–1 Correct Coding Policies ...... Integumentary–1 A. Introduction ...... Integumentary–1 B. Evaluation and Management ...... Integumentary–1 C. Anesthesia...... Integumentary–1 D. Incision and Drainage ...... Integumentary–1 E. Lesion Removal ...... Integumentary–2 F. Repair and Tissue Transfer ...... Integumentary–3 G. Grafts and Flaps ...... Integumentary–3
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Contents
Radiology Services CPT (Codes 70000–79999) ...... Radiology–1 Correct Coding Policies ...... Radiology–1 A. Introduction ...... Radiology–1 B. Non-interventional Diagnostic Imaging ...... Radiology–1 C. Interventional/Invasive Diagnostic Imaging ...... Radiology–1 D. Evaluation and Management ...... Radiology–1 E. Nuclear Medicine ...... Radiology–2 F. General Policy Statements ...... Radiology–2 Code Tables ...... Radiology–3 Pathology/Laboratory Services (CPT Codes 80000–89999) ...... Pathology–1 Correct Coding Policies ...... Pathology–1 A. Introduction ...... Pathology–1 B. Organ or Disease Oriented Panels ...... Pathology–1 C. Evocative/Suppression Testing ...... Pathology–1 D. General Policy Statements ...... Pathology–1 Code Tables ...... Pathology–3 Medicine, Evaluation and Management Services (CPT Codes 90000–99999) ...... Medicine–1 Correct Coding Polices ...... Medicine–1 A. Introduction ...... Medicine–1 B. Therapeutic or Diagnostic Infusions/Injections ...... Medicine–1 C. Psychiatric Services ...... Medicine–1 D. Biofeedback ...... Medicine–1 E. Gastroenterology ...... Medicine–1 F. Ophthalmology ...... Medicine–1 G. Otorhinolaryngologic Services ...... Medicine–2 H. Cardiovascular Services ...... Medicine–2 I. Pulmonary Services ...... Medicine–2 J. Allergy Testing and Immunotherapy ...... Medicine–3 K. Neurology and Neuromuscular Procedures ...... Medicine–3 L. Chemotherapy Administration ...... Medicine–3 M. Osteopathic Manipulative Treatment...... Medicine–4 N. Chiropractic Manipulative Treatment ...... Medicine–4 O. Miscellaneous Services ...... Medicine–4 P. Evaluation and Management ...... Medicine–4 Q. General Policy Statements ...... Medicine–4 Code Tables ...... Medicine–7 Medicine Services ...... Medicine–7 Evaluation and Management Services...... Medicine–125 Category III Codes (CPT Codes 0001T–0099T)...... Category III–1 Code Tables ...... Category III–3 HCPCS Level II (Supplemental Services) (Codes A0000–V9999) ...... HCPCS–1 Correct Coding Policies ...... HCPCS–1 A. Introduction ...... HCPCS–1 B. General Policy Statements ...... HCPCS–1 Code Tables ...... HCPCS–3 Appendix A: Geographic Practice Cost Indices by Medicare Locality ...... Appendix A–1 Appendix B: CPT Modifiers ...... Appendix B–1
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Introduction
Procuring reimbursement for health care services is one of the most complex Other factors that can affect the payment amount for services under the Phy- processes of the health care system. The impact of the billing and reim- sician Fee Schedule are the use of modifiers, the site of service, global sur- bursement system certainly permeates the entire health care system. And gery periods, and payment status. Each of these factors will be explained in since the cost of health care has risen dramatically, the federal government detail under separate headings. has taken the lead in cost containment through a number of legislative enactments affecting the reimbursement system. Relative Value Units The Total Relative Value Unit (RVUt) of a service or procedure is comprised On December 19, 1989, the Omnibus Budget Reconciliation Act of 1989 of three components: (P.L. 101-239) was enacted. Section 6102 of P.L. 101-239 amended Title XVIII of the Social Security Act (the Act) by adding a new section 1848, Pay- Work (RVUw): Physician work RVU reflecting the ment for Physicians’ Services. This section of the Act provided for replacing resources of skill, time, and intensity of the previous reasonable charge mechanism of actual, customary, and pre- effort to furnish the service. vailing charges with a resource based relative value scale (RBRVS) fee Practice (PE-RVU): Practice RVU reflecting the overhead schedule that began in 1992. The intent of this physician payment reform expenses incurred to provide the space, was to establish consistent payment policies as well as payment equity. equipment, supplies, and support per- sonnel cost for providing the services. The Resource Based Relative Value System (RBRVS) was created to accu- rately reflect the skill, time, and resources required for each procedure or Malpractice (RVUm): Malpractice RVU reflecting the cost of office visit. The Centers for Medicare and Medicaid Services (CMS) annually professional liability insurance as a per- makes revisions to the payment policies and adjustments to the relative centage of physician revenue. value units which is released as the Medicare Physician Fee Schedule Data PE-RVU Transition Base (MPFSDB) published in the Federal Register. These changes are effec- The four-year transition from charge-based to resource-based practice tive January 1st of each year. expense relative value units (PE-RVUs) became effective Jan. 1, 1999. Pre- With the implementation of the RBRVS system, it was increasingly impor- vious to this year, PE-RVUs were based on historical physician charge data. tant to assure that uniform payment policies and procedures were followed The resource-based RVU system, based on a methodology developed by by all carriers. This launched the Correct Coding Initiative. The goal of the CMS, takes into consideration the staff, supplies and equipment used to pro- Correct Coding Initiative was to develop correct coding methodologies based vide medical and surgical services in different settings. on the coding conventions in the American Medical Association’s Physi- For 2001, percentages were 25 percent charge-based and 75 percent cians’ Current Procedural Terminology (CPT®) book, in national and local resource-based. For 2002 and subsequent years, PE RVUs will be com- policies and edits, in coding guidelines developed by national societies, in pletely resource-based. analysis of standard medical and surgical practices, and in review of current coding practices. Initiated in January 1996 and updated quarterly as an There are two types of PE RVUs—facility (PE-f ) (hospital, skilled nursing ongoing refinement process, the Correct Coding Initiative developed correct facility or an ambulatory surgery center ) and non-facility (PE-nf) (physician’s coding edits that would ensure uniform payment for the same service ren- office, patient’s home, or any other facility or institution, such as a residen- dered regardless of carrier jurisdictions. As a result improper coding prac- tial care setting that is not a hospital, SNF or ASC). This will also eliminate tices that lead to inappropriate increased payment for services rendered to the site-of-service differential, which resulted in the past in the reduction of Medicare Part B beneficiaries would be controlled. PE-RVUs by 50 percent for designated codes performed outside of the phy- sician’s office. Medicare Correct Coding and Guide is a comprehensive manual which alerts the user to essential information concerning rules, payment restrictions and Conversion Factor claim submission edits that are critical for reporting procedures and services The Conversion Factor (CF) is a nationally uniform dollar conversion factor correctly. Please note that this manual does not include codes that are for the services that convert the relative values into payment amounts. The excluded from or not covered under the physician fee schedule, unless there conversion factor for fiscal year 2004 is $35.1339. are associated correct coding edits. Also be aware that codes with a status indicator of not valid may have relative value units indicated, however Medi- Note: At the time of printing there was legislation pending that may affect care does not recognize these codes and the indicated RVUs are not used for the conversion factor for 2004. If changes are made to the conversion fac- Medicare payment. The introduction of this manual includes the following tor, you will be notified via e-mail of the changes and given instructions as explanatory sections: the RBRVS system, the Correct Coding Policies, and to where to locate the revised information on the Ingenix Web site. step by step instructions to assist in the use of the manual. Geographical Practice Cost Indices Resource Based Relative Value System (RBRVS) For each of the relative value units there is a geographical practice cost index (GPCI) that reflects the relative costs for each of the units for that specific Payment Computation geographic area in comparison to the national average for each of the units. The major factors for computing the payment amount under the RBRVS sys- This factor is set annually by CMS according to the mechanisms defined in tem are: Section 1848(b)(1) of the Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239). ■ Relative Value Units (RVUs) ■ Conversion Factor (CF) See Appendix A for a complete listing of the Geographic Practice Cost Indi- ces. ■ Geographical Practice Cost Indices (GPCIs)
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Introduction expansion of these ideas and concepts is planned for future refinement To reinforce the importance of following correct coding methodologies, the years. final chapter presents an overview of fraud and abuse in the health care sys- tem, including a summary of pertinent sections of the Health Insurance Port- If you have any questions regarding the National Correct Coding Policy, ability and Accountability Act of 1996. please contact the provider relations staff of your Medicare carrier or submit your comments in writing to: Finally, for your convenience, several reference appendices are supplied to CMS Correct Coding Initiative provide you with supplementary information germane to reimbursement AdminaStar Federal issues. P.O. Box 50469 Indianapolis, IN 46250-0469 How to Use Note: The following steps are based on data contained in the 2004 fee The Commercial “Black Box” Edits schedule as posted on CMS’s Web site. At the time of printing there was leg- Beginning October 1, 1998, CMS implemented the use of additional com- islation pending that may affect the conversion factor and GPCIs for 2004. mercial edits in order to improve Medicare’s auditing system for detecting If changes are made to the conversion factor and the GPCI, you will be noti- unbundling in procedure coding. These commercial edits (approximately fied via e-mail of the changes and given instructions as to where to locate 500) are also known as black box edits or commercial off-the shelf (COTS) the revised information on the Ingenix Web site. edits. The new commercial procedure to procedure edits system will be used concurrently with the National Correct Coding Initiative edits (approxi- Step by Step Instructions mately 108,000). There will be no way of determining the source of the The steps to follow for successful use of the Medicare Correct Coding and edits since, the same EOMB will apply for both sets of edits. Payment Manual for Procedures and Services are delineated below. The new commercial edits were developed by a private commercial claims Step 1 auditing vendor and CMS intends to protect the proprietary rights attached Assign the initial code using the CPT manual. Locate the section of this to these edits. No explicit Medicare policies require the disclosure of the manual containing the desired code series. Review the section information specific edits, therefore, publishing the commercial edits will not be an concerning the correct coding policies. option. Ingenix will continue to provide you with the most current version Example: You have assigned the CPT code 11450 using the source docu- of the NCCI edits, but we are prohibited from including the new commercial ment and current CPT manual. Turn to section 10000-19999 in edits. this manual. Review the introductory information. Manual Organization Step 2 Medicare Correct Coding and Payment Manual was developed with the pro- Locate the specific CPT code. Review and verify the code description. vider of services in mind. This manual presents the essential information 11450 Excision of skin and subcutaneous tissue for hidradenitis, needed to submit claims correctly, completely and accurately every time in a axillary; with simple or intermediate repair convenient, efficient format. With this information, you will experience more proficient reimbursement, encounter fewer delays, denials and requests for Step 3 information, and avoid improper coding that may trigger an audit. Listed directly below the code and narrative are the relative value units for The initial chapters contain an overview of the prominent legislative enact- this procedure. The formula for determining the payment amount under the ments affecting the reimbursement system, a summary of the major compo- fee schedule is shown below. nents of the Medicare physician fee schedule for services rendered, and [RVUw X GPCI work] + [PE-RVU X GPCIp]+ [RVUm X GPCIm] X CF = general information concerning the general correct coding policies including Dollar Payment Amount a quick reference section for the coding policy explanations. Refer to Appendix A for component GPCIs, if calculating payment manually. Following the introductory chapters, the manual provides a comprehensive For this example, the clinic which provided the service is located in Ala- summary of the reimbursement factors for each CPT code. Subsequent bama. chapters are arranged by code series arranged in ascending numerical order noted on the individual tabs for quick location of a code or group of codes. Example: Provided at the beginning of each of the code series are the coding policies that apply specifically to that code series. Explicit examples of each of the RELATIVE VALUE UNITS coding policies specific to each section is included in the section introduc- Work Malpractice PE–nf PE–f Total–nf Total–f tion. Immediately following the coding policies and examples are the CPT 2.71 0.31 5.20 2.06 8.22 5.08 codes with full description, complete relative value units, payment indica- tors, and the correct coding edits for the code. Some chapters provide fur- Work 2.71 X GPCIw 0.978 = 2.650 ther subdivision of the codes by body system. ADD A chapter listing the above mentioned information for the HCPCS Level II Practice Expense 5.20 X GPCIp 0.870 = 4.524 codes for nonphysician services and supplies complements the previous ADD CPT coding system information to complete the coding process for proce- dures and services. Malpractice 0.31 X GPCIm 0.779 = 0.241 In order to implement the information presented in the first three sections of Subtotal = 7.415 this manual accurately, a chapter is devoted to completing the CMS-1500 Insert the RVUs for code 11450 into the formula for calculating payment. form with line by line instructions.
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General Correct Coding Policies
A. Introduction Some examples of generic services integral to standard of medical/surgical The Physicians' Current Procedural Terminology (CPT) developed by the services would include: American Medical Association and HCPCS Level II codes developed by the ■ Cleansing, shaving and prepping of skin Centers for Medicare and Medicaid Services (CMS) are listings of descriptive terms and identifying codes for reporting medical services and procedures ■ Draping of patient; positioning of patient performed by physicians. The codes in the CPT Manual are copyrighted by ■ Insertion of intravenous access for medication the AMA, and updated annually by the CPT Editorial Panel based on input ■ from the AMA Advisory Committee which serves as a channel for requests Sedative administration by the physician performing the proce- from various providers and specialty societies. The purpose of both coding dure (see Chapter II, Anesthesia section, for the separate policy) systems and annual updates is to communicate specific services rendered ■ Local, topical or regional anesthetic administered by physician by physicians and other providers, usually for the purpose of claim submis- performing procedure sion to third party (insurance) carriers. A multitude of codes is necessary ■ because of the wide spectrum of services provided by various medical care Surgical approach, including identification of anatomical land- providers. Because many medical services can be rendered by different marks, incision, evaluation of the surgical field, simple debride- methods and combinations of various procedures, multiple codes describ- ment of traumatized tissue, lysis of simple adhesions, isolation of ing similar services are frequently necessary to accurately reflect what ser- neurovascular, muscular (including stimulation for identification), vice a physician performs. While often only one procedure is performed at a bony or other structures limiting access to surgical field patient encounter, multiple procedures are performed at the same session at ■ Surgical cultures other times. In the latter case, the pre-procedure and post-procedure work ■ does not have to be repeated and, therefore, a comprehensive code, describ- Wound irrigation ing the multiple services commonly performed together, can be defined. ■ Insertion and removal of drains, suction devices,dressings, pumps into same site Third party payers have adopted the CPT coding system for use by provid- ers to communicate payable services. It therefore becomes more important ■ Surgical closure to identify the various potential combinations of services to accurately adju- ■ Application, management, and removal of postoperative dress- dicate claims. ings including analgesic devices (peri-incisional TENS unit, insti- There are two types of Correct Coding Initiative edits, column 1/column 2 tution of Patient Controlled Analgesia) correct coding (formerly known as comprehensive/component) edits and ■ Preoperative, intraoperative and postoperative documentation, in- mutually exclusive edits. All edits consist of code pairs that are arranged in cluding photographs, drawings, dictation, transcription as neces- column 1 and column 2 of the tables. All edits are included in one table. sary to document the services provided The column 2 code is not payable with the column 1 code unless the edit permits use of a modifier associated with CCI (Chapter I, Section H). The ■ Surgical supplies, unless excepted by existing CMS policy correct coding edit table contains many edits where the column 2 code is a In the case of individual services, there are numerous specific services that component of the column 1 comprehensive code. However, there are many may typically be involved in order to accomplish a column 1 procedure. edits where there is no comprehensive/component relationship, but the col- Generally, performance of these services represents the standard of practice umn 1 code and column 2 code should not be reported together for other for a more comprehensive procedure and the services are therefore to be reasons. The following policies encompass general issues/coding principles included in that service. that are to be applied in all subsequent chapters. Specific examples are stated to clarify the policy but do not represent the only code or service that Because many of these services are unique to individual CPT coding sec- is included in the policy. tions, the rationale for correct coding will be described in that particular sec- tion. The principle of the policy to include these services into the column 1 B. Coding Based on Standard of Medical/Surgical Practice procedure remains the same as the principle applied to the generic service In order for this system to be effective, it is essential that the coding descrip- list noted above. Specifically, these principles include: tion accurately describe what actually transpired at the patient encounter. Because many physician activities are so integral to a procedure, it is 1. The service represents the standard of care in accomplishing the impractical and unnecessary to list every event common to all procedures of overall procedure. a similar nature as part of the narrative description for a code. Many of 2. The service is necessary to successfully accomplish the column 1 these common activities reflect simply normal principles of medical/surgical procedure; failure to perform the service may compromise the suc- care. These “generic” activities are assumed to be included as acceptable cess of the procedure. medical/surgical practice and, while they could be performed separately, they should not be considered as such when a code descriptor is defined. 3. The service does not represent a separately identifiable procedure Accordingly, all services integral to accomplishing a procedure will be con- unrelated to the column 1 procedure planned. sidered included in that procedure. Specific examples consist of: Many of these generic activities are common to virtually all procedures. On other occasions, some are integral to only a certain group of procedures but Medical: are still essential to accomplish these particular procedures. Accordingly, it 1. Procurement of a rhythm strip in conjunction with an electrocardio- would be inappropriate to separately code these services based on standard gram. The rhythm strip would not be separately reported if it was medical and surgical principles.
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Medicare Correct Coding Guide (CCI Version 10.0)
5. “With” and “without” CPT codes are reported. The “without” proce- priate to report the separate component codes individually nor is it appropri- dure is included in the “with” procedure. ate to report the component code (s) with the comprehensive code.
J. HCPCS/CPT Coding Manual Instruction/Guideline M. More Extensive Procedure Each of the six major sections of the CPT Manual and several of the major When procedures are performed together that are basically the same, or per- subsections include guidelines that are unique to that section. These direc- formed on the same site but are qualified by an increased level of complex- tions are not all inclusive or limited to definitions of terms, modifiers, ity, the less extensive procedure is included in the more extensive procedure. unlisted procedures or services, special or written reports, details about In the following situations, the procedure viewed as the most complex reporting separate, multiple or starred procedures and qualifying circum- would be reported: stances. These instructions appear in various places and are found at the 1. “Simple” and “complex” CPT codes reported; the simple procedure beginning of each major section, at the beginning of subsections, and before is included in the complex procedure on the same site. or after a series of codes or individual codes. They define items or provide explanations that are necessary to appropriately interpret and report the 2. “Limited” and “complete” CPT codes reported; the limited procedure procedures or services and to define terms that apply to a particular section. is included in the complete procedure on the same site. Notations are made in parentheses when CPT codes are deleted or cross-ref- erenced to another similar code so that the provider has better guidance in 3. “Simple” and “complicated” CPT codes reported; the simple proce- the appropriate assignment of a CPT code for the service. Providers should dure is included in the complicated procedure on the same site. not report CPT codes that are contrary to CPT instructions. 4. “Superficial” and “deep” CPT codes reported; the superficial proce- K. Separate Procedure dure is included in the deep procedure on the same site. The narrative for many CPT codes includes a parenthetical statement that the procedure represents a “separate procedure.” The inclusion of this state- 5. “Intermediate” and “comprehensive” CPT codes reported; the inter- ment indicates that the procedure, can be performed separately but should mediate procedure is included in the comprehensive procedure on not be reported when a related service is performed. The “separate proce- the same site. dure” designation is used with codes in the surgery (CPT codes 10000- 69999), radiology (CPT codes 70000-79999) and medicine (CPT codes 6. “Incomplete” and “complete” CPT codes reported; the incomplete 90000-99199) sections. When a related procedure is performed, a code procedure is included in the complete procedure on the same site. with the designation of “separate procedure” is not to be reported with the 7. “External” and “internal” CPT codes reported; the external proce- primary procedure. dure is included in the internal procedure on the same site. Example: If the code identified as a “separate procedure” is reported with a related procedure code, such as when a sesamoidectomy, thumb or finger N. Sequential Procedure (CPT code 26185) is reported with an excision or curettage of a bone cyst or An initial approach to a procedure may be followed at the same encounter benign tumor of the proximal, middle, or distal phalanx of the finger with by a second, usually more invasive approach. There may be separate CPT autograft (CPT code 26215), then the sesamoidectomy (separate procedure) codes describing each service. The second procedure is usually performed should not be reported. By definition the “separate procedure” is commonly because the initial approach was unsuccessful in accomplishing the medi- performed as integral and part of a larger service and usually represents a cally necessary service; these procedures are considered “sequential proce- procedure that the physician performs through the same incision or orifice, dures”. Only the CPT code for one of the services, generally the more at the same site, or using the same approach. invasive service, should be reported. An example of this situation is a failed laparoscopic cholecystectomy, followed by an open cholecystectomy at the In the case where a “separate procedure” is performed on the same day but same session. Only the code for the successful procedure, in this case the at a different session, or at an anatomically unrelated site, the “separate pro- open cholecystectomy, should be reported. cedure” code may be reported in addition to a code for a procedure that would be related if performed at the same patient encounter or at an ana- O. Laboratory Panel tomically related site. Modifier -59 should be included indicating that this When all component tests of a specific organ or disease oriented laboratory service was, in fact, a separate service. panel (e.g. CPT codes 80074,80061) are reported separately, they should be reported in the comprehensive panel code that includes the multiple com- In other sections of the CPT Manual, the word “separate” is used in a phrase ponent tests. The individual tests that make up a panel are not to be sepa- identified as “separate or multiple procedures” with a different meaning. rately reported. L. Family of Codes Example: CPT code 80061(Lipid panel) includes the following tests: In a family of codes, there are two or more component codes that are not reported separately because they are included in a more comprehensive CPT code 82465: Cholesterol, serum or whole blood, total code as members of the code family. Comprehensive codes include certain CPT code 83718: Lipoprotein, direct measurement; high density services that are separately identifiable by other component codes. The cholesterol (HDL cholesterol) component codes as members of the comprehensive code family represent CPT code 84478: Triglycerides parts of the procedure that should not be listed separately when the com- plete procedure is done. However, the component codes are considered When all 3 tests are performed, the panel test (CPT code 80061) should be individually if performed independently of the complete procedure and if not reported in place of the individual tests. all the services listed in the comprehensive codes were rendered to make up P. Misuse of Column 2 Code with Column 1 Code the total service. If all multiple services described by a comprehensive code In general, CPT codes have been written as precisely as possible to not only are performed, the comprehensive code should be reported. It is not appro- describe a specific service or procedure but to also avoid describing similar services or procedures which are already defined by other CPT codes. When
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Code Pair Additions
Column 1 Column 2 Column 1 Column 2 Column 1 Column 2 Column 1 Column 2 0009T ...... 76940 32654 ...... 00529 33414...... 33310, 33315 33619...... 33310, 33315 0046T ...... 00400 32655 ...... 00529 33415...... 33310, 33315 33641...... 33310, 33315 0047T ...... 00400 32656 ...... 00529 33416...... 33310, 33315 33645...... 33310, 33315 0057T ...... 00520, 00740, 43235 32657...... 00529 33417...... 33310, 33315 33647 ...... 33310, 33315 0061T ...... 00400, 76000, 76001, 32658 ...... 00529 33420...... 33310, 33315 33660...... 33310, 33315 76003 32659 ...... 00529 33422...... 33310, 33315 33665...... 33310, 33315 10060...... 64449 32660 ...... 00529 33425...... 33310, 33315 33670 ...... 33310, 33315 10061...... 64449 32661 ...... 00529 33426...... 33310, 33315 33681...... 33310, 33315 11000 ...... 64449 32662 ...... 00529 33427...... 33310, 33315 33684...... 33310, 33315 11040...... 64449 32663 ...... 00529 33430...... 33310, 33315 33688...... 33310, 33315 11041...... 64449 32664 ...... 00529 33460...... 33310, 33315 33690...... 33310, 33315 11042...... 64449 32665 ...... 00529 33463...... 33310, 33315 33692...... 33310, 33315 11043...... 64449 33120 ...... 33310, 33315 33464...... 33310, 33315 33694...... 33310, 33315 11044...... 64449 33130 ...... 33310, 33315 33465...... 33310, 33315 33697 ...... 33310, 33315 20982...... 36000, 36410, 37202, 33206 ...... 36555, 36556, 36568, 33468...... 33310, 33315 33702 ...... 33310, 33315 62318, 62319, 64415, 36569 33470...... 33310, 33315 33710 ...... 33310, 33315 64416, 64417, 64450, 33207...... 36555, 36556, 36568, 33471...... 33310, 33315 33720 ...... 33310, 33315 64470, 64475, 69990, 36569 33472...... 33310, 33315 33722 ...... 33310, 33315 76360, 76362, 90780 33208 ...... 36555, 36556, 36568, 33474 ...... 33310, 33315 33730 ...... 33310, 33315 21116 ...... J1644 36569 33475...... 33310, 33315 33732 ...... 33310, 33315 21685...... 36000, 36410, 37202, 33210 ...... 36555, 36556, 36568, 33476...... 33310, 33315 33735 ...... 33310, 33315 62318, 62319, 64415, 36569 64416, 64417, 64450, 33478...... 33310, 33315 33736 ...... 33310, 33315 33211 ...... 36555, 36556, 36568, 33496...... 33310, 33315 33737 ...... 33310, 33315 64470, 64475, 69990, 36569 33500...... 33310, 33315 33750 ...... 33310, 33315 90780 33214 ...... 36555, 36556, 36568, 33501...... 33310, 33315 33755 ...... 33310, 33315 22325 ...... 22521 36569 33502...... 33310, 33315 33762 ...... 33310, 33315 22327 ...... 22520 33215 ...... 36555, 36556, 36568, 22520 ...... 20220, 20225, 20250, 36569 33503...... 33310, 33315 33764 ...... 33310, 33315 22305, 22310, 22315 33216 ...... 36555, 36556, 36568, 33504...... 33310, 33315 33766 ...... 33310, 33315 22521 ...... 20220, 20225, 20251, 36569 33505...... 33310, 33315 33767 ...... 33310, 33315 22305, 22310, 22315 33217 ...... 36555, 36556, 36568, 33506...... 33310, 33315 33770...... 33310, 33315 22532 ...... 36000, 36410, 37202, 36569 33508...... 33310, 33315 33771 ...... 33310, 33315 62310, 62318, 62319, 33218 ...... 36555, 36556, 36568, 33510...... 33310 33774...... 33310, 33315 64415, 64416, 64417, 36569 33511...... 33310 33775 ...... 33310, 33315 64450, 64470, 64475, 33220 ...... 36555, 36556, 36568, 33512...... 33310, 33315 33776...... 33310, 33315 64479, 69990, 90780 36569 33513...... 33310 33777...... 33310, 33315 22533 ...... 36000, 36410, 37202, 33226 ...... 75860 33514...... 33310 33778...... 33310, 33315 62311, 62318, 62319, 33234 ...... 36555, 36556, 36568, 64415, 64416, 64417, 33516...... 33310 33779...... 33310, 33315 36569 64450, 64470, 64475, 33517...... 33310, 33315 33780 ...... 33310, 33315 64483, 69990, 90780 33235 ...... 36555, 36556, 36568, 33518...... 33310, 33315 33781 ...... 33310, 33315 36569 24220 ...... J1644 33519...... 33310, 33315 33786 ...... 33310, 33315 33249 ...... 36555, 36556, 36568, 25246...... J1644 33521...... 33310, 33315 33788 ...... 33310, 33315 36569 27093 ...... J1644 33522...... 33310, 33315 33800...... 33310, 33315 33300 ...... 33310, 33315 27095 ...... J1644 33523...... 33310, 33315 33802...... 33310, 33315 33305 ...... 33310, 33315 27096...... J1644 33530...... 33310, 33315 33803...... 33310, 33315 33320 ...... 33310, 33315 27370 ...... J1644 33533...... 33310, 33315 33813...... 33310, 33315 33321 ...... 33310, 33315 27648 ...... J1644 33534...... 33310, 33315 33814...... 33310, 33315 33322 ...... 33310, 33315 31623...... 00529 33535...... 33310, 33315 33820...... 33310, 33315 33330 ...... 33310, 33315 31624...... 00529 33536...... 33310, 33315 33822...... 33310, 33315 33332 ...... 33310, 33315 31641 ...... 31640 33542...... 33310, 33315 33824...... 33310, 33315 33335 ...... 33310, 33315 31643 ...... 00529 33545...... 33310, 33315 33840...... 33310, 33315 33400 ...... 33310, 33315 32601...... 00529 33572...... 33310, 33315 33845...... 33310, 33315 33401 ...... 33310, 33315 32602...... 00529 33600...... 33310, 33315 33851...... 33310, 33315 33403 ...... 33310, 33315 32603...... 00529 33602...... 33310, 33315 33852...... 33310, 33315 33404 ...... 33310, 33315 32604...... 00529 33606...... 33310, 33315 33853...... 33310, 33315 33405 ...... 33310, 33315 32605...... 00529 33608...... 33310, 33315 33860...... 33310, 33315 33406 ...... 33310, 33315 32606...... 00529 33610...... 33310, 33315 33861...... 33310, 33315 33410 ...... 33310, 33315 32650...... 00529 33611...... 33310, 33315 33863...... 33310, 33315 33411 ...... 33310, 33315 32651 ...... 00529 33612...... 33310, 33315 33870 ...... 33310, 33315 33412 ...... 33310, 33315 32652 ...... 00529 33615...... 33310, 33315 33875 ...... 33310, 33315 33413 ...... 33310, 33315 32653 ...... 00529 33617...... 33310, 33315 33877 ...... 33310, 33315
©2004 Ingenix, Inc. Jan. 04 Summary of Changes–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Code Pair Additions
Column 1 Column 2 Column 1 Column 2 Column 1 Column 2 Column 1 Column 2 47605 ...... 43752 49180 ...... 43752 57425 ...... 36000, 36410, 37202, 61735...... 61863 47610 ...... 43752 49200 ...... 43752 62318, 62319, 64415, 61750...... 61863 47612 ...... 43752 49201 ...... 43752 64416, 64417, 64450, 61751...... 61863 47620 ...... 43752 49215 ...... 43752 64470, 64475, 69990, 61760 ...... 61863 47630 ...... 43752 49220 ...... 43752 90780 61770 ...... 61863 47700...... 43752 49250 ...... 43752 58340...... J1644 61791 ...... 61863 47701...... 43752 49255 ...... 43752 59070...... 36000, 36410, 37202, 61793 ...... 61863 62318, 62319, 64415, 47711 ...... 43752 49320 ...... 43752 61795 ...... 70557, 70558, 70559 64416, 64417, 64450, 47712 ...... 43752 49321 ...... 43752 64470, 64475, 69990, 61850...... 95961 47715 ...... 43752 49322 ...... 43752 76942, 76986, 90780 61860...... 61863, 95961 47716 ...... 43752 49323 ...... 43752 59072...... 36000, 36410, 37202, 61863...... 36000, 36410, 37202, 47720 ...... 43752 49400 ...... 43752 62318, 62319, 64415, 61790, 61795, 61850, 47721 ...... 43752 49419 ...... 43752, J1642 64416, 64417, 64450, 61880, 62318, 62319, 47740...... 43752 49420 ...... 43752 64470, 64475, 69990, 64415, 64416, 64417, 47741...... 43752 49421 ...... 43752 76942, 76986, 90780 64450, 64470, 64475, 64550, 64553, 64555, 47760 ...... 43752 49422 ...... 43752 59074 ...... 36000, 36410, 37202, 62318, 62319, 64415, 64560, 64565, 64573, 47765...... 43752 49423 ...... 43752 64575, 64577, 64580, 47780 ...... 43752 49424 ...... 43752 64416, 64417, 64450, 64470, 64475, 69990, 69990, 90780, 95925, 47785...... 43752 49425 ...... 43752 76942, 76986, 90780 95926, 95927, 95961, 47801 ...... 43752 49426 ...... 43752 G0173, G0242, G0243, 59076...... 36000, 36410, 37202, G0251 47802 ...... 43752 49427 ...... 43752 62318, 62319, 64415, 47900 ...... 43752 49428 ...... 43752 64416, 64417, 64450, 61867...... 36000, 36410, 37202, 48000...... 43752 49429 ...... 43752 64470, 64475, 69990, 61720, 61735, 61750, 48001...... 43752 49560 ...... 43752 76942, 76986, 90780 61751, 61760, 61770, 61790, 61791, 61793, 48005...... 43752 49561 ...... 43752 59400...... 01958 61795, 61850, 61860, 48020...... 43752 49565 ...... 43752 59409...... 01958 61870, 61875, 61880, 48100...... 43752 49566 ...... 43752 59410...... 01958 62318, 62319, 64415, 48102...... 43752 49568 ...... 43752 59412...... 01958 64416, 64417, 64450, 48120...... 43752 49570...... 43752 59510...... 01958 64470, 64475, 64550, 48140...... 43752 49572...... 43752 59514...... 01958 64553, 64555, 64560, 48145...... 43752 49580 ...... 43752 59610...... 01958 64565, 64573, 64575, 48146...... 43752 49582 ...... 43752 59612...... 01958 64577, 64580, 69990, 48148...... 43752 49585 ...... 43752 59614...... 01958 90780, 95925, 95926, 48150...... 43752 49587...... 43752 59618...... 01958 95937, 95961, G0173, G0242, G0243, G0251 48152...... 43752 49590 ...... 43752 59620...... 01958 61870 ...... 61863, 95961 48153...... 43752 49600 ...... 43752 59622...... 01958 61875 ...... 61863, 95961 48154...... 43752 49605 ...... 43752 59897...... 36000, 36410, 37202, 48155...... 43752 49606 ...... 43752 62318, 62319, 64415, 62350...... 95991 48180...... 43752 49610 ...... 43752 64416, 64417, 64450, 62351...... 95991 48400...... 43752 49611 ...... 43752 64470, 64475, 69990, 62360...... 95991 48500...... 43752 49905 ...... 43752 76942, 76986, 90780 62361...... 95991 48510...... 43752 49906 ...... 43752 61215...... 95991 62362...... 95991 48511...... 43752 50562...... 50557 61537...... 36000, 36410, 37202, 63001...... 20926 48520...... 43752 50684 ...... J1644 62318, 62319, 64415, 63003...... 20926 64416, 64417, 64450, 48540...... 43752 50690...... J1644 63011...... 20926 64470, 64475, 90780, 48545...... 43752 51605 ...... J1644 63015...... 20926 95829, 95920 63016...... 20926 48547 ...... 43752 52325 ...... 52005 61538...... 95829, 95920 48550...... 43752 52327 ...... 52005 63045...... 20926 61539...... 95829, 95920 63046...... 20926 48554...... 43752 52330 ...... 52005 61540...... 36000, 36410, 37202, 48556...... 43752 52334 ...... 52005 63101...... 36000, 36410, 37202, 62318, 62319, 64415, 62310, 62318, 62319, 49000...... 43752 52347...... 52010 64416, 64417, 64450, 64415, 64416, 64417, 49002...... 43752 52355 ...... 52354 64470, 64475, 90780, 64450, 64470, 64475, 49010...... 43752 53500 ...... 00910, 36000, 36410, 95829, 95920 90780 49020...... 43752 37202, 51701, 51702, 61566...... 36000, 36410, 37202, 63102...... 36000, 36410, 37202, 49021...... 43752 51703, 52000, 53660, 62318, 62319, 64415, 62311, 62318, 62319, 49040...... 43752 53661, 53665, 62318, 64416, 64417, 64450, 64415, 64416, 64417, 49041...... 43752 62319, 64415, 64416, 64470, 64475, 90780 64450, 64470, 64475, 64417, 64450, 64470, 49060...... 43752 61567...... 36000, 36410, 37202, 90780 64475, 69990, 90780 62318, 62319, 64415, 49061...... 43752 63170 ...... 20926 55873...... 76940 64416, 64417, 64450, 63172...... 20926 49062...... 43752 64470, 64475, 90780, 63173...... 20926 49080...... 43752 95829, 95920 63180...... 20926 49081...... 43752 61720...... 61863 49085...... 43752 63182...... 20926
©2004 Ingenix, Inc. Jan. 04 Summary of Changes–5 CPT only ©2003 American Medical Association. All Rights Reserved.
´Code Pair Deletions
Column 1 Column 2 Column 1 Column 2 Column 1 Column 2 Column 1 Column 2 0018T ...... 90871 46320 ...... 46080 90829...... 96155 99214...... 96155 0019T ...... 0020T, 76880, 76977, 46940...... 46080 90845...... 96155 99215...... 96155 76986, 76999 46942 ...... 46080 90846...... 90871, 96155 99217...... 90918, 90919, 90920, 0027T ...... 64470, 64479 58150 ...... 57280 90847...... 90871, 96155 90921, 96155 27093 ...... 62318, 64470, 64475 62263 ...... 62281, 62310, 62318, 90849...... 90871, 96155 99218...... 90918, 90919, 90920, 27096...... 62318, 64470, 64475 64470, 64475, 64479 90853...... 90871, 96155 90921, 96155 31640...... 31641 62264 ...... 62281, 62310, 62318, 90857...... 90871, 96155 99219...... 90918, 90919, 90920, 33510 ...... 93971 64470, 64475, 64479 90862 ...... 96155 90921, 96155 33511 ...... 93971 62281 ...... 62319, 64475 90865...... 96155 99220...... 90918, 90919, 90920, 33512 ...... 93971 62282 ...... 62318, 64470 90870...... 96155 90921, 96155 33513 ...... 93971 62290 ...... 62311, 64470, 64475, 90871...... 00104, 90801, 90802, 99221...... 96155 33514 ...... 93971 64483 90804, 90805, 90806, 99222...... 96155 33516 ...... 93971 62310 ...... 62319 90807, 90808, 90809, 99223...... 96155 33517 ...... 93971 62311 ...... 62318 90810, 90811, 90812, 99231...... 96155 33518 ...... 93971 62318 ...... 01996 90813, 90814, 90815, 99232...... 96155 33519 ...... 93971 62319 ...... 01996 90816, 90817, 90818, 99233...... 96155 90819, 90821, 90822, 33521 ...... 93971 75952 ...... 75966 99234...... 96155 75953 ...... 75966 90823, 90824, 90826, 99235...... 96155 33522 ...... 93971 90827, 90828, 90829, 75954 ...... 75966 99236...... 96155 33523 ...... 93971 90865, 90870, 90880, 99238...... 96155 34800...... 75966 76856 ...... 93975 96150, 96151, 96152, 34802...... 75966 77427...... 96155 96153, 96154, 96155, 99239...... 96155 34804...... 75966 77431...... 96155 97802, 97803, 97804, 99241...... 96155 34825...... 75966 77432...... 96155 G0270, G0271 99242...... 96155 34900...... 75966 77470 ...... 96155 90880 ...... 96155 99243...... 96155 35501...... 93971 90645 ...... 90748 90918...... 97802, 97803, 97804, 99244...... 96155 35506...... 93971 90646...... 90748 G0270, G0271 99245...... 96155 35507 ...... 93971 90647 ...... 90748 90919...... 90918, 97802, 97803, 99251...... 96155 35508...... 93971 90648...... 90748 97804, G0270, G0271 99252...... 96155 35509...... 93971 90720 ...... 90748 90920...... 90918, 90919, 97802, 99253...... 96155 97803, 97804, G0270, 35511 ...... 93971 90721 ...... 90748 99254...... 96155 G0271 35515 ...... 93971 90723 ...... 90636, 90700, 90701, 99255...... 96155 90702, 90703, 90712, 90921...... 90918, 90919, 90920, 99261...... 96155 35516 ...... 93971 97802, 97803, 97804, 35518 ...... 93971 90713, 90718, 90719, 99262...... 96155 90720, 90721, 90748, G0181, G0270, G0271 35521 ...... 93971 99263...... 96155 90782 90922...... 90918, 90919, 90920, 35526 ...... 93971 99271...... 96155 90748...... 90636, 90782 90921 35531 ...... 93971 99272...... 96155 90801 ...... 96155 90923...... 90918, 90919, 90920, 35533 ...... 93971 99273...... 96155 90802 ...... 96155 90921 35536...... 93971 99274 ...... 96155 90804...... 96155 90924...... 90918, 90919, 90920, 35541 ...... 93971 90921 99275...... 96155 90805 ...... 96155 35546...... 93971 90925...... 90918, 90919, 90920, 99281...... 96155 90806...... 96155 35548...... 93971 90921 99282...... 96155 90807 ...... 96155 35549 ...... 93971 92002...... 96155 99283...... 96155 90808...... 96155 35551 ...... 93971 92004...... 96155 99284...... 96155 90809...... 96155 35556...... 93971 92012...... 96155 99285...... 96155 90810 ...... 96155 35558...... 93971 92014...... 96155 99291...... 96155 90811 ...... 96155 35560...... 93971 96150...... 96155 99292...... 96155 90812 ...... 96155 35563...... 93971 96153...... 96155 99293...... 90918, 90919, 90920, 90813 ...... 96155 35565...... 93971 96155...... 96151, 96152, 96154 90921, 96155 90814 ...... 96155 35566...... 93971 97001...... 96155 99294...... 90918, 90919, 90920, 90815 ...... 96155 90921, 96155 35571 ...... 93971 97002...... 96155 90816 ...... 96155 99295...... 90918, 90919, 90920, 35582...... 93971 97003...... 96155 90817 ...... 96155 90921, 96155 35583...... 93971 97004...... 96155 90818 ...... 96155 99296...... 90918, 90919, 90920, 35585...... 93971 99201...... 96155 90819 ...... 96155 90921, 96155 35587 ...... 93971 99202...... 96155 90821 ...... 96155 99298...... 90918, 90919, 90920, 43247 ...... 43450, 43453 99203...... 96155 90822 ...... 96155 90921, 96155 43450...... 43200 99204...... 96155 90823 ...... 96155 99299...... 90918, 90919, 90920, 45905...... 46080 99205...... 96155 90824 ...... 96155 90921, 96155 46030...... 46080 99211...... 96155 90826 ...... 96155 99301...... 96155 46050...... 46080 99212...... 96155 90827 ...... 96155 99302...... 96155 46221...... 46080 99213...... 96155 90828...... 96155 99303...... 96155
©2004 Ingenix, Inc. Jan. 04 Summary of Changes–13 CPT only ©2003 American Medical Association. All Rights Reserved.
Modifier Revisions
Column 1 Column 2 MODIFIER Column 1 Column 2 MODIFIER Column 1 Column 2 MODIFIER Column 1 Column 2 MODIFIER 10.0 9.3 10.0 9.3 10.0 9.3 10.0 9.3 0008T 00740 0 1 11470 01995 0 1 12015 01995 0 1 15576 01995 0 1 10040 01995 0 1 11471 01995 0 1 12016 01995 0 1 15600 01995 0 1 10060 01995 0 1 11600 01995 0 1 12017 01995 0 1 15610 01995 0 1 10061 01995 0 1 11601 01995 0 1 12018 01995 0 1 15620 01995 0 1 10080 01995 0 1 11602 01995 0 1 12020 01995 0 1 15630 01995 0 1 10081 01995 0 1 11603 01995 0 1 12021 01995 0 1 15650 01995 0 1 10120 01995 0 1 11604 01995 0 1 12031 01995 0 1 15732 01995 0 1 10121 01995 0 1 11606 01995 0 1 12032 01995 0 1 15734 01995 0 1 10140 01995 0 1 11620 01995 0 1 12034 01995 0 1 15736 01995 0 1 10160 01995 0 1 11621 01995 0 1 12035 01995 0 1 15738 01995 0 1 10180 01995 0 1 11622 01995 0 1 12036 01995 0 1 15740 01995 0 1 11000 01995 0 1 11623 01995 0 1 12037 01995 0 1 15750 01995 0 1 11010 01995 0 1 11624 01995 0 1 12041 01995 0 1 15756 01995 0 1 11011 01995 0 1 11626 01995 0 1 12042 01995 0 1 15757 01995 0 1 11012 01995 0 1 11640 01995 0 1 12044 01995 0 1 15758 01995 0 1 11040 01995 0 1 11641 01995 0 1 12045 01995 0 1 15760 01995 0 1 11041 01995 0 1 11642 01995 0 1 12046 01995 0 1 15770 01995 0 1 11042 01995 0 1 11643 01995 0 1 12047 01995 0 1 15775 01995 0 1 11043 01995 0 1 11644 01995 0 1 12051 01995 0 1 15776 01995 0 1 11044 01995 0 1 11646 01995 0 1 12052 01995 0 1 15780 01995 0 1 11055 01995 0 1 11719 01995 0 1 12053 01995 0 1 15781 01995 0 1 11056 01995 0 1 11720 01995 0 1 12054 01995 0 1 15782 01995 0 1 11057 01995 0 1 11721 01995 0 1 12055 01995 0 1 15783 01995 0 1 11100 01995 0 1 11730 01995 0 1 12056 01995 0 1 15786 01995 0 1 11200 01995 0 1 11740 01995 0 1 12057 01995 0 1 15788 01995 0 1 11300 01995 0 1 11750 01995 0 1 13100 01995 0 1 15789 01995 0 1 11301 01995 0 1 11752 01995 0 1 13101 01995 0 1 15792 01995 0 1 11302 01995 0 1 11755 01995 0 1 13120 01995 0 1 15793 01995 0 1 11303 01995 0 1 11760 01995 0 1 13121 01995 0 1 15810 01995 0 1 11305 01995 0 1 11762 01995 0 1 13131 01995 0 1 15811 01995 0 1 11306 01995 0 1 11765 01995 0 1 13132 01995 0 1 15819 01995 0 1 11307 01995 0 1 11770 01995 0 1 13150 01995 0 1 15820 01995 0 1 11308 01995 0 1 11771 01995 0 1 13151 01995 0 1 15821 01995 0 1 11310 01995 0 1 11772 01995 0 1 13152 01995 0 1 15822 01995 0 1 11311 01995 0 1 11900 01995 0 1 13160 01995 0 1 15823 01995 0 1 11312 01995 0 1 11901 01995 0 1 14000 01995 0 1 15824 01995 0 1 11313 01995 0 1 11920 01995 0 1 14001 01995 0 1 15825 01995 0 1 11400 01995 0 1 11921 01995 0 1 14020 01995 0 1 15826 01995 0 1 11401 01995 0 1 11950 01995 0 1 14021 01995 0 1 15828 01995 0 1 11402 01995 0 1 11951 01995 0 1 14040 01995 0 1 15829 01995 0 1 11403 01995 0 1 11952 01995 0 1 14041 01995 0 1 15831 01995 0 1 11404 01995 0 1 11954 01995 0 1 14060 01995 0 1 15832 01995 0 1 11406 01995 0 1 11960 01995 0 1 14061 01995 0 1 15833 01995 0 1 11420 01995 0 1 11970 01995 0 1 14300 01995 0 1 15834 01995 0 1 11421 01995 0 1 11971 01995 0 1 14350 01995 0 1 15835 01995 0 1 11422 01995 0 1 11976 01995 0 1 15000 01995 0 1 15836 01995 0 1 11423 01995 0 1 11980 01995 0 1 15050 01995 0 1 15837 01995 0 1 11424 01995 0 1 11981 01995 0 1 15100 01995 0 1 15838 01995 0 1 11426 01995 0 1 11982 01995 0 1 15120 01995 0 1 15839 01995 0 1 11440 01995 0 1 11983 01995 0 1 15200 01995 0 1 15840 01995 0 1 11441 01995 0 1 12001 01995 0 1 15220 01995 0 1 15841 01995 0 1 11442 01995 0 1 12002 01995 0 1 15240 01995 0 1 15842 01995 0 1 11443 01995 0 1 12004 01995 0 1 15260 01995 0 1 15845 01995 0 1 11444 01995 0 1 12005 01995 0 1 15342 01995 0 1 15851 01995 0 1 11446 01995 0 1 12006 01995 0 1 15350 01995 0 1 15852 01995 0 1 11450 01995 0 1 12007 01995 0 1 15400 01995 0 1 15860 01995 0 1 11451 01995 0 1 12011 01995 0 1 15570 01995 0 1 15876 01995 0 1 11462 01995 0 1 12013 01995 0 1 15572 01995 0 1 15877 01995 0 1 11463 01995 0 1 12014 01995 0 1 15574 01995 0 1 15878 01995 0 1
©2004 Ingenix, Inc. Jan. 04 Summary of Changes–15 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI—Version 10.0)
Column 1 Column 2 MODIFIER Column 1 Column 2 MODIFIER Column 1 Column 2 MODIFIER Column 1 Column 2 MODIFIER 9.3 9.2 9.3 9.2 9.3 9.2 9.3 9.2 28092 01995 0 1 28298 01995 0 1 28645 01995 0 1 29883 01995 0 1 28100 01995 0 1 28299 01995 0 1 28660 01995 0 1 29884 01995 0 1 28102 01995 0 1 28300 01995 0 1 28665 01995 0 1 29885 01995 0 1 28103 01995 0 1 28302 01995 0 1 28666 01995 0 1 29886 01995 0 1 28104 01995 0 1 28304 01995 0 1 28675 01995 0 1 29887 01995 0 1 28106 01995 0 1 28305 01995 0 1 28705 01995 0 1 29888 01995 0 1 28107 01995 0 1 28306 01995 0 1 28715 01995 0 1 29889 01995 0 1 28108 01995 0 1 28307 01995 0 1 28725 01995 0 1 29891 01995 0 1 28110 01995 0 1 28308 01995 0 1 28730 01995 0 1 29892 01995 0 1 28111 01995 0 1 28309 01995 0 1 28735 01995 0 1 29893 01995 0 1 28112 01995 0 1 28310 01995 0 1 28737 01995 0 1 29894 01995 0 1 28113 01995 0 1 28312 01995 0 1 28740 01995 0 1 29895 01995 0 1 28114 01995 0 1 28313 01995 0 1 28750 01995 0 1 29897 01995 0 1 28116 01995 0 1 28315 01995 0 1 28755 01995 0 1 29898 01995 0 1 28118 01995 0 1 28320 01995 0 1 28760 01995 0 1 29900 01995 0 1 28119 01995 0 1 28322 01995 0 1 28800 01995 0 1 29901 01995 0 1 28120 01995 0 1 28340 01995 0 1 28805 01995 0 1 29902 01995 0 1 28122 01995 0 1 28341 01995 0 1 28810 01995 0 1 31623 00528 0 1 28124 01995 0 1 28344 01995 0 1 28820 01995 0 1 31624 00528 0 1 28126 01995 0 1 28345 01995 0 1 28825 01995 0 1 31643 00528 0 1 28130 01995 0 1 28360 01995 0 1 29805 01995 0 1 32997 00520 0 1 28140 01995 0 1 28400 01995 0 1 29806 01995 0 1 32997 00524 0 1 28150 01995 0 1 28405 01995 0 1 29807 01995 0 1 35207 69990 1 0 28153 01995 0 1 28406 01995 0 1 29819 01995 0 1 36100 69990 1 0 28160 01995 0 1 28415 01995 0 1 29820 01995 0 1 36120 69990 1 0 28171 01995 0 1 28420 01995 0 1 29821 01995 0 1 36140 69990 1 0 28173 01995 0 1 28430 01995 0 1 29822 01995 0 1 36215 69990 1 0 28175 01995 0 1 28435 01995 0 1 29823 01995 0 1 36216 69990 1 0 28190 01995 0 1 28436 01995 0 1 29824 01995 0 1 36217 69990 1 0 28192 01995 0 1 28445 01995 0 1 29825 01995 0 1 52320 52005 0 1 28193 01995 0 1 28450 01995 0 1 29826 01995 0 1 52332 52005 0 1 28200 01995 0 1 28455 01995 0 1 29830 01995 0 1 52341 52005 0 1 28202 01995 0 1 28456 01995 0 1 29834 01995 0 1 52342 52005 0 1 28208 01995 0 1 28465 01995 0 1 29835 01995 0 1 52343 52005 0 1 28210 01995 0 1 28470 01995 0 1 29836 01995 0 1 52344 52005 0 1 28220 01995 0 1 28475 01995 0 1 29837 01995 0 1 52345 52005 0 1 28222 01995 0 1 28476 01995 0 1 29838 01995 0 1 52346 52005 0 1 28225 01995 0 1 28485 01995 0 1 29840 01995 0 1 52351 52005 0 1 28226 01995 0 1 28490 01995 0 1 29843 01995 0 1 52352 52005 0 1 28230 01995 0 1 28495 01995 0 1 29844 01995 0 1 52353 52005 0 1 28232 01995 0 1 28496 01995 0 1 29845 01995 0 1 52354 52005 0 1 28234 01995 0 1 28505 01995 0 1 29846 01995 0 1 52355 52005 0 1 28238 01995 0 1 28510 01995 0 1 29847 01995 0 1 61105 69990 1 0 28240 01995 0 1 28515 01995 0 1 29848 01995 0 1 61107 69990 1 0 28250 01995 0 1 28525 01995 0 1 29850 01995 0 1 61108 69990 1 0 28260 01995 0 1 28530 01995 0 1 29851 01995 0 1 61120 69990 1 0 28261 01995 0 1 28531 01995 0 1 29855 01995 0 1 61140 69990 1 0 28262 01995 0 1 28540 01995 0 1 29856 01995 0 1 61150 69990 1 0 28264 01995 0 1 28545 01995 0 1 29860 01995 0 1 61151 69990 1 0 28270 01995 0 1 28546 01995 0 1 29861 01995 0 1 61154 69990 1 0 28272 01995 0 1 28555 01995 0 1 29862 01995 0 1 61156 69990 1 0 28280 01995 0 1 28570 01995 0 1 29863 01995 0 1 61210 69990 1 0 28285 01995 0 1 28575 01995 0 1 29870 01995 0 1 64702 01995 0 1 28286 01995 0 1 28576 01995 0 1 29871 01995 0 1 64704 01995 0 1 28288 01995 0 1 28585 01995 0 1 29874 01995 0 1 64708 01995 0 1 28289 01995 0 1 28600 01995 0 1 29875 01995 0 1 64712 01995 0 1 28290 01995 0 1 28605 01995 0 1 29876 01995 0 1 64718 01995 0 1 28292 01995 0 1 28606 01995 0 1 29877 01995 0 1 64719 01995 0 1 28293 01995 0 1 28615 01995 0 1 29879 01995 0 1 64721 01995 0 1 28294 01995 0 1 28630 01995 0 1 29880 01995 0 1 64722 01995 0 1 28296 01995 0 1 28635 01995 0 1 29881 01995 0 1 64726 01995 0 1 28297 01995 0 1 28636 01995 0 1 29882 01995 0 1 64774 01995 0 1
Summary of Changes–20 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Integumentary System (CPT Codes 10000–19999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction C. Anesthesia CPT coding of the integumentary system includes coding narrative for ser- Anesthesia for dermatologic procedures, when provided by the physician vices performed by a number of specialties. While the coding system is ori- performing the procedure, is considered part of the procedure. This would ented toward dermatological procedures, the dermatological aspects of the include local infiltration, regional block, sedation, etc. performed by the phy- practice of plastic surgery are covered as are the dermatologic elements sician doing the procedure. Local anesthesia or local anesthesia with seda- (particularly closure, tissue transfer, grafts, adjacent and distant flaps) of tion is often accomplished by the physician providing the primary services. multiple surgical procedures, especially radical or mutilative surgical proce- General anesthesia or monitored anesthesia care may be required for more dures. Integumentary procedures are also often performed in staged fash- extensive dermatologic procedures (extensive debridement, flaps, grafts, ions due to the sophistication of services rendered. etc.). In these cases, if anesthesia services are performed by another pro- vider, the different physician may bill separately for his/her services. Billing Generally, integumentary procedures include incision, biopsy, removal, par- for “anesthesia” services rendered by a nurse or other office personnel ing/curettement, shaving, destruction (multiple methodologies), excision, (unless the nurse is an independent certified nurse anesthetist, CRNA, etc.) repair, adjacent tissue rearrangement, grafts, flaps, and specialized services is inappropriate as these services are “incident” to the physician’s services. such as burn management and Mohs' Micrographic Surgery. Use of injection codes for therapeutic injection or aspiration of lesions is When a column 1 code describes other column 2 codes, all of which were inappropriate if the injection is administered for local anesthesia for a spe- performed, the column 1 code should be used rather than listing the individ- cific procedure. CPT codes such as 10160 (puncture aspiration), 20500- ual column 2 codes. Additionally, because of the technical advances and 20501 (injection of sinus), 20550 (injection(s)of tendon sheath, ligament, changes in technology, standard medical practice should be as accurately etc.), 20600-20610 (arthrocentesis) are not to be reported separately if they reflected in CPT coding as possible. The CPT code should reflect what tran- are used to reflect local anesthetic techniques for another procedure. spires in a standard surgical setting. Necessary services performed in order to accomplish a more comprehensive service are included in the CPT code In the postoperative state, patients treated with epidural or subarachnoid describing the more complex service. continuous drug administration will require daily hospital adjustment/man- agement of the catheter, dosage, etc. (CPT code 01996). This service may B. Evaluation and Management be coded by the anesthesiologist for payment. The management of postop- Evaluation and Management (E & M) of integumentary disorders may repre- erative pain by the surgeon, including epidural or subarachnoid drug sent a separately identifiable service, serve as a prelude to a decision to per- administration, is included in the global period associated with the opera- form a service, or be performed in follow-up of previously performed tive procedure. If no surgery is performed but a catheter is placed for pain procedures. Policies referable to the appropriateness of reporting evaluation control (e.g. burn injury not requiring surgery), CPT code 01996 (daily hos- and management codes in conjunction with surgical procedures are well pital management of epidural or subarachnoid continuous drug administra- established in the standard CMS Global Surgery Policy. In essence, if the tion) is appropriately reported by the managing physician. evaluation and management service provided is for the purpose of deciding that a major surgical procedure is to be performed, this service is a signifi- D. Incision and Drainage cant, separately identifiable service and may be reported separately, by Incision and drainage services, as related to the integumentary system, gen- attaching modifier -57 to the appropriate level of evaluation and manage- erally involve cutaneous or subcutaneous drainage of cysts, pustules, infec- ment service code. Surgical procedures have a “global period” following tions, hematomas, seromas or fluid collections. In cases where, in the surgery (generally 0, 10 or 90 days); during this time E & M services pro- course of an excision of a lesion, an area of involvement is identified which vided in follow-up to the surgical procedure have been calculated into the requires drainage, either as a part of the procedure or in order to gain access relative value units for the surgery and are not to be separately reported. On to the area of interest, coding/billing for incision and drainage of this fluid the occasion when a separate condition is evaluated and a significant, sepa- collection would be inappropriate if the excision or other procedure is per- rately identifiable service for a different problem is provided postoperatively, formed in the same session. a separate E & M code may be reported and indicated with the -24 modifier. Example: A patient who presents with a pilonidal cyst may require simple Surgical dressings, supplies, and local anesthetics used for a procedure are incision/drainage or may require an extensive excision. In the former case, not to be separately reported as routine. There are some exceptions to this the appropriate CPT coding is 10080 (or 10081 if complicated). If the policy (e.g. surgical tray used for some office procedures). Wound closures pilonidal cyst is excised, while it is obvious that drainage from the cyst will using adhesive strips, topical skin adhesive, or tape alone do not represent occur in the course of its excision, the appropriate coding is CPT code a separately identifiable surgical procedure and are, therefore, included in 11770 (or 11771 or 11772, depending on the complexity), not CPT codes the appropriate E & M service. 10080 and 11770. If it is evident that an extensive cellulitis is present around the cyst preventing the complete procedure from being accom- plished, it may be reasonable to bill for CPT code 10080, then, after per-
©2004 Ingenix, Inc. Jan. 04 Integumentary–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Integumentary System
12001 - 12018 (Repair - simple) 3. Flap grafts (CPT codes 15570-15576) include excision of lesions at 12020 - 12021 (Treatment of wound dehiscence) the same site (CPT codes 11400-11646). 12031 - 12057 (Repair - intermediate) H. Breast (Incision, Excision, Introduction, Repair and 13100 - 13160 (Repair - complex) Reconstruction) 11719 - 11762 (Trimming, debridement and excision of nails) Because of the unique nature of procedures developed to address breast dis- 11770 - 11772 (Excision of pilonidal cysts) ease, a section of CPT (19000-19499) is set aside for such services. 11765 (Wedge excision) Fine needle aspiration biopsies, core biopsies, open incisional or excisional biopsies, and related procedures performed to procure tissue from a lesion F. Repair and Tissue Transfer for which an established diagnosis exists are not to be reported separately When lesional excision is of such an extent that closure cannot be accom- at the time of a lesion excision unless performed on a different lesion or on plished by simple, intermediate, or complex closure, other methodology the contralateral breast. However, if a diagnosis is not established, and the must be employed. Frequently adjacent tissue transfer or tissue rearrange- decision to perform the excision or mastectomy is dependent on the results ment is employed (Z-plasty, W-plasty, flaps, etc.). This family of codes, (CPT of the biopsy, then the biopsy is separately reported. The -58 modifier may codes 14000-14350), involves excision with adjacent tissue transfer and be used appropriately to indicate that the biopsy and the excision or mastec- correlates to excision codes. Excision CPT codes (11400-11646) and repair tomy are staged or planned procedures. CPT codes (12001 – 13160) are not to be separately reported when CPT codes 14000-14350 are reported. On the other hand, skin grafting per- Because excision of lesions occur in the course of performing a mastectomy, formed in conjunction with these codes may be separately reported if it is breast excisions are not separately reported from a mastectomy unless per- not included in the specific code definition. In the case of closure of trau- formed to establish the malignant diagnosis before proceeding to the mas- matic wounds, these codes are appropriate only when the closure requires tectomy. Specifically CPT codes 19110-19126 (breast excision) are in the surgeon to develop a specific adjacent tissue transfer; lacerations that general included in all mastectomy CPT codes 19140-19240 of the same coincidentally are approximated using a tissue transfer technique (e.g. Z- side. However, if the excision is performed to obtain tissue to determine plasty, W-plasty) should be reported with the more simple closure code. pathologic diagnosis of malignancy prior to proceeding to a mastectomy, Debridement necessary to accomplish these tissue transfer procedures is the excision is separately reportable with the mastectomy. The –58 modi- part of the column 1 procedure performed. Separate debridement CPT codes fier should be utilized in this situation. (11000-11042) or repair CPT codes (12001-13160) would be inappropri- Use of other integumentary codes for incision and closure are included in ately reported with these CPT codes (14000-14350) for the same lesion/ the codes describing various breast excision or mastectomy codes. Because injury. Procurement of cultures or tissue samples as a part of a closure are of the frequent need to biopsy lymph nodes or remove muscle tissue in con- included in the closure code and are not to be separately reported. junction with mastectomies, these procedures have been included in the G. Grafts and Flaps CPT coding for mastectomy. It would be inappropriate to separately bill for Free skin grafts are coded by type (split or full), location, and size. For a spe- ipsilateral lymph node dissection in conjunction with the appropriate mas- cific location, a primary code is defined and followed by a supplemental tectomy codes. In the circumstance where a breast lesion is identified and code for additional coverage area. As a result of this coding scheme, for a treated and it is determined to be medically necessary to biopsy the con- given area of involvement, the initial code is limited to one unit of service; tralateral nodes, use of the biopsy or lymph node dissection codes (using the supplemental code may have multiple units of service depending on the the appropriate anatomic modifier, -LT or -RT for left or right, to indicate this) area to be covered. Because, for a specific area, only one type of skin graft is would be acceptable. Additionally, breast reconstruction codes that include typically applied, the primary free skin graft CPT codes (15100, 15120, the insertion of a prosthetic implant are not to be reported with CPT codes 15200, 15220, 15240, 15260) are mutually exclusive to one another. If that describe the insertion of a breast prosthesis only. multiple areas require different grafts, a modifier indicating different sites The CPT coding for breast procedures generally refers to unilateral proce- should be used (anatomic or -59 modifier). dures; when performed bilaterally, the -50 modifier would be appropriate. Generally, debridement of non-intact skin (CPT codes 11000-11042) in This is identified parenthetically, where appropriate, in the CPT narrative. anticipation of a skin graft is necessary prior to application of the skin graft I. Add-on Codes and is included in the skin graft (CPT codes 15050-15400). When skin is There are a number of supplemental CPT codes defined in the CPT Manual. intact, however, and the graft is being performed after excisional prepara- The following is a listing of supplemental codes present in the integumen- tion of intact skin, the CPT code 15000 (Excisional preparation) is sepa- tary section of the CPT Manual. Although, not all-inclusive, the supplemen- rately reported. CPT code 15000 is not to be used to describe debridement tal code must be used in combination with the primary CPT code or the of non-intact, necrotic or infected skin, nor is its use indicated with other supplemental code cannot be reported. lesion removal codes.
1. CPT codes 15350 (application of allograft) and 15400 (application Primary CPT code Add-on CPT code of xenograft) are part of all other graft codes and are not to be sepa- rately reported with other grafts (CPT codes 15050 - 15261) for 11000 (Debridement up to 11001 (Each additional 10%) graft placement on the same site. 10%)
2. The CPT code 67911 describes the “Correction of lid retraction;” a 11200 (Removal of skin tags, 11201 (Each additional 10 parenthetical notation is added advising that, if autogenous graft up to and including 15 lesions) materials are used, tissue graft codes 20920, 20922 or 20926 can lesions) be reported. Accordingly, all other procedures necessary to accom- plish the service are included.
©2004 Ingenix, Inc. Jan. 04 Integumentary–3 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI Version 10.0)
11101 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including 11301 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; simple closure), unless otherwise listed; each separate/additional lesion lesion diameter 0.6 to 1.0 cm (List separately in addition to code for primary procedure) RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.85 0.05 1.13 0.38 2.03 1.28 0 0.41 0.02 0.34 0.19 0.77 0.62 INC MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDDOC 09 A 2NANPDNPDNPD09 A CORRECT CODING EDITS
CORRECT CODING EDITS 01995●, ¥¥<11100>¥¥<> ✚, ¥¥<11900>¥¥<> ■, ¥¥<11901>¥¥<> ■, ¥¥<12001>¥¥<> ✚, ¥¥<12002>¥¥<> ✚, ¥¥<12004>¥¥<> ✚, ¥¥<12005>¥¥<> ✚, ¥¥<12006>¥¥<> ✚, ✚ ✚ ✚ ✚ ✚ ✚ ✚ ✚ ✚ NA ¥¥<12007>¥¥<> , ¥¥<12011>¥¥<> , ¥¥<12013>¥¥<> , ¥¥<12014>¥¥<> , ¥¥<12015>¥¥<> , ¥¥<12016>¥¥<> , ¥¥<12017>¥¥<> , ¥¥<12018>¥¥<> , ¥¥<17250>¥¥<> , ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥
★ Sequential Procedures ✓ Mutually Exclusive Procedures ✰ Standard Preparation/Monitoring Services ❐ “With” versus “Without” Procedures ■ Misuse of Column 2 with Column 1 <¥¥>¥¥<> Modifier use may allow separate payment ▲ Laboratory Panels Integumentary–10 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Integumentary System
10021 Fine needle aspiration; without imaging guidance 10061 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); com- RELATIVE VALUE UNITS plicated or multiple Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 1.26 0.08 2.22 0.55 3.56 1.89 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 2.39 0.20 1.84 1.53 4.43 4.12 10 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 2NANPDNPDDOC 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24NPDNPDNPD 09 A ■ ❆ ❆ ■ ■ ■ ■ ■ ■ ¥¥<19290>¥¥<> , ¥¥<36>¥¥<> 000 , ¥¥<3>¥¥<> 6410 , ¥¥<3>¥¥<> 7202 , ¥¥<6>¥¥<> 2318 , ¥¥<6>¥¥<> 2319 , ¥¥<64415>¥¥<> , ¥¥<64416>¥¥<> , ¥¥<64417>¥¥<> , CORRECT CODING EDITS ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<76>¥¥<> 000■, ¥¥<76>¥¥<> 003◆, ¥¥<76>¥¥<> 360◆, ¥¥<76393>¥¥<> ◆, ¥¥<76>¥¥<> 942◆, ¥¥<9>¥¥<> 0780❆ 01995●, ¥¥<10>¥¥<> 060▼, ¥¥<11055>¥¥<> ▼, ¥¥<11056>¥¥<> ❆, ¥¥<11057>¥¥<> ❆, ¥¥<11>¥¥<> 406✓, ¥¥<11424>¥¥<> ✓, ¥¥<11426>¥¥<> ✓, ¥¥<11440>¥¥<> ✓, ¥¥<11444>¥¥<> ✓, ¥¥<11446>¥¥<> ✓, ¥¥<11450>¥¥<> ✓, ¥¥<11451>¥¥<> ✓, ¥¥<11463>¥¥<> ✓, ¥¥<11>¥¥<> 470✓, ¥¥<11471>¥¥<> ✓, ¥¥<11>¥¥<> 604✓, ¥¥<11>¥¥<> 606✓, ✓ ✓ ✓ ✓ ✓ ✓ ❆ ❆ ❆ Fine needle aspiration; with imaging guidance ¥¥<11623>¥¥<> , ¥¥<11624>¥¥<> , ¥¥<11626>¥¥<> , ¥¥<11643>¥¥<> , ¥¥<11644>¥¥<> , ¥¥<11646>¥¥<> , ¥¥<11719>¥¥<> , ¥¥<11720>¥¥<> , ¥¥<11721>¥¥<> , 10022 ¥¥<11730>¥¥<> ▼, ¥¥<11740>¥¥<> ❆, ¥¥<11750>¥¥<> ❆, ¥¥<11760>¥¥<> ❆, ¥¥<11765>¥¥<> ❆, ¥¥<20005>¥¥<> ✓, ¥¥<20500>¥¥<> ❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ■ ■ ■ ● ● ● ● ● ● RELATIVE VALUE UNITS ¥¥<3>¥¥<> 7202 , ¥¥<6>¥¥<> 2318 , ¥¥<6>¥¥<> 2319 , ¥¥<64400>¥¥<> , ¥¥<64402>¥¥<> , ¥¥<64405>¥¥<> , ¥¥<64>¥¥<> 408 , ¥¥<64410>¥¥<> , ¥¥<64412>¥¥<> , ¥¥<64413>¥¥<> ●, ¥¥<64415>¥¥<> ●, ¥¥<64416>¥¥<> ●, ¥¥<64417>¥¥<> ●, ¥¥<64418>¥¥<> ●, ¥¥<64420>¥¥<> ●, ¥¥<64421>¥¥<> ●, ¥¥<64425>¥¥<> ●, ¥¥<64430>¥¥<> ●, Work MP PE–nf PE–f Total–nf Total–f Global P ¥¥<64435>¥¥<> ●, ¥¥<64445>¥¥<> ●, ¥¥<64446>¥¥<> ●, ¥¥<64447>¥¥<> ●, ¥¥<64448>¥¥<> ●, ¥¥<64449>¥¥<> ●, ¥¥<64450>¥¥<> ●, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ●, 1.26 0.06 2.65 0.43 3.97 1.75 NA ¥¥<64>¥¥<> 479●, ¥¥<64483>¥¥<> ●, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<97601>¥¥<> ❆, ¥¥
01995●, ¥¥<11055>¥¥<> ▼, ¥¥<11056>¥¥<> ❆, ¥¥<11057>¥¥<> ❆, ¥¥<11401>¥¥<> ✓, ¥¥<11402>¥¥<> ✓, ¥¥<11403>¥¥<> ✓, ¥¥<11>¥¥<> 404✓, ¥¥<11>¥¥<> 406✓, MODIFIERS INDICATORS ¥¥<11421>¥¥<> ✓, ¥¥<11422>¥¥<> ✓, ¥¥<11423>¥¥<> ✓, ¥¥<11424>¥¥<> ✓, ¥¥<11426>¥¥<> ✓, ¥¥<11441>¥¥<> ✓, ¥¥<11442>¥¥<> ✓, ¥¥<11443>¥¥<> ✓, ¥¥<11444>¥¥<> ✓, -50 -51 -62 -66 -80, -82 Suprv Status ¥¥<11446>¥¥<> ✓, ¥¥<11450>¥¥<> ✓, ¥¥<11451>¥¥<> ✓, ¥¥<11>¥¥<> 462✓, ¥¥<11463>¥¥<> ✓, ¥¥<11>¥¥<> 470✓, ¥¥<11471>¥¥<> ✓, ¥¥<11600>¥¥<> ✓, ¥¥<11601>¥¥<> ✓, 24NPDNPDNPD 09 A ¥¥<11602>¥¥<> ✓, ¥¥<11603>¥¥<> ✓, ¥¥<11>¥¥<> 604✓, ¥¥<11>¥¥<> 606✓, ¥¥<11620>¥¥<> ✓, ¥¥<11621>¥¥<> ✓, ¥¥<11622>¥¥<> ✓, ¥¥<11623>¥¥<> ✓, ¥¥<11624>¥¥<> ✓, ¥¥<11626>¥¥<> ✓, ¥¥<11640>¥¥<> ✓, ¥¥<11641>¥¥<> ✓, ¥¥<11642>¥¥<> ✓, ¥¥<11643>¥¥<> ✓, ¥¥<11644>¥¥<> ✓, ¥¥<11646>¥¥<> ✓, ¥¥<11719>¥¥<> ❆, ¥¥<11720>¥¥<> ❆, CORRECT CODING EDITS ¥¥<11721>¥¥<> ❆, ¥¥<11730>¥¥<> ▼, ¥¥<11740>¥¥<> ❆, ¥¥<11765>¥¥<> ❆, ¥¥<20000>¥¥<> ✓, ¥¥<20005>¥¥<> ✓, ¥¥<20500>¥¥<> ❍, ¥¥<3>¥¥<> 0000✓, ¥¥<36>¥¥<> 000❆, 01995●, ¥¥<11055>¥¥<> ▼, ¥¥<11056>¥¥<> ❆, ¥¥<11057>¥¥<> ❆, ¥¥<11719>¥¥<> ❆, ¥¥<11720>¥¥<> ❆, ¥¥<11721>¥¥<> ❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64400>¥¥<> ●, ¥¥<64402>¥¥<> ●, ¥¥<64405>¥¥<> ●, ¥¥<64>¥¥<> 408●, ¥¥<64410>¥¥<> ●, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<64412>¥¥<> ●, ¥¥<64413>¥¥<> ●, ¥¥<64415>¥¥<> ●, ¥¥<64416>¥¥<> ●, ¥¥<64417>¥¥<> ●, ¥¥<64418>¥¥<> ●, ¥¥<64420>¥¥<> ●, ¥¥<64421>¥¥<> ●, ¥¥<64425>¥¥<> ●, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Integumentary–5 CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Musculoskeletal System (CPT Codes 20000–29999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction devices by a physician other than the physician who initially The general guidelines regarding correct coding apply to the CPT codes in applied the device. These codes are not to be reported by the same the range of 20000-29999. Specific issues unique to this section of CPT entity (physician, practice, group, etc.) that performed the initial are clarified in the following guidelines. application service. When the initial service includes only an evalu- ation and management service and does not include a definitive B. Anesthesia procedure (e.g. surgical repair, reduction of a fracture or joint dislo- Anesthesia administered by a physician performing a procedure is included cation) the cast/strapping may be separately reported from the eval- in the procedure. Accordingly, injections of local anesthesia for musculosk- uation and management service. When the only service rendered at eletal procedures (surgical or manipulative) are not to be separately a visit is cast or strapping application, a separate evaluation and reported. Specifically, the CPT codes 20526-20553 (therapeutic injection management service should not be reported unless separate evalu- and injections of tendon sheath, ligament, muscle) are not to be used as an ation/management services are performed that satisfy the evalua- injection code to provide local anesthesia for a surgical, closed, manipula- tion and management guidelines. CPT codes describing tive or other procedure; this is not the intent of the CPT code. Many code modification or removal of casts (e.g. 29700-29750) are not to be pair edits are included in the Correct Coding Initiative based on this policy. reported when these modifications are performed at the same ses- When separate anatomic areas are being treated, the appropriate anatomic sion as the primary (open or closed) procedure. modifier or the -59 modifier should be used to indicate this situation. 2. Different codes have been created for removal of internal fixation C. Biopsy devices as a separate procedure and modification/removal of these In accordance with the sequential procedure policy, when a biopsy is per- devices in conjunction with other procedures. When a superficial or formed in conjunction with any excision, destruction, removal, repair or deep implant (buried wire, pin, rod) requires a surgical procedure to internal fixation procedure, the biopsy procedure is not to be separately remove (e.g. CPT code 20670), and it is performed as a separate coded assuming a diagnosis has already been established which makes the procedure, this service may be reported. On the other hand, when excision, destruction, removal, repair or fixation procedure medically neces- the service is necessary to accomplish another procedure involving sary. If the biopsy is performed at a different site and represents a signifi- the same area, it is not to be reported separately. cant, separately identifiable service, a biopsy service can be reported. For example, if a patient presents with an upper extremity fracture and, during 3. In accordance with the general policy on most extensive procedures, an internal fixation procedure, it is determined to be medically reasonable to when a fracture requires closed reduction followed by open reduc- perform a bone biopsy of the iliac crest while under the same anesthetic, a tion at the same patient encounter (e.g. inability to accomplish the separate service for a bone biopsy, with the -59 modifier, could be reported. closed reduction), only the open reduction service is reported. If, however, through the same incision, a biopsy of the humerus was obtained, this service is not to be separately reported. In the circumstance 4. When interdental wiring (e.g. CPT code 21497) is necessary in the where the decision to perform the more comprehensive procedure (excision, treatment of facial (or other) fractures, as part of a facial reconstruc- destruction, removal, repair or fixation procedure) is dependent on the tive surgery, or arthroplasty, it is included as part of the service; results of the biopsy procedure, the biopsy procedure may be separately accordingly, a separate service using the CPT code 21497 is not reported. reported. If reported with other head and neck procedure codes, it should be coded with the -59 modifier, indicating a separate distinct Additionally, in accordance with the sequential procedure policy, when an service was performed. The medical record should reflect the nature arthroscopic procedure is followed by an open procedure at the same ses- of the separately identifiable service. sion, only the column 1 service is reported; generally, this would be the open procedure. If an arthroscopic service is performed at one site and an 5. When it is necessary to perform skeletal/joint manipulation under open procedure is performed at another, the arthroscopic service is reported anesthesia to assess range of motion or accomplish fracture reduc- with a modifier indicating that these services were performed at different tion as part of another related procedure, the corresponding manip- anatomic sites (e.g. -RT or -LT modifier, -59 modifier, etc.) ulation code (e.g. CPT codes 22505, 23700, 27275, 27570, 27860) is not to be separately reported. D. Fractures 1. In general, the application of external immobilization devices 6. CPT codes 22840-22848, 22851 (spinal instrumentation) are to (including casts) at the time of a procedure also includes removal be reported with only CPT codes 22325, 22326, 22327, 22548- services during (or after) the post-procedure period. CPT codes 22812 for fracture, dislocation, or arthrodesis of the spine. have been included for removal and modification of external fixation
©2004 Ingenix, Inc. Jan. 04 Musculoskeletal–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI—Version 10.0) E. General Policy Statements sue due to the fracture should be separately reported using the CPT 1. When a tissue transfer procedure (e.g. graft) is described in the prin- codes 11010-11012. cipal procedure code, a separate service is not reported for perform- ing the tissue transfer service necessary to complete the procedure. 6. Grafts, such as CPT codes 20900-20924, are only to be separately reported if the major procedure code description does not include 2. In situations where monitoring of interstitial fluid pressure is rou- graft in its definition. tinely performed as part of the postoperative care (e.g. distal lower extremity procedures with risk of anterior compartment compres- 7. The CPT code 20926 is a general code for tissue grafting (e.g. sion), a separate code for monitoring of interstitial fluid pressure paratenon, fat, dermis) to be used when the primary procedure does (e.g. CPT code 20950) should not be reported. not include grafting and when another graft code does not more accurately describe the nature of the grafting procedure being per- 3. When electrical stimulation is used to aid bone healing, the appro- formed. Accordingly, it should not be used with codes in which the priate bone stimulation codes (CPT codes 20974-20975) should be graft is already listed as a part of the procedure or with other graft- reported; the codes for nerve stimulation (CPT codes 64550- ing codes (see Chapter III for other graft codes). 64595) are inappropriate for this service. If a neurostimulator is medically necessary for other indications (e.g. pain control), a sepa- 8. CPT codes 29874 (Surgical knee arthroscopy for removal of loose rate service is reported, however, the -59 modifier should be body or foreign body) and 29877 (Surgical knee arthroscopy for attached indicating that this service is distinct in that it represents debridement/shaving of articular cartilage) should not be reported treatment of different symptoms; accordingly the medical record with other knee arthroscopy codes (29871-29889). Report G0289 should reflect the indication for the nerve stimulator. In addition, (Surgical knee arthroscopy for removal of loose body, foreign body, CPT codes 97014 and 97032 (physical medicine for electrical stim- debridement/shaving of articular cartilage at the time of other surgi- ulation) are not to be reported in conjunction with the above listed cal knee arthroscopy in a different compartment of the same knee). codes by the surgeon. 9. Medicare Global Surgery Rules prevent separate payment for post- 4. Routinely, exploration of the surgical field is performed during a operative pain management when provided by the physician per- surgical session; codes describing independent exploratory services forming an operative procedure. CPT codes 36000, 36410, are not to be reported when a more comprehensive procedure is 37202, 62318-62319, 64415-64417, 64450, 64470, 64475 being performed in the same area. Specifically, an exploration code and 90780 describe services that may be utilized for postoperative such as CPT code 22830 (exploration of spinal fusion) is not pain management. The services described by these codes may be reported with other procedures involving the spine unless per- reported only if performed for purposes unrelated to the postopera- formed at a different site/different incision from the other procedure tive pain management. (s). If, for example, a cervical spine procedure was being performed, 10. Medicare Anesthesia Rules prevent separate payment for anesthesia and, at the same operative session, a lumbar fusion was explored when provided by the physician performing a medical or surgical through a separate incision, the CPT code 22830-59 could be service. The physician should not report CPT codes 00100-01999. reported assuming the requirement for medical necessity was satis- Additionally, the physician should not unbundle the anesthesia pro- fied. cedure and report component codes individually. For example, 5. Debridements (CPT codes 11040-11042, and 11720-11721) are introduction of a needle or intracatheter into a vein (CPT code included in the surgical procedures conducted on the musculoskele- 36000), venipuncture (CPT code 36410), or intravenous infusion tal system when debridement of tissue is in the immediate surgical (CPT code 90780) should not be reported when these services are field of other than fractures and dislocations. If, however, tissue related to the delivery of an anesthetic agent. debridement is necessary for a more extensive area (e.g. concurrent soft tissue damage due to trauma), the debridement codes can be reported. In open fractures and/or dislocations, debridement of tis-
Musculoskeletal–2 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI Version 10.0)
29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondro- 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) plasty where necessary) or multiple drilling or microfracture RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 10.99 1.59 9.00 9.00 21.58 21.58 90 7. 99 1.35 7.05 7.05 16.39 16.39 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 15NPDNPDDOC 09 A 15NPDNPDDOC 09 A CORRECT CODING EDITS CORRECT CODING EDITS 01995●, ¥¥<20610>¥¥<> ❆, ¥¥<27347>¥¥<> ▼, ¥¥<27>¥¥<> 570❆, ¥¥<29870>¥¥<> ❍, 29874■, ¥¥<29875>¥¥<> ❍, 29877■, ¥¥<2>¥¥<> 9882◆, 01995●, ¥¥<20610>¥¥<> ❆, ¥¥<27>¥¥<> 570❆, ¥¥<29870>¥¥<> ❍, 29874■, ¥¥<29875>¥¥<> ❍, 29877■, ¥¥<2>¥¥<> 9883✓, ¥¥<2>¥¥<> 9884❍, ¥¥<2>¥¥<> 9884❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
Arthroscopy, knee, surgical; with lysis of adhesions, with or without Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, 29884 29880 manipulation (separate procedure) including any meniscal shaving) RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 7.29 1.23 6.63 6.63 15.15 15.15 90 8.45 1.43 7.29 7.29 17.17 17.17 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 15DOC DOC 8 09 A 15DOC DOC DOC 09 A CORRECT CODING EDITS CORRECT CODING EDITS 01995●, ¥¥<27>¥¥<> 570❆, ¥¥<29870>¥¥<> ❍, 29874■, ¥¥<29875>¥¥<> ❍, 29877■, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 01995●, ¥¥<20610>¥¥<> ❆, ¥¥<27347>¥¥<> ▼, ¥¥<27>¥¥<> 570❆, ¥¥<29870>¥¥<> ❍, ¥¥<29871>¥¥<> ▼, 29874■, ¥¥<29875>¥¥<> ❍, 29877■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<2>¥¥<> 9881◆, ¥¥<2>¥¥<> 9882✓, ¥¥<2>¥¥<> 9883✓, ¥¥<2>¥¥<> 9884❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<9>¥¥<> 0780❆ ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, 29885 29881 bone grafting, with or without internal fixation (including debridement of including any meniscal shaving) base of lesion) RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 7.72 1.31 6.89 6.89 15.92 15.92 90 9.04 1.52 7.89 7.89 18.45 18.45 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 15NPDNPDDOC 09 A 15DOC DOC 8 09 A CORRECT CODING EDITS CORRECT CODING EDITS 01995●, ¥¥<20610>¥¥<> ❆, ¥¥<27347>¥¥<> ▼, ¥¥<27>¥¥<> 570❆, ¥¥<29870>¥¥<> ❍, ¥¥<29871>¥¥<> ▼, 29874■, ¥¥<29875>¥¥<> ▼, 29877■, ¥¥<0012T>¥¥<> ▼, ¥¥<0013T>¥¥<> ▼, 01995●, ¥¥<20610>¥¥<> ❆, ¥¥<27>¥¥<> 570❆, ¥¥<29870>¥¥<> ❍, 29874■, ¥¥<29875>¥¥<> ❍, ¥¥<29876>¥¥<> ▼, ¥¥<2>¥¥<> 9882✓, ¥¥<2>¥¥<> 9883✓, ¥¥<2>¥¥<> 9884❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, 29877■, ¥¥<29879>¥¥<> ▼, ¥¥<2>¥¥<> 9884❍, ¥¥<2>¥¥<> 9886◆, ¥¥<2>¥¥<> 9887◆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) 29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans RELATIVE VALUE UNITS lesion Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 8.60 1.31 7.18 7.18 17.09 17.09 90 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 7. 50 1.27 6.77 6.77 15.54 15.54 90 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 15NPDNPDNPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 15NPDNPDNPD 09 A
01995●, ¥¥<20610>¥¥<> ❆, ¥¥<27347>¥¥<> ▼, ¥¥<27>¥¥<> 570❆, ¥¥<29870>¥¥<> ❍, 29874■, ¥¥<29875>¥¥<> ❍, 29877■, ¥¥<2>¥¥<> 9884❍, CORRECT CODING EDITS ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, 01995●, ¥¥<20610>¥¥<> ❆, ¥¥<27>¥¥<> 570❆, ¥¥<29870>¥¥<> ❍, 29874■, ¥¥<29875>¥¥<> ❍, ¥¥<29876>¥¥<> ✓, 29877■, ¥¥<29879>¥¥<> ✓, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<2>¥¥<> 9884❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
★ Sequential Procedures ✓ Mutually Exclusive Procedures ✰ Standard Preparation/Monitoring Services ❐ “With” versus “Without” Procedures ■ Misuse of Column 2 with Column 1 <¥¥>¥¥<> Modifier use may allow separate payment ▲ Laboratory Panels Musculoskeletal–186 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Musculoskeletal System
20000 Incision of soft tissue abscess (eg, secondary to osteomyelitis); superficial 20102 Exploration of penetrating wound (separate procedure); abdomen/flank/ back RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 2.11 0.20 2.38 1.63 4.69 3.94 10 3.92 0.42 3.56 1.82 7.90 6.16 10 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDNPD 09 A 24NPDNPD809A CORRECT CODING EDITS CORRECT CODING EDITS ¥¥<10061>¥¥<> ✓, ¥¥<20500>¥¥<> ❍, ¥¥<29>¥¥<> 580❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<11000>¥¥<> ✚, ¥¥<11041>¥¥<> ✚, ¥¥<11042>¥¥<> ✚, ¥¥<11043>¥¥<> ✚, ¥¥<11044>¥¥<> ✚, ¥¥<12001>¥¥<> ✚, ¥¥<12002>¥¥<> ✚, ¥¥<12004>¥¥<> ✚, ¥¥<12005>¥¥<> ✚, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<97601>¥¥<> ❆ ¥¥<12006>¥¥<> ✚, ¥¥<12007>¥¥<> ✚, ¥¥<12020>¥¥<> ✚, ¥¥<12021>¥¥<> ✚, ¥¥<12031>¥¥<> ✚, ¥¥<12032>¥¥<> ✚, ¥¥<12034>¥¥<> ✚, ¥¥<12035>¥¥<> ✚, ¥¥<12036>¥¥<> ✚, ¥¥<12037>¥¥<> ✚, ¥¥<13100>¥¥<> ✚, ¥¥<13101>¥¥<> ✚, ¥¥<13102>¥¥<> ✚, ¥¥<13122>¥¥<> ✚, ¥¥<13133>¥¥<> ✚, ¥¥<13160>¥¥<> ✚, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, Incision of soft tissue abscess (eg, secondary to osteomyelitis); deep or 20005 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<97601>¥¥<> ❆, ¥¥
¥¥<11000>¥¥<> ✚, ¥¥<11010>¥¥<> ❆, ¥¥<11011>¥¥<> ❆, ¥¥<11>¥¥<> 040✚, ¥¥<11041>¥¥<> ✚, ¥¥<11042>¥¥<> ✚, ¥¥<11043>¥¥<> ✚, ¥¥<11044>¥¥<> ✚, ¥¥<12001>¥¥<> ✚, 20100 Exploration of penetrating wound (separate procedure); neck ¥¥<12002>¥¥<> ✚, ¥¥<12005>¥¥<> ✚, ¥¥<12006>¥¥<> ✚, ¥¥<12007>¥¥<> ✚, ¥¥<12020>¥¥<> ✚, ¥¥<12021>¥¥<> ✚, ¥¥<12031>¥¥<> ✚, ¥¥<12032>¥¥<> ✚, ¥¥<12034>¥¥<> ✚, ¥¥<12035>¥¥<> ✚, ¥¥<12036>¥¥<> ✚, ¥¥<12037>¥¥<> ✚, ¥¥<12041>¥¥<> ✚, ¥¥<12042>¥¥<> ✚, ¥¥<12044>¥¥<> ✚, ¥¥<12045>¥¥<> ✚, ¥¥<12>¥¥<> 046✚, ¥¥<12047>¥¥<> ✚, RELATIVE VALUE UNITS ¥¥<13102>¥¥<> ✚, ¥¥<13120>¥¥<> ✚, ¥¥<13121>¥¥<> ✚, ¥¥<13122>¥¥<> ✚, ¥¥<13131>¥¥<> ✚, ¥¥<13132>¥¥<> ✚, ¥¥<13133>¥¥<> ✚, ¥¥<13160>¥¥<> ✚, ¥¥<24300>¥¥<> ❆, ¥¥<25259>¥¥<> ❆, ¥¥<26340>¥¥<> ❆, ¥¥<29105>¥¥<> ❆, ¥¥<29515>¥¥<> ❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, Work MP PE–nf PE–f Total–nf Total–f Global P ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<6>¥¥<> 4704❆, 69990■, ¥¥<9>¥¥<> 0780❆, 10.02 1.19 5.86 4.42 17.07 15.63 10 ¥¥<97601>¥¥<> ❆, ¥¥
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Musculoskeletal–3 CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Respiratory, Cardiovascular, Hemic, Lymphatic, Mediastinum and Diaphragm (CPT Codes 30000–39999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction nasal endoscopy simply because the approach to the sinus was The general guidelines regarding correct coding apply to the CPT codes in transnasal. As another example, fiberoptic bronchoscopy services the range of 30000-39999. Specific issues unique to this section of the routinely involve a limited inspection of the nasal cavity, the phar- CPT Manual are clarified in the following guidelines. ynx and the larynx; only the bronchoscopic code is reported, not with the nasal endoscopy, laryngoscopy, etc., for this service as this B. Respiratory System service is routine and incidental to the bronchoscopy. 1. Because the upper airway is bordered by a mucocutaneous margin, several CPT codes may define services involving biopsy, destruc- If a diagnostic endoscopy is performed, and this results in a deci- tion, excision, removal, revision, etc. of lesions of this margin, spe- sion to perform a (non-endoscopic) surgical procedure, then this cifically the nasal and oral surfaces. When billing a CPT code for endoscopy could be separately reported, indicating that this repre- these services, only one CPT code which most accurately describes sented a distinct diagnostic service. The -58 modifier may be used the service performed should be coded, generally either from the to denote that the diagnostic endoscopy and the non-endoscopic CPT section describing integumentary services (CPT codes 10040- surgical procedure are staged or planned procedures. Diagnostic 19499) or respiratory services (CPT codes 30000-32999). When endoscopy of the respiratory system (e.g. sinus endoscopy, laryn- the narrative accompanying the CPT codes from the respiratory sys- goscopy, bronchoscopy, pleuroscopy, etc.) performed at the same tem section includes tissue transfer (grafts, flaps, etc.), individual encounter as a surgical endoscopy is included in the surgical endo- tissue transfer/graft/flap codes (e.g. CPT codes 14000-15770) are scopy according to CPT Manual guidelines. However, when an not to be separately coded. open surgical procedure is performed and, at the same session, is accompanied by a “scout” endoscopy to evaluate the surgical field, 2. In keeping with the general guidelines previously promulgated, the endoscopy code is not reported separately. This policy applies when a biopsy of an established lesion of the respiratory system is either if the endoscopic procedure is to confirm the anatomical obtained as part of an excision, destruction, or other type of nature of the patient's respiratory system or adequacy of the surgi- removal, either endoscopically or surgically, at the same session, a cal procedure (e.g. tracheostomy, etc.). Additionally if an attempt to biopsy code is not to be reported by the surgeon in addition to the perform an endoscopic procedure fails and is converted to an open removal code. In the case of multiple similar or identical lesions, procedure, the endoscopic procedure is not separately reportable the biopsy code is not separately reported even if performed in a dif- with the open procedure. ferent area. As noted previously, in the circumstance where the decision to perform the more comprehensive procedure (excision, Example: If a patient presents with aspiration of a foreign body and destruction, or other type of removal) is dependent on the results of a bronchoscopy is performed indicating a lobar foreign body the biopsy, the procedure may be separately reported. If, at the obstruction, an attempt may be made to remove this bronchoscopi- same session, a biopsy is necessary to establish the need for sur- cally. It would be inappropriate to code and bill for CPT codes gery, the -58 modifier would be used to indicate this. 31622 (bronchoscopy - diagnostic) and 31635 (surgical bronchos- copy with removal of foreign body); only the “surgical” endoscopy, Example: If a patient presents with nasal obstruction, sinus obstruc- CPT code 31635, would be appropriate. In this example, if the tion and multiple nasal polyps, it may be reasonable to perform a endoscopic effort is unsuccessful and a thoracotomy is planned, the biopsy prior to, or in conjunction with, polypectomy and ethmoidec- diagnostic bronchoscopy could be separately coded in addition to tomy; in this case a separate code (e.g. CPT code 31237 for nasal/ the thoracotomy. The -58 modifier may be used to indicate that the sinus endoscopy) is not to be reported with the column 1 nasal/ diagnostic bronchoscopy and the thoracotomy are staged or sinus endoscopy code (e.g. CPT code 31255) even though the latter planned procedures. If the surgeon decided to repeat the bronchos- code does not specifically list a biopsy in its CPT narrative because copy after induction of general anesthesia to confirm the surgical the biopsy tissue is procured as part of the surgery, not to establish approach to the foreign body, billing a service for this confirmatory the need for surgery. bronchoscopy is inappropriate, although the initial diagnostic bron- choscopy could still be reported. Additionally, the failed broncho- 3. When a diagnostic endoscopy of the respiratory system is per- scopic attempt to remove the foreign body should not be reported formed, it is routine to evaluate the access regions as part of the with an open procedure to remove the foreign body. medically necessary service; a separate service for this evaluation is not to be reported. For example, if an anterior ethmoidectomy is 4. When a sinusotomy is performed in conjunction with a sinus endo- endoscopically performed, it is inappropriate to bill a diagnostic scopy, only one service is reported. If the medically necessary ser-
©2004 Ingenix, Inc. Jan. 04 Respiratory–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Respiratory, Cardiovascular, Hemic, Lymphatic, Mediastinum and Diaphragm
etc. followed by a similar open procedure such as thromboendarter- CPT codes are available describing the separate services (CPT codes ectomy), only the service for the successful procedure, which is usu- 34001 - 34203) and describing these services with thromboendar- ally the most extensive, open procedure is reported (see sequential terectomy (CPT codes 35301 - 35381). Only the most comprehen- procedure policy, Chapter I, Section N). In the case where a percuta- sive code describing the services performed for a given site can be neous procedure is performed at the site of one lesion, and an open reported; therefore, for a given site, a code from both of the above procedure is performed at a separate lesion, the services for the per- groups cannot be reported together. Additionally, in accordance cutaneous procedure should be reported with the -59 modifier only with the sequential procedure policy, if a balloon thrombectomy if the lesions are in distinct anatomical vessels. fails, and requires a performance of an open thromboendarterec- tomy, only the more comprehensive service that was performed 7. The HCPCS/CPT codes 36000, 36406, 36410, 90784, etc. repre- (generally the open procedure) is reported. sent very common procedures performed to gain venous access for phlebotomy, prophylactic intravenous access, infusion therapy, che- 13. When percutaneous angioplasty of a vascular lesion is followed at motherapy, drug administration, among others. When intravenous the same session by a percutaneous or open atherectomy, generally access is routinely obtained in the course of performing other medi- due to insufficient improvement in vascular flow with angioplasty cal/diagnostic/surgical procedures, or is necessary to accomplish alone, only the column 1 atherectomy procedure that was per- the procedure (e.g. infusion therapy, chemotherapy), it is inappropri- formed (generally the open procedure) is reported (see sequential ate to bill separately for the venous access services. The work of procedure policy, Chapter I, Section N). gaining routine vascular access is integral to and therefore included in the work value of the procedure. When the service is performed 14. CPT codes 35800-35860 are to be used when a return to the oper- alone or a service does not routinely require vascular access, these ating room is necessary for exploration for postoperative hemor- codes may be separately reported. While this represents a general rhage; accordingly, these codes are not to be coded for bleeding that policy statement, specific policy statements are written for further occurs during the initial operative session. Generally, when these clarification elsewhere. When transcatheter therapy services are codes are used, they are to be reported with the -78 modifier indi- performed, the placement of the needle and catheter are included in cating that the service represents a return to the operating room for the primary service. a related procedure during the postoperative period.
8. When (non-coronary) transluminal angioplasty or other translumi- D. Hemic and Lymphatic Systems nal procedure is performed at the same session/site as angiogra- When bone marrow aspiration is performed alone, the appropriate code to phy, only one selective catheter placement code for the involved site report is CPT code 38220. When a bone marrow biopsy is performed, the should be reported. If the angiogram and the angioplasty or other appropriate code is CPT code 38221 (bone marrow biopsy); this code can- transluminal procedure are not performed in immediate sequence not be reported with CPT code 20220 (bone biopsy). CPT codes 38220 and the catheters are left in place during the interim, a second selec- and 38221 may only be reported together if the two procedures are per- tive catheter placement or access code should not be reported. Addi- formed at separate sites or at separate patient encounters. Separate sites tionally, dye injections to position the catheter should not be include bone marrow aspiration and biopsy in different bones or two sepa- reported as a second angiography procedure. rate skin incisions over the same bone. When both a bone marrow biopsy (CPT code 38221) and bone marrow aspiration (CPT code 38220) are per- 9. When a median sternotomy is performed to accomplish cardiotho- formed at the same site through the same skin incision, only the bone mar- racic procedures, the repair of the sternal incision is part of the pri- row biopsy (CPT 38221) should be reported. mary procedure. The CPT codes 21820-21825 (treatment of sternum fracture) are not separately reported nor should the E. General Policy Statements removal of embedded wires be reported if a repeat procedure or 1. Medicare Global Surgery Rules prevent separate payment for post- return to the operating room (e.g. postoperative hemorrhage on the operative pain management when provided by the physician per- day of surgery) is necessary. forming an operative procedure. CPT codes 36000, 36410, 37202, 62318-62319, 64415-64417, 64450, 64470, 64475 10. When existing vascular access lines or selectively placed catheters and 90780 describe services that may be utilized for postoperative are used to procure arterial or venous samples, billing for the sam- pain management. The services described by these codes may be ple collection separately is inappropriate. reported only if performed for purposes unrelated to the postopera- tive pain management. 11. Peripheral vascular bypass CPT codes describe bypass procedures using venous grafts (CPT codes 35501-35587) and using other 2. Medicare Anesthesia Rules prevent separate payment for anesthesia types of bypass procedures (arterial reconstruction, composite). when provided by the physician performing a medical or surgical Because, at a given site of obstruction, only one type of bypass is service. The physician should not report CPT codes 00100-01999. performed, these groups of codes are mutually exclusive. When dif- Additionally, the physician should not unbundle the anesthesia pro- ferent sites are treated with different bypass procedures in the same cedure and report component codes individually. For example, operative session, the different bypass procedures may be sepa- introduction of a needle or intracatheter into a vein (CPT code rately reported, using an anatomic modifier or the -59 modifier. 36000), venipuncture (CPT code 36410), or intravenous infusion (CPT code 90780) should not be reported when these services are 12. Vascular obstruction may be caused by thrombosis, embolism and/ related to the delivery of an anesthetic agent. or atherosclerosis as well as other conditions. Treatment may, therefore, include thrombectomy, embolectomy and/or endarterec- tomy; these procedures may be performed alone or in combination.
©2004 Ingenix, Inc. Jan. 04 Respiratory–3 CPT only ©2003 American Medical Association. All Rights Reserved.
Mediastinum and Diaphragm 39000 Mediastinotomy with exploration, drainage, removal of foreign body, or 39400 Mediastinoscopy, with or without biopsy biopsy; cervical approach RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 5.58 0.83 4.65 4.65 11.06 11.06 10 6.07 0.87 4.51 4.51 11.45 11.45 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDNPD 09 A 24DOC DOC 8 09 A CORRECT CODING EDITS CORRECT CODING EDITS 00528●, 00529●, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 60520❍, ¥¥<6>¥¥<> 0521❍, ¥¥<6>¥¥<> 0522❍, ¥¥<6>¥¥<> 2318■, ¥¥<32002>¥¥<> ❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<39>¥¥<> 010✓, 60520❍, 60521❍, 60522❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
Repair, laceration of diaphragm, any approach 39010 Mediastinotomy with exploration, drainage, removal of foreign body, or 39501 biopsy; transthoracic approach, including either transthoracic or median RELATIVE VALUE UNITS sternotomy Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 13.11 1.65 6.53 6.53 21.29 21.29 90 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 11.72 1.75 6.43 6.43 19.90 19.90 90 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 24DOC DOC 8 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24DOC DOC 8 09 A ¥¥<32002>¥¥<> ❍, ¥¥<32020>¥¥<> ❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<39560>¥¥<> ▼, 44005❍, ¥¥<44200>¥¥<> ❍, 44850❍, CORRECT CODING EDITS 44950✚, 49000❍, ¥¥<49002>¥¥<> ❆, 49010❍, 49255❍, 49570❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<32002>¥¥<> ❍, ¥¥<32020>¥¥<> ❍, ¥¥<35820>¥¥<> ❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 38530▼, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 39502 Repair, paraesophageal hiatus hernia, transabdominal, with or without 39200 Excision of mediastinal cyst fundoplasty, vagotomy, and/or pyloroplasty, except neonatal RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 16.24 2.01 7.25 7.25 25.50 25.50 90 13.54 1.98 6.61 6.61 22.13 22.13 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24DOC DOC 8 09 A 24DOC DOC 8 09 A CORRECT CODING EDITS CORRECT CODING EDITS ¥¥<32002>¥¥<> ❍, ¥¥<32020>¥¥<> ❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<39560>¥¥<> ▼, 43324◆, 44005❍, 44200❍, ★ ★ ❍ ❍ ❆ ❆ ■ ❍ ❍ ¥¥<10021>¥¥<> , ¥¥<10022>¥¥<> , ¥¥<32002>¥¥<> , ¥¥<32020>¥¥<> , ¥¥<36>¥¥<> 000 , ¥¥<3>¥¥<> 6410 , ¥¥<3>¥¥<> 7202 , 60520 , 60521 , 44820❍, 44850❍, 44950✚, 49000❍, ¥¥<49002>¥¥<> ❆, 49010❍, 49255❍, 49570❍, ¥¥<6>¥¥<> 2318■, ❍ ■ ■ ■ ■ ■ ■ ■ ■ 60522 , ¥¥<6>¥¥<> 2318 , ¥¥<6>¥¥<> 2319 , ¥¥<64415>¥¥<> , ¥¥<64416>¥¥<> , ¥¥<64417>¥¥<> , ¥¥<64450>¥¥<> , ¥¥<64>¥¥<> 470 , ¥¥<64475>¥¥<> , ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 69990■, ¥¥<9>¥¥<> 0780❆
39503 Repair, neonatal diaphragmatic hernia, with or without chest tube inser- 39220 Excision of mediastinal tumor tion and with or without creation of ventral hernia RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 17.32 2.52 8.31 8.31 28.15 28.15 90 94.46 4.22 33.85 33.85 132.53 132.53 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24DOC DOC 8 09 A 24DOC DOC 8 09 A CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<32002>¥¥<> ❍, ¥¥<32020>¥¥<> ❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 60520❍, 60522❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<32002>¥¥<> ❍, ¥¥<32020>¥¥<> ❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<39560>¥¥<> ▼, ¥¥<39561>¥¥<> ▼, 44005❍, ¥¥<44200>¥¥<> ❍, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 44820❍, 44850❍, 44950✚, 49000❍, ¥¥<49002>¥¥<> ❆, 49010❍, 49255❍, 49570❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
★ Sequential Procedures ✓ Mutually Exclusive Procedures ✰ Standard Preparation/Monitoring Services ❐ “With” versus “Without” Procedures ■ Misuse of Column 2 with Column 1 <¥¥>¥¥<> Modifier use may allow separate payment ▲ Laboratory Panels Respiratory–114 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Respiratory System
30000 Drainage abscess or hematoma, nasal, internal approach 30117 Excision or destruction (eg, laser), intranasal lesion; internal approach RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 1.42 0.12 4.24 1.43 5.78 2.97 10 3.14 0.26 4.43 3.31 7.83 6.71 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDDOC 09 A 24NPDNPDNPD 09 A CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<10140>¥¥<> ✓, ¥¥<3>¥¥<> 0200❆, ¥¥<30801>¥¥<> ❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<3>¥¥<> 0000▼, ¥¥<3>¥¥<> 0020▼, ¥¥<3>¥¥<> 0118✓, ¥¥<3>¥¥<> 0200❆, ¥¥<3>¥¥<> 0320✓, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ 30020 Drainage abscess or hematoma, nasal septum 30118 Excision or destruction (eg, laser), intranasal lesion; external approach RELATIVE VALUE UNITS (lateral rhinotomy) Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 1.42 0.10 3.39 1.50 4.91 3.02 10 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 9.63 0.79 7.35 7.35 17.77 17.77 90 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 24NPDNPDNPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24DOC DOC 8 09 A ¥¥<3>¥¥<> 0000▼, ¥¥<3>¥¥<> 0200❆, ¥¥<30801>¥¥<> ❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, CORRECT CODING EDITS ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ ¥¥<3>¥¥<> 0200❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ 30100 Biopsy, intranasal RELATIVE VALUE UNITS 30120 Excision or surgical planing of skin of nose for rhinophyma Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 0.93 0.07 2.07 0.82 3.07 1.82 0 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 5.24 0.49 5.59 5.54 11.32 11.27 90 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 24NPDNPDNPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24NPDNPDNPD 09 A ¥¥<10021>¥¥<> ★, ¥¥<10022>¥¥<> ★, ¥¥<3>¥¥<> 0200❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, CORRECT CODING EDITS ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ ¥¥<3>¥¥<> 0200❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ 30110 Excision, nasal polyp(s), simple RELATIVE VALUE UNITS 30124 Excision dermoid cyst, nose; simple, skin, subcutaneous Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 1.62 0.14 3.40 1.60 5.16 3.36 10 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 3.08 0.24 3.07 3.07 6.39 6.39 90 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 14NPDNPDNPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24NPDNPDNPD 09 A ¥¥<3>¥¥<> 0100▼, ¥¥<3>¥¥<> 0200❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, CORRECT CODING EDITS ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ ¥¥<3>¥¥<> 0200❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ 30115 Excision, nasal polyp(s), extensive RELATIVE VALUE UNITS 30125 Excision dermoid cyst, nose; complex, under bone or cartilage Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 4.33 0.37 4.06 4.06 8.76 8.76 90 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 7.12 0.65 5.98 5.98 13.75 13.75 90 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 14NPDNPDNPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24NPDNPD809A ¥¥<3>¥¥<> 0100▼, ¥¥<3>¥¥<> 0110▼, ¥¥<3>¥¥<> 0200❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, CORRECT CODING EDITS ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ ¥¥<3>¥¥<> 0124▼, ¥¥<3>¥¥<> 0200❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Respiratory–5 CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Digestive System (CPT Codes 40000–49999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction anatomical landmarks (“scout” endoscopy), the endoscopic proce- The general policy statements defined previously also apply to procedures dure is not separately reported. In the case where the endoscopic described by the CPT range of codes, 40490-49999, that deal with the procedure is performed as a diagnostic procedure upon which the digestive system. The nature of services identified in this section requires decision to perform a more extensive (open) procedure is made, the specific clarification in relationship to these general policy statements. endoscopic procedure may be separately reported. The -58 modi- fier may be used to indicate that the diagnostic endoscopy and the B. Endoscopic Services more extensive, open procedure are staged or planned services. Endoscopic services are performed in many settings, i.e. office, outpatient, and ambulatory surgical centers (ASC). Procedures that are performed as an 5. When endoscopic esophageal dilation is performed, the appropriate integral part of an endoscopic procedure are considered part of the endo- endoscopic esophageal dilation code is to be reported. The CPT scopic procedure. Services such as venous access (e.g. CPT code 36000) codes 43450-43458 (dilation of esophagus) are not used in addi- and/or injection (e.g. CPT codes 90780-90784), non-invasive oximetry tion (even if attempted unsuccessfully prior to endoscopic dilation); (e.g. CPT codes 94760 and 94761), anesthesia provided by the surgeon, in such a case, the -22 modifier could be used to indicate an etc. are included in the endoscopic procedure code. These column 2 codes unusual endoscopic dilation procedure. are not to be reported separately. 6. When it is necessary to perform diagnostic endoscopy of the 1. When a diagnostic endoscopy is performed in conjunction with hepatic/biliary/pancreatic system using separate approaches (e.g. endoscopic therapeutic services, the appropriate CPT code to use is biliary T-tube endoscopy with ERCP, etc.) the appropriate CPT codes the most comprehensive endoscopy code describing the service per- for both may be reported. However, the code should include the -51 formed. If the same therapeutic endoscopy service is performed modifier indicating multiple procedures were performed at the same repeatedly (e.g. polyp removal) in the same area described by the session. CPT narrative, only one CPT code is reported with one unit of ser- vice. If different therapeutic services are performed and are not ade- 7. When intubation of the GI tract is performed (e.g. percutaneous G- quately described by a more comprehensive CPT code, the tube placement, etc.), it is not appropriate to bill a separate code for appropriate codes can be designated in accordance with the multi- tube removal. Specifically, the CPT code 43247 (endoscopic ple GI endoscopy rules previously established by CMS. removal of foreign body) is not to be reported for routine removal of therapeutic devices previously placed. 2. When a diagnostic endoscopy is followed by a surgical endoscopy, the diagnostic endoscopy is considered part of the surgical endos- 8. When an endoscopic or open procedure is performed and a biopsy copy (per CPT definition) and is not to be separately reported. is also performed, followed by excision, destruction or removal of the biopsied lesion, the biopsy is not separately reported. Addition- 3. Gastroenterologic tests included in CPT codes 91000-91299 are ally, when bleeding results from an endoscopic or surgical service, frequently complementary to endoscopic procedures. Esophageal the control of bleeding at the time of the service is included in the and gastric washings for cytology are described as part of an upper endoscopic procedure. Separate procedure codes for control of endoscopy (CPT code 43235) and, therefore, CPT codes 91000 bleeding are not to be coded. In the case of endoscopy, if it is neces- (esophageal intubation) and 91055 (gastric intubation) should not sary to repeat the endoscopy at a later time during the same day to be separately reported when performed as part of an upper endo- control bleeding, a procedure code for endoscopic control of bleed- scopic procedure. Provocative testing (CPT code 91052) can be ing may be reported with the -78 modifier, indicating that this ser- expedited during gastrointestinal endoscopy (procurement of gas- vice represents a return to the endoscopy suite or operating room tric specimens); when performed at the same time as GI endoscopy, for a related procedure during the postoperative period. In the case CPT code 91052 should be coded with the -52 modifier indicating of open surgical services, the appropriate complication codes may a reduced level of service was performed. be reported if a return to the operating room is necessary, but the complication code should not be reported if the complication 4. When a small intestinal endoscopy or enteroscopy is performed as described by the CPT code occurred during the same operative ses- a necessary part of a procedure, only the most comprehensive (col- sion. umn 1) code describing the service performed is to be reported. When services described by the range of CPT codes 44360-44386 9. Only the most extensive endoscopic procedure is reported for a ses- (small intestinal endoscopies) are performed as part of another ser- sion. For example if a sigmoidoscopy is completed and the physi- vice (e.g. surgical repair or creation of enterostomy, etc.), these cian performs a colonoscopy during the same session only the codes are not separately reported. As noted previously, when an colonoscopy, is coded. It is, however, acceptable to bill for multiple endoscopic procedure is confirmatory or is performed to establish services provided during an endoscopic procedure (with the excep-
©2004 Ingenix, Inc. Jan. 04 Digestive–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI—Version 10.0)
tion of treating bleeding induced by the procedure); these services 3. In accordance with the sequential procedure policy, only one code would be reimbursed under the multiple endoscopic payment rules for hemorrhoidectomy is reported; the most extensive procedure for gastrointestinal endoscopy. necessary to successfully accomplish the hemorrhoidectomy would be appropriate. Additionally, if, in the course of a hemorrhoidec- 10. When a transabdominal colonoscopy (via colotomy)(CPT code tomy, an abscess is identified and drained, a separate procedure 45355) and/or standard sigmoidoscopy or colonoscopy is per- code is not reported for the incision and drainage, as this was per- formed as a necessary part of an open procedure (e.g. colectomy), formed in the course of the hemorrhoidectomy. If the incision and the endoscopic procedure(s) is (are) not separately reported. On the drainage of the abscess occurred at a different site than the hemor- other hand, if either endoscopic procedure is performed as a diag- rhoidectomy, then this procedure could appropriately be reported nostic procedure upon which the decision to perform the open pro- with a -59 modifier. cedure is made, the procedure(s) may be reported separately. The -58 modifier may be used to indicate that the diagnostic endoscopy 4. A number of groups of codes describe surgical procedures of a pro- and the open procedure are staged or planned services. gressively more comprehensive nature or with different approaches to accomplish similar services. In general, these groups of codes C. Abdominal Procedures are not to be reported together (see mutually exclusive policy). When any open abdominal procedure is performed, an exploration of the While a number of these groups of codes exist in CPT, several spe- surgical field is routinely performed to identify anatomic structures or any cific examples include CPT codes 45110-45123 for proctectomies, anomalies that may be present. Accordingly, an exploratory laparotomy CPT codes 44140-44160 for colectomies, CPT codes 43620- (CPT code 49000) is not separately reported with any open abdominal pro- 43639 for gastrectomies, and CPT codes 48140-48180 for pan- cedure. If routine exploration of the abdomen during an open abdominal createctomies. procedure identifies abnormalities requiring a more extensive surgical field that makes the procedure unusual, the -22 modifier may be reported with 5. When it is necessary to create or revise an enterostomy, or remove supporting documentation in the medical record, indicating that an unusual or excise a section of bowel due to fistula formation, a separate procedural service was performed. enterostomy closure code or fistula closure code is not reported. In the case of creating or revising an enterostomy, the closure is mutu- When, in the course of a hepatectomy, a cholecystectomy is necessary in ally exclusive and in the case of fistula excision, the closure is order to successfully perform the hepatectomy, a separate procedure code is included in the excision procedure. not coded for the cholecystectomy; component column 2 procedures neces- sary to perform a more comprehensive column 1 procedure are included in 6. Because the digestive tract is bordered by a mucocutaneous margin, the column 1 code describing the more comprehensive service. several CPT codes may define services involving biopsy, destruc- tion, excision, removal, etc. of lesions of this margin. When a lesion Appendectomies are commonly performed incidentally during many involving this margin is identified and it is medically necessary to abdominal procedures. The appendectomy is only to be reported separately remove, only one code which most accurately describes the service if it is medically necessary. If done incidental to another procedure, the performed should be submitted, generally either from the CPT sec- appendectomy would be included in the major procedure performed. tion describing integumentary services (10040-19499) or diges- When, in the course of an open abdominal procedure, a hernia repair is per- tive services (40490-49999). For example, if a patient presents formed, a service is reported only if the hernia repair is medically necessary with a benign lip lesion, and it is removed with a wedge excision, it at a different incisional site. Incidental hernia repair in the course of an would be acceptable to bill the CPT code 40510 (excision of lip) or abdominal procedure that is not medically necessary should not be the appropriate code from CPT codes 11440-11446 (excision of reported. The medical record should document the medical necessity of the lesions); billing a code from both sections would be inappropriate. service if it is reported. 7. Laparoscopic procedures performed in place of an open procedure When a recurrent hernia requires repair, the appropriate recurrent hernia are subject to the standard surgical practice guidelines. repair code is reported. A code for incisional hernia repair is not to be reported in addition to the recurrent hernia repair unless a medically neces- 8. Medicare Global Surgery Rules prevent separate payment for post- sary incisional hernia repair is performed at a different site. In this case, the operative pain management when provided by the physician per- -59 modifier should be attached to the incisional hernia repair code. forming an operative procedure. CPT codes 36000, 36410, 37202, 62318-62319, 64415-64417, 64450, 64470, 64475 D. General Policy Statements and 90780 describe services that may be utilized for postoperative 1. When a vagotomy is performed in conjunction with esophageal or pain management. The services described by these codes may be gastric surgery, the appropriate CPT code describing the compre- reported only if performed for purposes unrelated to the postopera- hensive column 1 coded service is reported. The range of CPT codes tive pain management. 64752-64760 includes services described by the vagotomy codes performed as separate procedures and are not reported in addition 9. Medicare Anesthesia Rules prevent separate payment for anesthesia to esophageal or gastric surgical CPT codes (e.g. 43635-43641) when provided by the physician performing a medical or surgical which include vagotomy as part of the service. service. The physician should not report CPT codes 00100-01999. Additionally, the physician should not unbundle the anesthesia pro- 2. When a closure of an enterostomy or enterovesical fistula requires cedure and report component codes individually. For example, the resection and anastomosis of a segment of bowel, the CPT introduction of a needle or intracatheter into a vein (CPT code codes 44626 and 44661, include the anastomosis or the enteric 36000), venipuncture (CPT code 36410), or intravenous infusion resection. Accordingly, additional enteric resection codes are not to (CPT code 90780) should not be reported when these services are be reported. related to the delivery of an anesthetic agent.
Digestive–2 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Digestive System
40490 Biopsy of lip 40525 Excision of lip; full thickness, reconstruction with local flap (eg, Estlander or fan) RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 1.21 0.07 1.87 0.62 3.15 1.90 0 7.51 0.82 6.98 6.98 15.31 15.31 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDNPD 09 A 24NPDNPDNPD 09 A CORRECT CODING EDITS CORRECT CODING EDITS 00170●, ¥¥<10021>¥¥<> ★, ¥¥<10022>¥¥<> ★, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, 00170●, ¥¥<11440>¥¥<> ▼, ¥¥<11441>¥¥<> ▼, ¥¥<11442>¥¥<> ▼, ¥¥<11443>¥¥<> ▼, ¥¥<11444>¥¥<> ▼, ¥¥<11446>¥¥<> ▼, ¥¥<11640>¥¥<> ▼, ¥¥<11641>¥¥<> ▼, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ ¥¥<11642>¥¥<> ▼, ¥¥<11643>¥¥<> ▼, ¥¥<11644>¥¥<> ▼, ¥¥<11646>¥¥<> ▼, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<40500>¥¥<> ▼, ¥¥<4>¥¥<> 0510▼, ¥¥<4>¥¥<> 0527✓, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ■ ❆ ❆ 40500 Vermilionectomy (lip shave), with mucosal advancement 69990 , ¥¥<9>¥¥<> 0780 , ¥¥<92502>¥¥<> RELATIVE VALUE UNITS 40527 Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Est- Work MP PE–nf PE–f Total–nf Total–f Global P lander) 4.26 0.37 6.15 4.95 10.78 9.58 90 RELATIVE VALUE UNITS MODIFIERS INDICATORS Work MP PE–nf PE–f Total–nf Total–f Global P -50 -51 -62 -66 -80, -82 Suprv Status 9.08 0.98 7.94 7.94 18.00 18.00 90 24NPDNPDNPD 09 A MODIFIERS INDICATORS CORRECT CODING EDITS -50 -51 -62 -66 -80, -82 Suprv Status 00170●, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, 24NPDNPDDOC 09 A ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ CORRECT CODING EDITS
00170●, ¥¥<11440>¥¥<> ▼, ¥¥<11441>¥¥<> ▼, ¥¥<11442>¥¥<> ▼, ¥¥<11443>¥¥<> ▼, ¥¥<11444>¥¥<> ▼, ¥¥<11446>¥¥<> ▼, ¥¥<11640>¥¥<> ▼, ¥¥<11641>¥¥<> ▼, 40510 Excision of lip; transverse wedge excision with primary closure ¥¥<11642>¥¥<> ▼, ¥¥<11643>¥¥<> ▼, ¥¥<11644>¥¥<> ▼, ¥¥<11646>¥¥<> ▼, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<40500>¥¥<> ▼, ¥¥<4>¥¥<> 0510▼, ¥¥<4>¥¥<> 0520▼, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, RELATIVE VALUE UNITS 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ Work MP PE–nf PE–f Total–nf Total–f Global P 4.67 0.46 6.90 4.84 12.03 9.97 90 Resection of lip, more than one-fourth, without reconstruction MODIFIERS INDICATORS 40530 -50 -51 -62 -66 -80, -82 Suprv Status RELATIVE VALUE UNITS 24NPDNPDNPD 09 A Work MP PE–nf PE–f Total–nf Total–f Global P CORRECT CODING EDITS 5.37 0.56 6.65 5.25 12.58 11.18 90
00170●, ¥¥<11440>¥¥<> ▼, ¥¥<11441>¥¥<> ▼, ¥¥<11442>¥¥<> ▼, ¥¥<11443>¥¥<> ▼, ¥¥<11444>¥¥<> ▼, ¥¥<11446>¥¥<> ▼, ¥¥<11640>¥¥<> ▼, ¥¥<11641>¥¥<> ▼, MODIFIERS INDICATORS ¥¥<11642>¥¥<> ▼, ¥¥<11643>¥¥<> ▼, ¥¥<11644>¥¥<> ▼, ¥¥<11646>¥¥<> ▼, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<40500>¥¥<> ▼, ¥¥<6>¥¥<> 2318■, -50 -51 -62 -66 -80, -82 Suprv Status ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, 24NPDNPDNPD 09 A ¥¥<92502>¥¥<> ❆ CORRECT CODING EDITS
00170●, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, 40520 Excision of lip; V-excision with primary direct linear closure ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆ RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P 40650 Repair lip, full thickness; vermilion only 4.64 0.50 7.41 5.09 12.55 10.23 90 RELATIVE VALUE UNITS MODIFIERS INDICATORS Work MP PE–nf PE–f Total–nf Total–f Global P -50 -51 -62 -66 -80, -82 Suprv Status 3.62 0.37 5.62 3.86 9.61 7.85 90 24NPDNPDNPD 09 A MODIFIERS INDICATORS CORRECT CODING EDITS -50 -51 -62 -66 -80, -82 Suprv Status 00170●, ¥¥<11440>¥¥<> ▼, ¥¥<11441>¥¥<> ▼, ¥¥<11442>¥¥<> ▼, ¥¥<11443>¥¥<> ▼, ¥¥<11444>¥¥<> ▼, ¥¥<11446>¥¥<> ▼, ¥¥<11640>¥¥<> ▼, ¥¥<11641>¥¥<> ▼, 24NPDNPDDOC 09 A ¥¥<11642>¥¥<> ▼, ¥¥<11643>¥¥<> ▼, ¥¥<11644>¥¥<> ▼, ¥¥<11646>¥¥<> ▼, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<40500>¥¥<> ▼, ¥¥<4>¥¥<> 0510▼, ¥¥<4>¥¥<> 0525✓, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, CORRECT CODING EDITS ■ ❆ ❆ 69990 , ¥¥<9>¥¥<> 0780 , ¥¥<92502>¥¥<> 00170●, ¥¥<13150>¥¥<> ✓, ¥¥<13151>¥¥<> ✓, ¥¥<13152>¥¥<> ✓, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<40>¥¥<> 652✓, ¥¥<40>¥¥<> 654✓, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥<92502>¥¥<> ❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Digestive–3 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI Version 10.0)
43264 Endoscopic retrograde cholangiopancreatography (ERCP); with endo- 43269 Endoscopic retrograde cholangiopancreatography (ERCP); with endo- scopic retrograde removal of calculus/calculi from biliary and/or pancre- scopic retrograde removal of foreign body and/or change of tube or stent atic ducts RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 8.16 0.34 3.13 3.13 11.63 11.63 0 8.85 0.49 3.37 3.37 12.71 12.71 0 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 25NPDNPDNPD 09 A 25NPDNPDNPD 09 A CORRECT CODING EDITS
CORRECT CODING EDITS 00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥¥<36>¥¥<> 000❆, ¥¥<36>¥¥<> 005❆, ¥¥<36>¥¥<> 010❆, 00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥¥<36>¥¥<> 000❆, ¥¥<36>¥¥<> 005❆, ¥¥<36>¥¥<> 010❆, ¥¥<36>¥¥<> 011❆, ¥¥<36>¥¥<> 012❆, ¥¥<36>¥¥<> 013❆, ¥¥<36>¥¥<> 014❆, ¥¥<36>¥¥<> 015❆, ¥¥<3>¥¥<> 6410❍, ¥¥<3>¥¥<> 7202■, 43200❍, ¥¥<43215>¥¥<> ▼, ¥¥<36>¥¥<> 011❆, ¥¥<36>¥¥<> 012❆, ¥¥<36>¥¥<> 013❆, ¥¥<36>¥¥<> 014❆, ¥¥<36>¥¥<> 015❆, ¥¥<3>¥¥<> 6410❍, ¥¥<3>¥¥<> 7202■, 43200❍, ¥¥<43215>¥¥<> ▼, 43234❍, ¥¥<43235>¥¥<> ❍, 43260❍, ¥¥<43268>¥¥<> ✓, 44360❍, 44376❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, 43234❍, ¥¥<43235>¥¥<> ❍, 43260❍, 44360❍, 44376❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<76>¥¥<> 000✚, ¥¥<76>¥¥<> 001✚, ¥¥<9>¥¥<> 0780❆, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<76>¥¥<> 000✚, ¥¥<76>¥¥<> 001✚, ¥¥<9>¥¥<> 0780❆, ¥¥<9>¥¥<> 0781❆, ¥¥<9>¥¥<> 0781❆, 90782❆, 90783❆, 90784❆, 92511❍, ¥¥<9>¥¥<> 4760❆, ¥¥<9>¥¥<> 4761❆ 90782❆, 90783❆, 90784❆, 92511❍, ¥¥<9>¥¥<> 4760❆, ¥¥<9>¥¥<> 4761❆ 43271 Endoscopic retrograde cholangiopancreatography (ERCP); with endo- 43265 Endoscopic retrograde cholangiopancreatography (ERCP); with endo- scopic retrograde balloon dilation of ampulla, biliary and/or pancreatic scopic retrograde destruction, lithotripsy of calculus/calculi, any method duct(s) RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 9.96 0.50 3.76 3.76 14.22 14.22 0 7.35 0.41 2.83 2.83 10.59 10.59 0 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 25NPDNPDNPD 09 A 25NPDNPDNPD 09 A CORRECT CODING EDITS CORRECT CODING EDITS
00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥¥<36>¥¥<> 000❆, ¥¥<36>¥¥<> 005❆, ¥¥<36>¥¥<> 010❆, 00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥¥<36>¥¥<> 000❆, ¥¥<36>¥¥<> 005❆, ¥¥<36>¥¥<> 010❆, ¥¥<36>¥¥<> 011❆, ¥¥<36>¥¥<> 012❆, ¥¥<36>¥¥<> 013❆, ¥¥<36>¥¥<> 014❆, ¥¥<36>¥¥<> 015❆, ¥¥<3>¥¥<> 6410❍, ¥¥<3>¥¥<> 7202■, 43200❍, 43234❍, ¥¥<36>¥¥<> 011❆, ¥¥<36>¥¥<> 012❆, ¥¥<36>¥¥<> 013❆, ¥¥<36>¥¥<> 014❆, ¥¥<36>¥¥<> 015❆, ¥¥<3>¥¥<> 6410❍, ¥¥<3>¥¥<> 7202■, 43200❍, 43234❍, ¥¥<43235>¥¥<> ❍, 43260❍, 44360❍, 44376❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<43235>¥¥<> ❍, 43260❍, 44360❍, 44376❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<76>¥¥<> 000✚, ¥¥<76>¥¥<> 001✚, ¥¥<9>¥¥<> 0780❆, ¥¥<9>¥¥<> 0781❆, 90782❆, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<76>¥¥<> 000✚, ¥¥<76>¥¥<> 001✚, ¥¥<9>¥¥<> 0780❆, ¥¥<9>¥¥<> 0781❆, 90782❆, 90783❆, 90784❆, 92511❍, ¥¥<9>¥¥<> 4760❆, ¥¥<9>¥¥<> 4761❆ 90783❆, 90784❆, 92511❍, ¥¥<9>¥¥<> 4760❆, ¥¥<9>¥¥<> 4761❆
43267 Endoscopic retrograde cholangiopancreatography (ERCP); with endo- 43272 Endoscopic retrograde cholangiopancreatography (ERCP); with ablation scopic retrograde insertion of nasobiliary or nasopancreatic drainage tube of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot RELATIVE VALUE UNITS biopsy forceps, bipolar cautery or snare technique Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 7.35 0.41 2.84 2.84 10.60 10.60 0 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 7.35 0.41 2.84 2.84 10.60 10.60 0 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 25NPDNPDNPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 25NPDNPDDOC 09 A
00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥¥<36>¥¥<> 000❆, ¥¥<36>¥¥<> 005❆, ¥¥<36>¥¥<> 010❆, CORRECT CODING EDITS ¥¥<36>¥¥<> 011❆, ¥¥<36>¥¥<> 012❆, ¥¥<36>¥¥<> 013❆, ¥¥<36>¥¥<> 014❆, ¥¥<36>¥¥<> 015❆, ¥¥<3>¥¥<> 6410❍, ¥¥<3>¥¥<> 7202■, 43200❍, ¥¥<43219>¥¥<> ▼, 00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥¥<36>¥¥<> 000❆, ¥¥<36>¥¥<> 005❆, ¥¥<36>¥¥<> 010❆, 43234❍, ¥¥<43235>¥¥<> ❍, 43260❍, 44360❍, 44376❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<36>¥¥<> 011❆, ¥¥<36>¥¥<> 012❆, ¥¥<36>¥¥<> 013❆, ¥¥<36>¥¥<> 014❆, ¥¥<36>¥¥<> 015❆, ¥¥<3>¥¥<> 6410❍, ¥¥<3>¥¥<> 7202■, 43200❍, ¥¥<43228>¥¥<> ▼, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<76>¥¥<> 000✚, ¥¥<76>¥¥<> 001✚, ¥¥<9>¥¥<> 0780❆, ¥¥<9>¥¥<> 0781❆, 43234❍, ¥¥<43235>¥¥<> ❍, ¥¥<43258>¥¥<> ▼, 43260❍, 44360❍, 44376❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, 90782❆, 90783❆, 90784❆, 92511❍, ¥¥<9>¥¥<> 4760❆, ¥¥<9>¥¥<> 4761❆ ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<76>¥¥<> 000✚, ¥¥<76>¥¥<> 001✚, ¥¥<9>¥¥<> 0780❆, ¥¥<9>¥¥<> 0781❆, 90782❆, 90783❆, 90784❆, 92511❍, ¥¥<9>¥¥<> 4760❆, ¥¥<9>¥¥<> 4761❆ 43268 Endoscopic retrograde cholangiopancreatography (ERCP); with endo- scopic retrograde insertion of tube or stent into bile or pancreatic duct 43280 Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet RELATIVE VALUE UNITS procedures) Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 7.35 0.41 2.94 2.94 10.70 10.70 0 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 17.15 2.11 7.40 7.40 26.66 26.66 90 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 25NPDNPDNPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24DOC DOC 8 09 A
00520●, 00740●, 00810■, 31505❍, 31525■, 31575■, ¥¥<36>¥¥<> 000❆, ¥¥<36>¥¥<> 005❆, ¥¥<36>¥¥<> 010❆, CORRECT CODING EDITS ¥¥<36>¥¥<> 011❆, ¥¥<36>¥¥<> 012❆, ¥¥<36>¥¥<> 013❆, ¥¥<36>¥¥<> 014❆, ¥¥<36>¥¥<> 015❆, ¥¥<3>¥¥<> 6410❍, ¥¥<3>¥¥<> 7202■, 43200❍, 43234❍, 00520●, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 43324▼, 43653❍, ¥¥<43752>¥¥<> ■, 44200❍, 49320✚, ¥¥<43235>¥¥<> ❍, 43260❍, ¥¥<43267>¥¥<> ✓, 44360❍, 44376❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, 58660❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<76>¥¥<> 000✚, ¥¥<76>¥¥<> 001✚, ¥¥<9>¥¥<> 0780❆, ¥¥<9>¥¥<> 0781❆, 69990■, ¥¥<9>¥¥<> 0780❆, ¥¥
★ Sequential Procedures ✓ Mutually Exclusive Procedures ✰ Standard Preparation/Monitoring Services ❐ “With” versus “Without” Procedures ■ Misuse of Column 2 with Column 1 <¥¥>¥¥<> Modifier use may allow separate payment ▲ Laboratory Panels Digestive–30 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Urinary, Male Genital, Female Genital, Maternity Care and Delivery Systems (CPT Codes 50000–59999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction that this service occurred at a different site (i.e., via a different inci- The general policies previously promulgated regarding CPT defined services sion). apply to the urinary tract. Because of the contiguous nature of the urinary tract, and the accessibility of the urinary tract to endoscopic intervention, 5. In general, multiple methods of accomplishing a procedure (e.g. several specific issues require emphasis. prostatectomy) are not performed at the same session (see general policy on mutually exclusive services); therefore, only one method B. Urinary System of accomplishing a given procedure can be reported. In the event 1. Many procedures involving the female and male urinary system that an initial approach is unsuccessful, and an alternative approach include the placement of a urethral catheter for postoperative drain- is undertaken, the approach which successfully accomplishes the age. Because this is integral to the service and represents the stan- procedure becomes the medically necessary service and is reported; dard of medical practice, placement of a urinary catheter is not if appropriate, a -22 modifier may be appended to the procedure separately coded. In addition, catheterizations (e.g. CPT codes code for the successful approach. 51701, 51702, and 51703) are not separately reported when done at the time of or just prior to a surgical procedure. 6. When an endoscopic procedure is performed as an integral part of an open procedure, only the open procedure is reported. If the 2. Many lesions of the genitourinary tract which require biopsy, exci- endoscopy is confirmatory or is performed to assess the surgical sion or destruction involve the mucocutaneous border and several field ("scout endoscopy"), the endoscopy does not represent a diag- CPT codes may generally describe the nature of the biopsy nostic or surgical endoscopy. The endoscopy represents explora- obtained. For a biopsy of a lesion or group of similar lesions, one tion of the surgical field, and should not be separately reported unit of service for the CPT code that most accurately describes the under the diagnostic or surgical endoscopy codes. When an endo- service rendered is reported. As noted in the general policies, in scopic procedure is attempted unsuccessfully and converted to an Chapter I, when a biopsy is followed by an excision or destruction open procedure, only the open procedure is reported (see general during the same session, only the most extensive service is policy on sequential procedures). If the endoscopy is performed for reported. Additionally, separate codes (e.g. integumentary and gen- diagnostic purposes and a subsequent therapeutic service can be itourinary excision codes) are not to be reported unless the biopsy, performed at the same session, the procedure is coded at the high- excision, destruction, etc., service involves completely separate est level of specificity. If the CPT Manual narrative includes endos- lesions; in these cases, the -59 modifier will indicate that separate copy, then the diagnostic endoscopy is not separately coded. If the lesions were removed. The medical record should reflect accurately narrative does not include endoscopy and a separate endoscopy is the precise location of the lesions removed, particularly if it is medi- necessary as a diagnostic procedure, this can be reported sepa- cally necessary to submit each lesion as a separate specimen for rately. The -58 modifier may be used to indicate that the diagnostic pathological evaluation. endoscopy and the subsequent therapeutic service are staged or planned procedures. The medical record must describe the intent 3. Policies regarding injections and infusions (e.g. HCPCS/CPT codes and findings of the diagnostic endoscopy in these cases. 36000, 36410, 90780 and 90781) as part of more extensive pro- cedures have previously been defined and apply to the genitouri- 7. When multiple endoscopic procedures are performed at the same nary family of codes. When irrigation procedures or drainage session, the most comprehensive code accurately describing the ser- procedures are necessary and are integral to successfully accom- vice performed is reported; if several procedures are performed at plish a genitourinary (or any other) procedure, only the more exten- the same endoscopic session, the -51 modifier is attached. (For sive service is reported. example, if a renal endoscopy is performed through an established nephrostomy, a biopsy is performed, a lesion is fulgurated and a 4. Unless otherwise defined by CPT Manual instructions, the repair foreign body (calculus) is removed, the appropriate CPT coding and closure of surgical procedures are included in the CPT code for would be CPT codes 50557 and 50561-51, not CPT codes 50551, the more extensive procedure and are not to be separately reported. 50555, 50557, and 50561.) This policy applies to endoscopic pro- In many genitourinary services, hernia repair is included in the CPT cedures in general and specifically to endoscopic procedures of the Manual descriptor for the service; accordingly, a hernia repair is not genitourinary system. separately reported. If the hernia repair performed is at a different site, this can be separately reported with the -59 modifier indicating 8. When bladder irrigation is performed as part of a more comprehen- sive procedure, or in order to accomplish access or visualization of
©2004 Ingenix, Inc. Jan. 04 Urinary–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI—Version 10.0)
the urinary system, the bladder irrigation (CPT code 51700) is not plish similar services. In general, these groups of codes are not to to be reported. This code is to be used for irrigation with therapeu- be reported together (see mutually exclusive policy). While a num- tic agents or for irrigation as an independent therapeutic service. ber of these groups of codes exist in CPT, a specific example includes the series of codes describing prostate procedures (CPT 9. When electromyography (EMG) is performed as part of a biofeed- codes 55801-55845). In addition, all prostatectomy procedures back session, neither CPT code 51784 nor 51785 is to be reported (e.g. CPT codes 52601-52648 and 55801-55845) are also mutu- unless a significant, separately identifiable diagnostic EMG service ally exclusive of one another. is provided. If either the CPT code 51784 or the CPT code 51785 is to be used for a diagnostic electromyogram, a separate report must D. Female Genital System be available in the medical record to indicate this service was per- 1. When a pelvic examination is performed in conjunction with a formed for diagnostic purposes. gynecologic procedure, either as a necessary part of the procedure or as a confirmatory examination, the pelvic examination is not sep- 10. When endoscopic visualization of the urinary system involves sev- arately reported. A diagnostic pelvic examination may be per- eral regions (e.g. kidney, renal pelvis, calyx, and ureter), the appro- formed for the purposes of deciding to perform a procedure; priate CPT code is defined by the approach (e.g. nephrostomy, however, this examination is included in the evaluation and man- pyelostomy, ureterostomy, etc.) as indicated in the CPT descriptor. agement service at the time the decision to perform the procedure is When multiple endoscopic approaches are simultaneously neces- made. sary to accomplish a medically necessary service (e.g. renal endos- copy through a nephrostomy and cystourethroscopy performed at 2. All surgical laparoscopic, hysteroscopic or peritoneoscopic proce- the same session), they may be separately coded with the multiple dures include diagnostic procedures. Therefore, CPT code 49320 is procedure modifier -51 on the less extensive codes. When multiple included in 38120, 38570-38572, 43280, 43651-43653, endoscopic approaches are necessary to accomplish the same pro- 44200-44202, 44970, 47560-47570, 49321-49323, 49650- cedure, the successful endoscopic approach should be reported. 49651, 54690-54692, 55550, 58545-58554, 58660-58673, 60650; and 58555 is included in 58558-58563. 11. When urethral catheterization or urethral dilation (e.g. CPT codes 51701-51703) is necessary to accomplish a more extensive proce- 3. Lysis of adhesions (CPT code 58660) is not to be reported sepa- dure, the urethral catheterization/dilation is not to be separately rately when done in conjunction with other surgical laparoscopic reported. procedures.
12. Multiple ureteral anastomosis procedures are defined by CPT codes 4. Pelvic exam under anesthesia indicated by CPT code 57410, is 50740-50810, and 50860. In general, they represent mutually included in all major and most minor gynecological procedures and exclusive procedures and are not to be reported together. If one is not to be reported separately. This procedure represents routine anastomosis is performed on one ureter, and a different anastomo- evaluation of the surgical field. sis is performed on a contralateral ureter, the appropriate modifier (e.g. -LT, -RT) is used with the appropriate CPT code to describe the 5. Dilation of vagina or cervix (CPT codes 57400 or 57800), when service performed on the respective ureter. done in conjunction with vaginal approach procedures, is not to be reported separately unless the CPT code manual description states 13. CPT code 50860 (ureterostomy, transplantation of ureter to skin) is "without cervical dilation." mutually exclusive of CPT codes 50800-50830 (e.g. ureterostomy, ureterocolon conduit, urinary undiversion) unless performed at dif- 6. Administration of anesthesia, when necessary, is included in every ferent locations in which case an anatomic modifier should be used. surgical procedure code, when performed by the surgeon.
14. The CPT codes 53502-53515 describe urethral repair codes for 7. Colposcopy (CPT codes 56820, 57420, 57452) should not be urethral wounds or injuries (urethrorrhaphy). When a urethroplasty reported separately when performed as a “scout” procedure to con- is performed, codes for urethrorrhaphy should not be reported in firm the lesion or to assess the surgical field prior to a surgical pro- addition since “suture to repair wound or injury” is included in the cedure. A diagnostic colposcopy resulting in the decision to perform urethroplasty service. a non-colposcopic procedure may be reported with modifier -58. Diagnostic colposcopies (56820, 57420, 57452) are not separately C. Male Genital System reported with other colposcopic procedures. 1. Transurethral drainage of a prostatic abscess (e.g. CPT code 52700) is included in male transurethral prostatic procedures and is not E. Maternity Care and Delivery reported separately. The majority of procedures in this section (CPT codes 59000-59899) include only what is described by the code in the CPT definition. Additional 2. Urethral catheterization (e.g. CPT codes 51701, 51702, and procedures performed on the same day would be reported separately. The 51703), when medically necessary to successfully accomplish a few exceptions to this rule consist of: procedure, should not be separately reported. ■ CPT codes 59050 and 59051(fetal monitoring during labor), 3. The puncture aspiration of a hydrocele (e.g. CPT code 55000) is 59300 (episiotomy) and 59414 (delivery of placenta) are includ- included in services involving the tunica vaginalis and proximate ed in CPT codes 59400 (routine obstetric care, vaginal delivery), anatomy (scrotum, vas deferens) and in inguinal hernia repairs. 59409 (vaginal delivery only), 59410 (vaginal delivery and post- partum care), 59510 (routine obstetric care, cesarean delivery), 4. A number of codes describe surgical procedures of a progressively 59514 (cesarean delivery only), 59515 (cesarean delivery and more comprehensive nature or with different approaches to accom- postpartum care), 59610 (routine obstetric care, vaginal delivery,
Urinary–2 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Male Genital System
54000 Slitting of prepuce, dorsal or lateral (separate procedure); newborn 54056 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 1.53 0.12 1.35 1.35 3.00 3.00 10 1.23 0.07 2.50 1.39 3.80 2.69 10 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDDOC 09 A 24NPDNPDNPD 09 A CORRECT CODING EDITS CORRECT CODING EDITS ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 51701❆, 51702❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ❆ ❆ ■ ❆ ❆ ✓ ✓ ✓ ■ ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<36>¥¥<> 000 , ¥¥<3>¥¥<> 6410 , ¥¥<3>¥¥<> 7202 , 51701 , 51702 , ¥¥<54050>¥¥<> , ¥¥<54055>¥¥<> , ¥¥<5>¥¥<> 4060 , ¥¥<6>¥¥<> 2318 , ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
54001 Slitting of prepuce, dorsal or lateral (separate procedure); except newborn 54057 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum RELATIVE VALUE UNITS contagiosum, herpetic vesicle), simple; laser surgery Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 2.18 0.17 4.35 1.53 6.70 3.88 10 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 1.23 0.10 0.88 0.88 2.21 2.21 10 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 24NPDNPDNPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24NPDNPDNPD 09 A
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 51701❆, 51702❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, CORRECT CODING EDITS ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 51701❆, 51702❆, ¥¥<54050>¥¥<> ✓, ¥¥<54055>¥¥<> ✓, ¥¥<54056>¥¥<> ✓, ¥¥<5>¥¥<> 4060✓, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 54015 Incision and drainage of penis, deep RELATIVE VALUE UNITS 54060 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum Work MP PE–nf PE–f Total–nf Total–f Global P contagiosum, herpetic vesicle), simple; surgical excision 5.29 0.40 2.61 2.61 8.30 8.30 10 RELATIVE VALUE UNITS MODIFIERS INDICATORS Work MP PE–nf PE–f Total–nf Total–f Global P -50 -51 -62 -66 -80, -82 Suprv Status 1.92 0.14 3.92 1.47 5.98 3.53 10 24NPDNPDDOC 09 A MODIFIERS INDICATORS CORRECT CODING EDITS -50 -51 -62 -66 -80, -82 Suprv Status ❆ ❆ ■ ❆ ❆ ❍ ❆ ■ ■ ¥¥<36>¥¥<> 000 , ¥¥<3>¥¥<> 6410 , ¥¥<3>¥¥<> 7202 , 51701 , 51702 , ¥¥<54001>¥¥<> , ¥¥<54450>¥¥<> , ¥¥<6>¥¥<> 2318 , ¥¥<6>¥¥<> 2319 , 24NPDNPDNPD 09 A ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ CORRECT CODING EDITS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 51701❆, 51702❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, 54050 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ contagiosum, herpetic vesicle), simple; chemical RELATIVE VALUE UNITS 54065 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum Work MP PE–nf PE–f Total–nf Total–f Global P contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosur- 1.23 0.08 1.71 1.06 3.02 2.37 10 gery, cryosurgery, chemosurgery) MODIFIERS INDICATORS RELATIVE VALUE UNITS -50 -51 -62 -66 -80, -82 Suprv Status Work MP PE–nf PE–f Total–nf Total–f Global P 24NPDNPDNPD 09 A 2.41 0.16 1.74 1.74 4.31 4.31 10 CORRECT CODING EDITS MODIFIERS INDICATORS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 51701❆, 51702❆, ¥¥<5>¥¥<> 4060✓, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, -50 -51 -62 -66 -80, -82 Suprv Status ■ ■ ■ ■ ■ ■ ❆ ¥¥<64416>¥¥<> , ¥¥<64417>¥¥<> , ¥¥<64450>¥¥<> , ¥¥<64>¥¥<> 470 , ¥¥<64475>¥¥<> , 69990 , ¥¥<9>¥¥<> 0780 24NPDNPDNPD 09 A CORRECT CODING EDITS 54055 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 51701❆, 51702❆, ¥¥<54050>¥¥<> ▼, ¥¥<54055>¥¥<> ▼, ¥¥<54056>¥¥<> ▼, ¥¥<54057>¥¥<> ▼, contagiosum, herpetic vesicle), simple; electrodesiccation ¥¥<5>¥¥<> 4060▼, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P 1.21 0.08 1.62 0.82 2.91 2.11 10 MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDNPD 09 A CORRECT CODING EDITS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 51701❆, 51702❆, ¥¥<5>¥¥<> 4060✓, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Urinary–45 CPT only ©2003 American Medical Association. All Rights Reserved.
Urinary System
50010 Renal exploration, not necessitating other specific procedures 50045 Nephrotomy, with exploration RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 10.92 0.95 5.48 5.48 17.35 17.35 90 15.37 1.27 6.88 6.88 23.52 23.52 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24DOC DOC 8 09 A 24DOC DOC 8 09 A CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 44950✚, 49000❍, ¥¥<49002>¥¥<> ❆, 49010❍, ¥¥<5>¥¥<> 0100❍, ¥¥<6>¥¥<> 0540❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 44950✚, 49000❍, ¥¥<49002>¥¥<> ❆, 49010❍, ¥¥<5>¥¥<> 0010❆, ¥¥<5>¥¥<> 0020▼, ¥¥<6>¥¥<> 0545❍, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<5>¥¥<> 0541▼, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 69990■, ¥¥<9>¥¥<> 0780❆
50020 Drainage of perirenal or renal abscess; open 50060 Nephrolithotomy; removal of calculus RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 14.58 0.96 8.90 8.90 24.44 24.44 90 19.19 1.37 8.13 8.13 28.69 28.69 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24DOC DOC NPD 09 A 24DOC DOC 8 09 A CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 44950✚, 49000❍, ¥¥<49002>¥¥<> ❆, 49010❍, ¥¥<49020>¥¥<> ✓, ¥¥<5>¥¥<> 0010❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 44950✚, 49000❍, ¥¥<49002>¥¥<> ❆, 49010❍, ¥¥<5>¥¥<> 0020▼, ¥¥<50040>¥¥<> ▼, ¥¥<5>¥¥<> 0205▼, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<50045>¥¥<> ▼, ¥¥<50065>¥¥<> ✓, ¥¥<50>¥¥<> 070✓, ¥¥<50075>¥¥<> ✓, ¥¥<50500>¥¥<> ❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
50021 Drainage of perirenal or renal abscess; percutaneous 50065 Nephrolithotomy; secondary surgical operation for calculus RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 3.36 0.18 1.11 1.11 4.65 4.65 0 20.67 1.35 6.38 6.38 28.40 28.40 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPD809A 24NPDNPD809A CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<4>¥¥<> 9061✓, ¥¥<49424>¥¥<> ❍, ¥¥<5>¥¥<> 0020✓, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 44950✚, 49000❍, ¥¥<49002>¥¥<> ❆, 49010❍, ¥¥<5>¥¥<> 0020▼, ¥¥<50040>¥¥<> ▼, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<50045>¥¥<> ▼, ¥¥<50075>¥¥<> ✓, ¥¥<50500>¥¥<> ❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 50040 Nephrostomy, nephrotomy with drainage 50070 Nephrolithotomy; complicated by congenital kidney abnormality RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 14.85 0.98 8.51 8.51 24.34 24.34 90 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 20.20 1.44 8.52 8.52 30.16 30.16 90 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 24DOC DOC NPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24DOC DOC 8 09 A CORRECT CODING EDITS ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 44950✚, 49000❍, ¥¥<49002>¥¥<> ❆, 49010❍, ¥¥<5>¥¥<> 0010❆, ¥¥<5>¥¥<> 0020▼, ¥¥<50045>¥¥<> ✓, ¥¥<50500>¥¥<> ❆, ¥¥<5>¥¥<> 0541▼, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, 44950✚, 49000❍, ¥¥<49002>¥¥<> ❆, 49010❍, ¥¥<5>¥¥<> 0020▼, ¥¥<50040>¥¥<> ▼, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<50045>¥¥<> ▼, ¥¥<50065>¥¥<> ✓, ¥¥<50075>¥¥<> ✓, ¥¥<50500>¥¥<> ❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Urinary–5 CPT only ©2003 American Medical Association. All Rights Reserved.
Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, Auditory Systems (CPT Codes 60000–69999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction Example: A patient with an open head injury and a contra-coup The section of CPT codes 60000-69979 includes surgical procedures subdural hematoma requires a craniectomy for the open head injury involving the endocrine and nervous systems, procedures involving eye, and a burr hole drainage on the opposite side for the subdural ocular adnexa, and ear. Because of the number of procedures involved, hematoma. The performance of a burr hole at the time of the these sections are subdivided. craniectomy would be considered part of the craniectomy. However, the contralateral burr hole would be considered a separate service In keeping with the general policies introduced earlier, most issues of correct not integral to the craniectomy. To correctly code the burr hole for coding can be identified and addressed by reviewing the CPT code defini- the contralateral subdural hematoma and the column 1 coded ser- tion for the appropriate service. vice (the craniectomy), the burr hole should be coded with the As a general guideline, when a component service, which is described by a appropriate modifier (-59, -RT, -LT, etc.). In this example the correct CPT code is necessary to accomplish a more comprehensive service, the coding would be CPT codes 61304 with one unit of service and component service is assumed to be included in the more comprehensive 61154-59 with one unit of service. service; therefore only the more comprehensive service which was per- 5. The use of general intravascular access devices (e.g. intravenous formed can be coded. lines, etc.), cardiac monitoring, oximetry, laboratory sample pro- B. Endocrine and Nervous Systems curement and other routine monitoring for patient safety has been 1. A burr hole is often necessary in anticipation for intracranial surgery addressed in the previous policy for general anesthesia or moni- (e.g. craniotomy, craniectomy), either to gain access to intracranial tored anesthesia care (MAC). These policies also apply for proce- contents, to alleviate pressure in anticipation of further surgery or to dures that do not require the presence of an anesthesiologist/ place an intracranial pressure monitoring device as part of the sur- certified registered nurse anesthetist. As an example, if a physician gery. As these services are integral to the performance of the subse- is performing a spinal puncture for intrathecal injection and admin- quent services, codes representing these services are not to be isters an anxiolytic agent, but the procedure does not require the separately reported if performed at the same session; if performed presence of an anesthesiologist/certified registered nurse anesthe- prior to the comprehensive procedure, the -58 modifier can be used tist, the vascular access and any appropriate monitoring necessary to indicate that the burr hole and the intracranial surgery are staged is considered part of the spinal puncture procedure and is not to be or planned services. reported separately.
In addition, taps, punctures or burr holes accompanied by drainage 6. When a spinal puncture is performed, the local anesthesia neces- procedures (e.g. hematoma, abscess, cyst, etc.) followed by other sary to perform the spinal puncture is included in the procedure procedures, are not separately reported unless performed as staged itself. The submission of nerve block or facet block codes for local procedures. The -58 modifier may be used to indicate staged or anesthesia for a diagnostic or therapeutic lumbar puncture is inap- planned services. Many intracranial procedures include bone grafts propriate when there is no independent medical necessity of the by CPT definition and these grafts should not be reported sepa- administration of local anesthetic except for the lumbar puncture. rately. Separate codes are not to be reported. In comparison, if, in the course of a nerve or other anesthetic block procedure, cerebrospinal 2. Biopsies performed in the course of Central Nervous System (CNS) fluid is withdrawn, it is inappropriate to bill for a diagnostic lumbar surgery should not be reported as separate procedures. puncture; only the nerve (or other) block should be reported; the CSF procurement is not for diagnostic purposes. 3. Craniotomies and craniectomies always include a general explora- tion of the accessible field; accordingly it is not appropriate to code 7. The appropriate code for the open treatment of median nerve com- an exploratory surgery (e.g. CPT codes 61304, 61305) when pression at the wrist (carpal tunnel syndrome) is CPT code 64721; another procedure is performed at the same session. according to CPT Manual definition, this includes the open release of the transverse carpal ligament. Additionally, if an arthroscopic 4. When services are performed at the same session, but represent dif- procedure (CPT code 29848) fails and must be followed by an open ferent types of services or are being performed at different sites (see procedure (CPT code 64721), only the open, or successful, proce- example below), the -59 modifier should be added. This modifier dure can be reported, if necessary, with a -22 modifier. indicates that this service was a distinct, separate service and should not be included in the column 1 code. 8. Nerve repairs by suture or neurorrhaphies (CPT codes 64831- 64876) include suture and anastomosis of nerves when performed
©2004 Ingenix, Inc. Jan. 04 Endocrine–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI—Version 10.0)
to correct traumatic injury to or anastomosis of nerves which are without other evidence for glaucoma, is not to be separately proximally associated (e.g. facial-spinal, facial-hypoglossal, etc.). reported. When neurorrhaphy is performed in conjunction with a nerve graft (CPT codes 64885-64907), a neuroplasty, transection, excision, 3. The various approaches to removing a cataract are mutually exclu- neurectomy, excision of neuroma, etc., a separate service is not sive of one another when performed on the same eye. reported for the primary nerve suture. 4. Some retinal detachment repair procedures include some vitreous 9. In the same area of the cortex, neurostimulator electrodes can be procedures (e.g. CPT code 67108 includes 67015, 67025, 67028, implanted in only one fashion; accordingly, the CPT code 61850 67031, 67036, 67039, and 67040). Certain retinal detachment (burr hole) is included in the CPT code 61860 (craniectomy). Codes repairs are mutually exclusive to anterior procedures such as focal describing craniotomy procedures (e.g. CPT codes 62100-62121) endolaser photocoagulation (e.g. CPT codes 67110 and 67112 are are generally bundled into craniectomy codes (e.g. CPT codes mutually exclusive to CPT code 67108). 61860-61875). 5. CPT codes 68020-68200 (incision, drainage, excision of the con- 10. Because procedures necessary to accomplish a column 1 procedure junctiva) are included in all conjunctivoplasties (CPT codes 68320- are included in the column 1 procedure, CPT codes such as 62310- 68362). 62311, 62318-62319 (injection of diagnostic or therapeutic sub- stances) are included in the codes describing more invasive back 6. CPT code 67950 (canthoplasty) is included in repair procedures procedures. Additionally, at the same site, codes describing lamino- such as blepharoplasties (CPT codes 67917, 67924, 67961, tomy procedures are included in laminectomy codes. CPT codes 67966). 22100-22116 (partial excision of vertebral components) represent 7. Correction of lid retraction (CPT code 67911) includes full thickness distinct procedures, and, accordingly, are not reported with laminot- graft (e.g. CPT code 15260) as part of the total service performed. omy/laminectomy procedures unless the services are performed as described in the codes. 8. In the circumstance that it is medically necessary and reasonable to inject sclerosing agents in the same session as surgery to correct 11. CPT codes describing the performance of a tracheostomy are not to glaucoma, the service is included in the glaucoma surgery. Accord- be reported with the CPT code 61576 (transoral approach to skull ingly, codes such as CPT codes 67500, 67515, and 68200 for base including tracheostomy) as this service is included in the injection of sclerosing agents (e.g. 5-FU, HCPCS/CPT code J9190) descriptor for the code. should not be reported with other pressure- reducing or glaucoma C. Ophthalmology procedures. 1. When a subconjunctival injection (e.g. CPT code 68200) with a D. Auditory System local anesthetic is performed as part of a more extensive anesthetic 1. When a mastoidectomy is included in the description of an auditory procedure (e.g. peribulbar or retrobulbar block), a separate service procedure (e.g. CPT codes 69530, 69802, 69910), separate codes for this procedure is not to be reported. This is a routine part of the describing mastoidectomy are not reported. anesthetic procedure and does not represent a separate service. 2. Myringotomies (e.g. CPT codes 69420 and 69421) are included in 2. Iridectomy, trabeculectomy, and anterior vitrectomy may be per- tympanoplasties and tympanostomies. formed in conjunction with cataract removal. When an iridectomy is performed in order to accomplish the cataract extraction, it is an E. General Policy Statements integral part of the procedure; it does not represent a separate ser- 1. Medicare Global Surgery Rules prevent separate payment for post- vice, and is not separately reported. Similarly, the minimal vitreous operative pain management when provided by the physician per- loss occurring during routine cataract extraction does not represent forming an operative procedure. CPT codes 36000, 36410, a vitrectomy and is not to be separately reported unless it is medi- 37202, 62318-62319, 64415-64417, 64450, 64470, 64475 cally necessary for a different diagnosis. While a trabeculectomy is and 90780 describe services that may be utilized for postoperative not performed as a part of a cataract extraction, it may be performed pain management. The services described by these codes may be to control glaucoma at the same time as a cataract extraction. If the reported only if performed for purposes unrelated to the postopera- procedure is medically necessary at the same time as a cataract tive pain management. extraction, it can be reported under a different diagnosis (e.g. glau- coma). The codes describing iridectomies, trabeculectomies, and 2. Medicare Anesthesia Rules prevent separate payment for anesthesia anterior vitrectomies, when performed with a cataract extraction when provided by the physician performing a medical or surgical under a separate diagnosis, must be reported with the -59 modifier. service. The physician should not report CPT codes 00100-01999. This indicates that the procedure was performed as a different ser- Additionally, the physician should not unbundle the anesthesia pro- vice for a separate situation. The medical record should reflect the cedure and report component codes individually. For example, medical necessity of the service if separately reported. For example, introduction of a needle or intracatheter into a vein (CPT code if a patient presents with a cataract and has evidence of glaucoma, 36000), venipuncture (CPT code 36410), or intravenous infusion (i.e. elevated intraocular pressure preoperatively) and a trabeculec- (CPT code 90780) should not be reported when these services are tomy represents the appropriate treatment for the glaucoma, a sepa- related to the delivery of an anesthetic agent. rate service for the trabeculectomy would be separately reported. Performance of a trabeculectomy as a preventative service for an expected transient increase in intraocular pressure postoperatively,
Endocrine–2 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Endocrine System
60000 Incision and drainage of thyroglossal duct cyst, infected 60212 Partial thyroid lobectomy, unilateral; with contralateral subtotal lobec- tomy, including isthmusectomy RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 1.75 0.17 2.20 2.07 4.12 3.99 10 15.94 1.81 7.88 7.88 25.63 25.63 90 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDDOC 09 A 24DOC DOC 8 09 A CORRECT CODING EDITS CORRECT CODING EDITS ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 0001▼, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ❆ ❆ ■ ▼ ▼ ▼ ▼ ▼ ▼ ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<36>¥¥<> 000 , ¥¥<3>¥¥<> 6410 , ¥¥<3>¥¥<> 7202 , ¥¥<6>¥¥<> 0000 , ¥¥<6>¥¥<> 0001 , ¥¥<6>¥¥<> 0100 , ¥¥<6>¥¥<> 0200 , ¥¥<6>¥¥<> 0210 , 60280 , 60281▼, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 60001 Aspiration and/or injection, thyroid cyst RELATIVE VALUE UNITS 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 0.96 0.07 1.52 0.35 2.55 1.38 0 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 11.83 1.16 6.35 6.35 19.34 19.34 90 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 24NPDNPDNPD 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24DOC DOC 8 09 A ★ ★ ❆ ❆ ■ ■ ■ ■ ■ ¥¥<10021>¥¥<> , ¥¥<10022>¥¥<> , ¥¥<36>¥¥<> 000 , ¥¥<3>¥¥<> 6410 , ¥¥<3>¥¥<> 7202 , ¥¥<6>¥¥<> 2318 , ¥¥<6>¥¥<> 2319 , ¥¥<64415>¥¥<> , ¥¥<64416>¥¥<> , CORRECT CODING EDITS ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 0000▼, ¥¥<6>¥¥<> 0001▼, ¥¥<6>¥¥<> 0100▼, ¥¥<6>¥¥<> 0200▼, ¥¥<6>¥¥<> 0210▼, ¥¥<6>¥¥<> 0212▼, ¥¥<60502>¥¥<> ❆, ¥¥<60505>¥¥<> ❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ■ ■ ❆ 60100 Biopsy thyroid, percutaneous core needle ¥¥<64475>¥¥<> , 69990 , ¥¥<9>¥¥<> 0780 RELATIVE VALUE UNITS Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, Work MP PE–nf PE–f Total–nf Total–f Global P 60225 including isthmusectomy 1.55 0.06 1.44 0.54 3.05 2.15 0 RELATIVE VALUE UNITS MODIFIERS INDICATORS Work MP PE–nf PE–f Total–nf Total–f Global P -50 -51 -62 -66 -80, -82 Suprv Status 14.11 1.57 7.62 7.62 23.30 23.30 90 24NPDNPDNPD 09 A MODIFIERS INDICATORS CORRECT CODING EDITS -50 -51 -62 -66 -80, -82 Suprv Status ¥¥<10021>¥¥<> ★, ¥¥<10022>¥¥<> ★, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, 24DOC DOC 8 09 A ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, 88172★, ¥¥<9>¥¥<> 0780❆ CORRECT CODING EDITS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 0000▼, ¥¥<6>¥¥<> 0001▼, ¥¥<6>¥¥<> 0100★, ¥¥<6>¥¥<> 0200▼, ¥¥<6>¥¥<> 0210▼, ¥¥<6>¥¥<> 0212▼, 60200 Excision of cyst or adenoma of thyroid, or transection of isthmus ¥¥<6>¥¥<> 0220◆, ¥¥<60500>¥¥<> ■, ¥¥<60502>¥¥<> ■, ¥¥<60505>¥¥<> ■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P 9.50 1.01 6.18 6.18 16.69 16.69 90 60240 Thyroidectomy, total or complete MODIFIERS INDICATORS RELATIVE VALUE UNITS -50 -51 -62 -66 -80, -82 Suprv Status Work MP PE–nf PE–f Total–nf Total–f Global P 24DOC DOC 8 09 A 15.97 1.80 7.82 7.82 25.59 25.59 90 CORRECT CODING EDITS MODIFIERS INDICATORS ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 0000▼, ¥¥<6>¥¥<> 0001▼, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, -50 -51 -62 -66 -80, -82 Suprv Status ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 24DOC DOC 8 09 A CORRECT CODING EDITS 60210 Partial thyroid lobectomy, unilateral; with or without isthmusectomy ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 0000▼, ¥¥<6>¥¥<> 0001▼, ¥¥<6>¥¥<> 0100▼, ¥¥<6>¥¥<> 0200▼, ¥¥<6>¥¥<> 0210▼, ¥¥<6>¥¥<> 0212▼, ¥¥<6>¥¥<> 0220◆, ¥¥<6>¥¥<> 0225◆, ¥¥<6>¥¥<> 0254✓, ¥¥<6>¥¥<> 0270✓, ¥¥<60280>¥¥<> ▼, ¥¥<60281>¥¥<> ▼, ¥¥<60500>¥¥<> ❆, ¥¥<60502>¥¥<> ❆, ¥¥<60505>¥¥<> ❆, RELATIVE VALUE UNITS ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, Work MP PE–nf PE–f Total–nf Total–f Global P ¥¥<9>¥¥<> 0780❆ 10.82 1.21 5.83 5.83 17.86 17.86 90 MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status 24DOC DOC 8 09 A CORRECT CODING EDITS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 0000▼, ¥¥<6>¥¥<> 0001▼, ¥¥<6>¥¥<> 0100▼, ¥¥<6>¥¥<> 0200▼, ¥¥<60280>¥¥<> ▼, ¥¥<60281>¥¥<> ▼, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Endocrine–3 CPT only ©2003 American Medical Association. All Rights Reserved.
Nervous System
61000 Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; 61050 Cisternal or lateral cervical (C1-C2) puncture; without injection (separate initial procedure) RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 1.57 0.16 0.97 0.97 2.70 2.70 0 1.50 0.16 1.28 1.28 2.94 2.94 0 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDNPD 09 A 24NPDNPDDOC 09 A CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
61001 Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; 61055 Cisternal or lateral cervical (C1-C2) puncture; with injection of medication subsequent taps or other substance for diagnosis or treatment (eg, C1-C2) RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 1.48 0.18 1.08 1.08 2.74 2.74 0 2.09 0.16 1.44 1.44 3.69 3.69 0 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDNPD 09 A 2NANPDNPDNPD09 A CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<61000>¥¥<> ✓, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, 01905●, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<61050>¥¥<> ◆, ¥¥<6>¥¥<> 2310●, ¥¥<6>¥¥<> 2318●, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<64>¥¥<> 479●, 69990■, ¥¥<9>¥¥<> 0780❆
61020 Ventricular puncture through previous burr hole, fontanelle, suture, or 61070 Puncture of shunt tubing or reservoir for aspiration or injection procedure implanted ventricular catheter/reservoir; without injection RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.88 0.11 1.05 1.05 2.04 2.04 0 1.50 0.31 1.38 1.38 3.19 3.19 0 MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 24NPDNPDNPD 09 A 24NPDNPDNPD 09 A CORRECT CODING EDITS CORRECT CODING EDITS ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<61000>¥¥<> ❆, ¥¥<61001>¥¥<> ❆, ¥¥<61>¥¥<> 070❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
Twist drill hole for subdural or ventricular puncture; 61026 Ventricular puncture through previous burr hole, fontanelle, suture, or 61105 implanted ventricular catheter/reservoir; with injection of medication or RELATIVE VALUE UNITS other substance for diagnosis or treatment Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 5.11 1.26 4.01 4.01 10.38 10.38 90 Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 1.68 0.25 1.45 1.45 3.38 3.38 0 -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 24NPDNPDDOC 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 24NPDNPDNPD 09 A ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<61793>¥¥<> ❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, CORRECT CODING EDITS ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<69990>¥¥<> ■, ¥¥<9>¥¥<> 0780❆, ¥¥
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<61000>¥¥<> ❆, ¥¥<61001>¥¥<> ❆, ¥¥<61020>¥¥<> ◆, ¥¥<61>¥¥<> 070❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 61107 Twist drill hole for subdural or ventricular puncture; for implanting ven- tricular catheter or pressure recording device RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P 4.97 1.22 3.36 3.36 9.55 9.55 0 MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDNPD09 A CORRECT CODING EDITS
¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<61105>¥¥<> ◆, ¥¥<61793>¥¥<> ❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<69990>¥¥<> ■, ¥¥<9>¥¥<> 0780❆, ¥¥
Radiology Services (CPT Codes 70000–79999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction patient variation. Accordingly, all radiographs necessary to complete a study The CPT Manual includes codes related to diagnostic radiology (imaging), are included in the CPT code description. Unless specifically noted, fluoros- ultrasound, radiation oncology and nuclear medicine. The diagnostic imag- copy necessary to complete a procedure and obtain the necessary perma- ing section includes non-invasive and invasive diagnostic and therapeutic nent radiographic record is included in the major procedure performed. (interventional) procedures, as well as computerized tomography and mag- Preliminary “scout” radiographs obtained prior to contrast administration or netic resonance imaging. Most correct coding issues are defined by CPT delayed imaging radiographs are often performed; when a separate CPT coding convention. code is available to include these radiographs, it should be used. If there is B. Non-interventional Diagnostic Imaging no separate CPT code including additional views, it is assumed that these Non-invasive/interventional diagnostic imaging includes standard radio- are included in the basic procedure. graphs, single or multiple views, contrast studies, computerized tomogra- C. Interventional/Invasive Diagnostic Imaging phy and magnetic resonance imaging. The CPT Manual allows for various When contrast can be administered orally (upper GI) or rectally (barium combinations of codes to address the number and type of radiographic enema), the administration is included as part of the procedure and no views. For a given radiographic series, the procedure code that most accu- administration service is reported. When contrast material is parenterally rately describes what was performed is appropriate. Because of the number administered, whether the timing of the injection has to correlate with the of combinations of views necessary to obtain medically useful information, procedure or not (e.g. IVP, CT scans, gadolinium), the administration and a complete review of CPT coding options for a given radiographic session is the injection (e.g. HCPCS/CPT codes 36000, 36406, 36410 and 90782- important to assure accurate coding with the most comprehensive code that 90784) are included in the contrast studies. describes the services performed rather than billing multiple codes to describe the service. When a contrast study is performed in which there is direct correlation of the timing of the study to the injection or administration (e.g. angiography), and In the event that radiographs have to be repeated in the course of a radio- different providers perform separate parts of the procedure, each provider graphic encounter due to substandard quality, only one unit of service for would bill the service he/she rendered. The procedural aspect of the service the code can be reported. Additionally, if after reviewing initial films, the is coded from outside the CPT 70000 series and the radiographic supervi- radiologist elects to obtain additional views in order to render an interpreta- sion and interpretation (S & I) service is coded from the 70000 series of tion, the Medicare policy on the ordering of diagnostic tests should be fol- codes. lowed and the CPT code describing the total service is reported, even if the patient was released from the radiology suite and had to return for addi- The individual CPT codes in the 70000 section identify which injection or tional services. The CPT descriptor for many of these services refers to a administration code is appropriate for a given procedure; in the absence of a “minimum” number of views. Accordingly, if more than the minimum num- parenthetical CPT note, it is not appropriate to submit an administration ber specified is necessary, and no other more specific CPT code is available, component. When an intravenous line is placed (e.g. CPT code 36000) sim- only that service should be billed. On the other hand, if additional films are ply for access in the event of a problem with the procedure or for administra- necessary due to a change in the patient’s condition, separate billing would tion of contrast, it is considered part of the procedure. A separate code (e.g. be appropriate. CPT code 36005), is available for the injection procedure for contrast venog- raphy and includes the introduction of a needle or an intracatheter (e.g. CPT CPT code descriptors which specify a minimum number of views should be code 36000). reported when the minimum number of views or if more than the minimum number of views must be obtained in order to satisfactorily complete the In the case of urologic procedures and other surgeries, insertion of a ure- radiographic study. For example, if three views of the shoulder are thral catheter (e.g. CPT code 51701-51702) is part of the procedure and is obtained, CPT code 73030, one unit of service, should be reported, not not to be separately reported. 73020 and 73030. The CPT codes 90783 and 90784 are for intra-arterial and intravenous When limited comparative radiographic studies are performed (e.g. post- therapeutic or diagnostic injections. Injections for contrast procedures are reduction radiographs, post-intubation, post-catheter placement, etc.), the included in the procedure; CPT codes 90783, and 90784 cannot be sepa- CPT code for a comprehensive radiographic series should be reported with a rately reported with radiographic, CT, MRI, or nuclear imaging codes to rep- -52 modifier, indicating that a reduced level of interpretive service was pro- resent part of the injection procedure. vided. D. Evaluation and Management Studies may be performed without contrast, with contrast or both with and When physician interaction with a patient is necessary to accomplish a without contrast. There are separate codes available to describe all of these radiographic procedure, typically occurring in invasive or interventional combinations of contrast usage. When studies require contrast, there is not radiology, the interaction generally involves limited pertinent historical generally an established number of radiographs to be obtained because of inquiry about reasons for the examination, the presence of allergies, acquisi-
©2004 Ingenix, Inc. Jan. 04 Radiology–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI—Version 10.0) tion of informed consent, discussion of follow-up, and the review of the 5. CPT code 76970 (ultrasound study, follow-up) cannot be reported medical record. In this setting, a separate evaluation and management ser- with any other echocardiographic or ultrasound guidance proce- vice is not reported. As a rule, if the medical decision making that evolves dures because it represents a follow-up procedure on the same day. from the procurement of the information from the patient is limited to whether or not the procedure should be performed, whether comorbidity 6. CPT code 77790 (supervision, handling, loading of radiation may impact the procedure, or involves discussion and education with the source) is not to be reported with any of the remote afterloading patient, an evaluation/management code is not reported separately. If a sig- brachytherapy codes (e.g. CPT codes 77781-77784) since these nificant, separately identifiable service is rendered, involving taking a his- procedures inherently include the supervision of the radioelement. tory, performing an exam, and making medical decisions distinct from the procedure, the appropriate evaluation and management service can be 7. Bone studies such as CPT codes 76020-76065 require a series of reported. The appropriate evaluation and management service code is cho- radiographs; billing separately for bone studies and individual sen based on the type of service rendered which satisfies the Evaluation and radiographs obtained in the course of the bone study is inappropri- Management guidelines developed by the AMA and CMS. ate. In radiation oncology, evaluation and management services would not be 8. Radiologic supervision and interpretation codes for specific proce- separately reported with the exception of an initial consultation at which dures include all the radiologic services necessary for that proce- time a decision is made whether to proceed with the treatment. Radiation dure. For example, do not additionally report fluoroscopy (e.g., CPT oncology includes clinical treatment planning, simulation, medical radiation codes 76000, 76001, 76003, 76005) or ultrasound guidance physics, dosimetry treatment devices, special services, and clinical treat- (e.g., CPT codes 76942, 76986). ment management procedures in teletherapy and brachytherapy. The categories of procedures in this subsection are well-defined according to levels of intensity for clinical treatment planning, devices, delivery and man- agement. E. Nuclear Medicine The general policies promulgated above apply to nuclear medicine as well as standard diagnostic imaging. Several issues specific to the practice of nuclear medicine require comment. The injection of the radionuclide is included as part of the procedure; sepa- rate injection codes (e.g. 36000, 90783) should not be reported. Single photon emission computed tomography (SPECT) studies represent an enhanced methodology over standard planar nuclear imaging. When a limited anatomic area is studied, there is no additional information procured by obtaining both planar and SPECT studies. While both represent medi- cally acceptable imaging studies, when a SPECT study of a limited area is performed, a planar study is not to be separately reported. When vascular flow studies are obtained using planar technology in addition to SPECT studies, the appropriate CPT code for the vascular flow study should be reported, not the flow, planar and SPECT studies. In cases where planar images must be procured because of the extent of the scanned area (e.g. bone imaging), both planar and SPECT scans may be necessary and reported separately. F. General Policy Statements 1. Any abdominal radiology procedure that has a radiological supervi- sion and interpretation code (e.g. CPT code 75625 for abdominal aortogram), would also include abdominal x-rays (e.g. CPT codes 74000-74022) as part of the total service.
2. Xeroradiography (e.g. CPT code 76150) is not to be reported with any mammography studies based on CPT coding instruction.
3. Guidance for placement of radiation fields by computerized tomog- raphy or ultrasound (CPT codes 76370 or 76950) for the same anatomical area are mutually exclusive of one another.
4. Ultrasound guidance services and diagnostic echography should be reported only when both procedures are performed. Ultrasound guidance services alone do not represent diagnostic echography.
Radiology–2 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Radiology
79100 Radiopharmaceutical therapy, polycythemia vera, chronic leukemia, 79300 Interstitial radioactive colloid therapy each treatment by intravenous injection RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 1.31 0.20 3.07 3.07 4.58 4.58 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 C 2NANPDNPDDOC 09 A CORRECT CODING EDITS CORRECT CODING EDITS ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❍, ¥¥<77750>¥¥<> ✓, ¥¥<77761>¥¥<> ✓, ¥¥<77762>¥¥<> ✓, ¥¥<77763>¥¥<> ✓, ¥¥<77776>¥¥<> ✓, ¥¥<77777>¥¥<> ✓, ¥¥<77778>¥¥<> ✓, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❍, ¥¥<76>¥¥<> 000■, ¥¥<76>¥¥<> 003■, ¥¥<76>¥¥<> 942■, ¥¥<7>¥¥<> 6986■, ¥¥<77750>¥¥<> ✓, ¥¥<77761>¥¥<> ✓, ¥¥<77762>¥¥<> ✓, ¥¥<77781>¥¥<> ✓, ¥¥<77782>¥¥<> ✓, ¥¥<77783>¥¥<> ✓, ¥¥<77784>¥¥<> ✓, ¥¥<77789>¥¥<> ✓, ¥¥<77790>¥¥<> ❆, ¥¥<7>¥¥<> 9200✓, ¥¥<9>¥¥<> 0780❆, 90784❆ ¥¥<77763>¥¥<> ✓, ¥¥<77776>¥¥<> ✓, ¥¥<77777>¥¥<> ✓, ¥¥<77778>¥¥<> ✓, ¥¥<77781>¥¥<> ✓, ¥¥<77782>¥¥<> ✓, ¥¥<77783>¥¥<> ✓, ¥¥<77784>¥¥<> ✓, ¥¥<77789>¥¥<> ✓, ¥¥<77790>¥¥<> ❆, ¥¥<79400>¥¥<> ✓, ¥¥<9>¥¥<> 0780❆, 90784❆ 79300-26 Interstitial radioactive colloid therapy 79100-26 Radiopharmaceutical therapy, polycythemia vera, chronic leukemia, RELATIVE VALUE UNITS each treatment by intravenous injection Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 1.59 0.08 0.57 0.57 2.24 2.24 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 1.31 0.06 0.47 0.47 1.84 1.84 NA -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 2NANPDNPDDOC 09 A -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A 79400 Radiopharmaceutical therapy, nonthyroid, nonhematologic by inter- venous injection 79100-TC Radiopharmaceutical therapy, polycythemia vera, chronic leukemia, RELATIVE VALUE UNITS each treatment by intravenous injection Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 1.95 0.24 3.27 3.27 5.46 5.46 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 0.00 0.14 2.60 2.60 2.74 2.74 NA -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 2NANPDNPDDOC 09 A -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 2NANPDNPDDOC 09 A ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❍, ¥¥<76>¥¥<> 000■, ¥¥<76>¥¥<> 003■, ¥¥<76>¥¥<> 942■, ¥¥<7>¥¥<> 6986■, ¥¥<77750>¥¥<> ✓, ¥¥<77761>¥¥<> ✓, ¥¥<77762>¥¥<> ✓, ¥¥<77763>¥¥<> ✓, ¥¥<77776>¥¥<> ✓, ¥¥<77777>¥¥<> ✓, ¥¥<77778>¥¥<> ✓, ¥¥<77781>¥¥<> ✓, ¥¥<77782>¥¥<> ✓, ¥¥<77783>¥¥<> ✓, ¥¥<77784>¥¥<> ✓, ¥¥<77789>¥¥<> ✓, ¥¥<77790>¥¥<> ❆, ¥¥<9>¥¥<> 0780❆, 90784❆ 79200 Intracavitary radioactive colloid therapy RELATIVE VALUE UNITS 79400-26 Radiopharmaceutical therapy, nonthyroid, nonhematologic by inter- Work MP PE–nf PE–f Total–nf Total–f Global P venous injection 1.98 0.22 3.29 3.29 5.49 5.49 NA RELATIVE VALUE UNITS MODIFIERS INDICATORS Work MP PE–nf PE–f Total–nf Total–f Global P -50 -51 -62 -66 -80, -82 Suprv Status 1.95 0.10 0.67 0.67 2.72 2.72 NA 2NANPDNPDDOC 09 A MODIFIERS INDICATORS CORRECT CODING EDITS -50 -51 -62 -66 -80, -82 Suprv Status ❆ ❍ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ¥¥<36>¥¥<> 000 , ¥¥<3>¥¥<> 6410 , ¥¥<77750>¥¥<> , ¥¥<77761>¥¥<> , ¥¥<77762>¥¥<> , ¥¥<77763>¥¥<> , ¥¥<77776>¥¥<> , ¥¥<77777>¥¥<> , ¥¥<77778>¥¥<> , 2NANPDNPDDOC 09 A ¥¥<77781>¥¥<> ✓, ¥¥<77782>¥¥<> ✓, ¥¥<77783>¥¥<> ✓, ¥¥<77784>¥¥<> ✓, ¥¥<77789>¥¥<> ✓, ¥¥<77790>¥¥<> ❆, ¥¥<9>¥¥<> 0780❆, 90784❆
79400-TC Radiopharmaceutical therapy, nonthyroid, nonhematologic by inter- 79200-26 Intracavitary radioactive colloid therapy venous injection RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 1.98 0.08 0.69 0.69 2.75 2.75 NA 0.00 0.14 2.60 2.60 2.74 2.74 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A 2NANPDNPDDOC 09 A
79200-TC Intracavitary radioactive colloid therapy RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.14 2.60 2.60 2.74 2.74 NA MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A ● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Radiology–179 CPT only ©2003 American Medical Association. All Rights Reserved.
Radiology
70010 Myelography, posterior fossa, radiological supervision and interpre- 70015-TC Cisternography, positive contrast, radiological supervision and inter- tation pretation RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 1.18 0.29 4.70 4.70 6.17 6.17 NA 0.00 0.08 1.34 1.34 1.42 1.42 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A 2NANPDNPDDOC 03 A CORRECT CODING EDITS ❆ ❆ ❆ ❆ ❆ ❆ ❆ ❆ ❆ ❆ ¥¥<36>¥¥<> 000 , ¥¥<36406>¥¥<> , ¥¥<3>¥¥<> 6410 , ¥¥<76>¥¥<> 000 , ¥¥<76>¥¥<> 001 , ¥¥<76>¥¥<> 003 , ¥¥<76>¥¥<> 005 , 90782 , 90783 , 90784 70030 Radiologic examination, eye, for detection of foreign body RELATIVE VALUE UNITS Myelography, posterior fossa, radiological supervision and interpre- 70010-26 Work MP PE–nf PE–f Total–nf Total–f Global P tation 0.17 0.03 0.48 0.48 0.68 0.68 NA RELATIVE VALUE UNITS MODIFIERS INDICATORS Work MP PE–nf PE–f Total–nf Total–f Global P -50 -51 -62 -66 -80, -82 Suprv Status 1.18 0.07 0.40 0.40 1.65 1.65 NA 3NANPDNPDDOC 09 A MODIFIERS INDICATORS CORRECT CODING EDITS -50 -51 -62 -66 -80, -82 Suprv Status NA 2NANPDNPDDOC 09 A
Radiologic examination, eye, for detection of foreign body 70010-TC Myelography, posterior fossa, radiological supervision and interpre- 70030-26 tation RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.17 0.01 0.06 0.06 0.24 0.24 NA 0.00 0.22 4.30 4.30 4.52 4.52 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 3NANPDNPDDOC 09 A 2NANPDNPDDOC 03 A 70030-TC Radiologic examination, eye, for detection of foreign body 70015 Cisternography, positive contrast, radiological supervision and inter- pretation RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 0.00 0.02 0.42 0.42 0.44 0.44 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 1.18 0.14 1.74 1.74 3.06 3.06 NA -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 3NANPDNPDDOC 01 A -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A CORRECT CODING EDITS 70100 Radiologic examination, mandible; partial, less than four views ¥¥<36>¥¥<> 000❆, ¥¥<36>¥¥<> 011❆, ¥¥<36406>¥¥<> ❆, ¥¥<3>¥¥<> 6410❆, ¥¥<76>¥¥<> 000❆, ¥¥<76>¥¥<> 001❆, ¥¥<76>¥¥<> 003❆, ¥¥<76>¥¥<> 005❆, 90782❆, RELATIVE VALUE UNITS 90783❆, 90784❆ Work MP PE–nf PE–f Total–nf Total–f Global P 0.18 0.03 0.58 0.58 0.79 0.79 NA 70015-26 Cisternography, positive contrast, radiological supervision and inter- MODIFIERS INDICATORS pretation -50 -51 -62 -66 -80, -82 Suprv Status RELATIVE VALUE UNITS 2NANPDNPDDOC 09 A Work MP PE–nf PE–f Total–nf Total–f Global P CORRECT CODING EDITS 1.18 0.06 0.40 0.40 1.64 1.64 NA NA MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A 70100-26 Radiologic examination, mandible; partial, less than four views RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P 0.18 0.01 0.06 0.06 0.25 0.25 NA MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Radiology–3 CPT only ©2003 American Medical Association. All Rights Reserved.
Pathology/Laboratory Services (CPT Codes 80000–89999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction ting, these codes are only reported if the physician performs the service per- Pathology and laboratory CPT coding includes services primarily reported to sonally. In the office setting, the service can be reported when performed by evaluate specimens obtained from patients (body fluids, cytological speci- office personnel if the physician is directly supervising the service. While mens, or tissue specimens obtained by invasive/surgical procedures) in supplies necessary to perform the testing are included in the testing, the order to provide information to the treating physician. This information, appropriate HCPCS J codes for the drugs can be separately reported for the coupled with information obtained from history and examination findings diagnostic agents. Separate evaluation and management services are not to and other data, provides the physician with the background upon which be reported, including prolonged services (in the case of prolonged infu- medical decision making is established. sions) unless a significant, separately identifiable service is provided and documented. If separate evaluation and management services are provided Generally, pathology and laboratory specimens are prepared and/or and reported, the injection procedure is included in this service and is not screened by laboratory personnel with a pathologist assuming responsibil- separately reported. ity for the integrity of the results generated by the laboratory. Certain types of specimens and tests are reviewed personally by the pathologist. CPT D. General Policy Statements coding for this section includes few codes requiring patient contact or evalu- 1. Multiple CPT codes are descriptive of services performed for bone ation and management services rendered directly by the pathologist. On and bone marrow evaluation. When a biopsy is performed for eval- the occasion that a pathologist provides evaluation and management ser- uation of bone matrix structure, the appropriate code to bill is CPT vices (significant, separately identifiable, patient care services that satisfy code 20220 for the biopsy and CPT code 88307 for the surgical the criteria set forth in the E/M guidelines developed by CMS, formerly pathology evaluation. HCFA, and the AMA), appropriate coding should be rendered from the evalu- ation and management section of the CPT Manual. When a bone marrow aspiration is performed alone, the appropri- ate coding is CPT code 38220. Appropriate coding for the interpre- If, after a test is ordered and performed, additional related procedures are tation is CPT code 85097 when the only service provided is the necessary to provide or confirm the result, these would be considered part interpretation of the bone marrow smear. When both are performed of the ordered test. For example, if a patient with leukemia has a thrombocy- by the same provider, both CPT codes may be reported. The patho- topenia, and a manual platelet count (CPT code 85032) is performed in logical interpretations (CPT code 88300-88309) are not reported in addition to the performance of an automated hemogram with automated addition to CPT code 85097 unless separate specimens are pro- platelet count (CPT code 85025), it would be inappropriate to report CPT cessed. codes 85032 and 85025 because the former provides a confirmatory test for the automated hemogram and platelet count (CPT code 85025). As When it is medically necessary to evaluate both bone structure and another example, if a patient has an abnormal test result and repeat perfor- bone marrow, and both services can be provided with one biopsy, mance of the test is done to verify the result, the test is reported as one unit only one code (CPT code 38221 or CPT code 20220) can be of service rather than two. reported. If two separate biopsies are necessary, then both can be reported using the -59 modifier on one of the codes. Pathological B. Organ or Disease Oriented Panel interpretation codes 88300-88309 may be separately reported for The CPT Manual assigns CPT codes to organ or disease oriented panels multiple separately submitted specimens. If only one specimen is consisting of a group of specified tests. If all tests of a CPT defined panel are submitted, only one code can be reported regardless of whether the performed, the provider may bill the panel code or the individual component report includes evaluation of both bone structure and bone marrow test codes. The panel codes may be used when the tests are ordered as that morphology or not. panel or if the individual component tests of a panel are ordered separately. For example, if the individually ordered tests are cholesterol (CPT code 2. The family of CPT codes 87040-87158 refers to microbial culture 82465), triglycerides (CPT code 84478), and HDL cholesterol (CPT code studies. The type of culture is coded to the highest level of specific- 83718), the service could be billed as a lipid panel (CPT code 80061). ity regarding source, type, etc. When a culture is processed by a commercial kit, report the code that describes the test to its highest C. Evocative/Suppression Testing level of specificity. A screening culture and culture for definitive iden- Evocative/suppression testing involves administration of agents to deter- tification are not performed on the same day on the same specimen mine a patient's response to those agents (CPT codes 80400-80440 are to and therefore are not reported together. be used for reporting the laboratory components of the testing). When the test requires physician administration of the evocative/suppression agent as 3. When cytopathology codes are reported, the appropriate CPT code described by CPT codes 90780-90784 (therapeutic/diagnostic injections/ to bill is that which describes, to the highest level of specificity, what infusions), these codes can be separately reported. However, when physi- services were rendered. Accordingly, for a given specimen, only cian attendance is not required, and the agent is administered by ancillary one code from a group of related codes describing a group of ser- personnel, these codes are not to be separately reported. In the inpatient set- vices that could be performed on a specimen with the same end
©2004 Ingenix, Inc. Jan. 04 Pathology–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI—Version 10.0)
result (e.g. 88104-88108, 88142-88143, 88150-88154, If the abnormal cells in two or more specimens are morphologically 88164-88167, etc.) is to be reported. If multiple services (i.e., sep- similar and testing on one specimen by one method (88342 or arate specimens) are reported, the -59 modifier should be used to 88180) establishes the diagnosis, the other method should not be indicate that different levels of service were provided for different reported on the same or similar specimen. Similar specimens would specimens. This should be reflected in the cytopathologic reports. A include, but are not limited to: cytopathology preparation from a fluid, washing, or brushing is to be reported using one code from the range of CPT codes 88104- (1) blood and bone marrow; 88108. It is inappropriate to additionally use CPT codes 88160- 88162 because the smears are included in the codes referable to (2) bone marrow aspiration and bone marrow biopsy; fluids (washings or brushings) and 88160-88162 references “any (3) two separate lymph nodes; or other source” which would exclude fluids, washings, or brushings. (4) lymph node and other tissue with lymphoid infiltrate. 4. The CPT codes 80500 and 80502 are used to indicate that a pathologist has reviewed and interpreted, with a subsequent writ- 8. Quantitative immunohistochemistry by digital cellular imaging ten report, a clinical pathology test. These codes additionally are should not be reported as CPT code 88342 with CPT code 88358. not to be used with any other pathology service that includes a phy- Prior to January 1, 2004, it should be reported as CPT code 88342. sician interpretation (e.g. surgical pathology). If an evaluation and Beginning January 1, 2004, it should be reported as CPT code management service (face-to-face contact with the patient) takes 88361. CPT code 88361 should not be used to report any service place by the pathologist, then the appropriate E/M code is reported, other than quantitative immunocytochemistry by digital cellular rather than the clinical pathology consultation codes, even if, as part imaging. Digital cellular imaging includes computer software anal- of the evaluation and management service, review of the test result ysis of stained microscopic slides. is performed. Reporting of these services (CPT codes 80500 and 80502) requires the written order for consultation by a treating 9. DNA ploidy and S-phase analysis of tumor by digital cellular imag- physician. ing technique should not be reported as CPT code 88313 with CPT code 88358. Prior to January 1, 2004, it should be reported as 5. The CPT codes 88321-88325 are to be used to review slides, tis- CPT code 88313. Beginning January 1, 2004, it should be sues, or other material obtained and prepared at a different location reported as CPT code 88358. Prior to January 1, 2004, CPT code and referred to a pathologist for a second opinion. (These codes 88358 should be utilized to report DNA ploidy and should not be reported by pathologists reporting a second opinion on slides, tissue, or material also examined and reported by S-phase analysis of tumor by non-digital cellular imaging tech- another pathologist in the same provider group.) Medicare gener- niques. CPT code 88358 should not be used to report any service ally does not pay twice for an interpretation of a given technical ser- other than DNA ploidy and S-phase analysis. One unit of service vice (e.g., EKGs, radiographs, etc.). When reporting CPT codes for CPT code 88358 includes both DNA ploidy and S-phase analy- 88321-88325, providers should not report other pathology CPT sis. codes such as 88312, 88313, 88342, 88180, etc., for interpreta- tion of stains, slides or material previously interpreted by another 10. CPT code 83721 (lipoprotein, direct measurement; direct measure- pathologist. CPT codes 88312, 88313 and 88342 may be ment, LDL cholesterol) is used to report direct measurement of the reported with CPT code 88323 if provider performs and interprets LDL cholesterol. It should not be used to report a calculated LDL these stains de novo. These codes are not to be used for a face-to- cholesterol. Direct measurement of LDL cholesterol in addition to face evaluation of a patient. In the event that a physician provides total cholesterol (CPT code 82465) or lipid panel (CPT code 80061) an evaluation and management service to a patient and, in the may be reasonable and necessary if the triglyceride level is too high course of this service, specimens obtained elsewhere are reviewed to permit calculation of the LDL cholesterol. In such situations, CPT as well, this is part of the evaluation and management service and code 83721 should be reported with modifier -59. is not to be reported separately. Only the evaluation and manage- ment service would be reported.
6. Multiple tests to identify the same analyte, marker, or infectious agent should not be reported separately. For example, it would not be appropriate to report both direct probe and amplified probe tech- nique tests for the same infectious agent.
7. Medicare does not pay for duplicate testing. CPT codes 88342 (immunocytochemistry, each antibody) and 88180 (flow cytometry) should not in general be reported for the same or similar speci- mens. The diagnosis should be established using one of these methods. The provider may report both CPT codes if both methods are required because the initial method is nondiagnostic or does not explain all the light microscopic findings. The provider can report both methods utilizing modifier -59 and document the need for both methods in the medical record.
Pathology–2 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Pathology and Laboratory Services
80048 Basic metabolic panel This panel must include the following: Cal- 80069 Renal function panel This panel must include the following: Albumin cium (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82040) Calcium (82310) Carbon dioxide (bicarbonate) (82374) (82565) Glucose (82947) Potassium (84132) Sodium (84295) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus Urea nitrogen (BUN) (84520) inorganic (phosphate) (84100) Potassium (84132) Sodium (84295) RELATIVE VALUE UNITS Urea nitrogen (BUN) (84520) Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 0.00 0.00 0.00 0.00 0.00 0.00 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 0.00 0.00 0.00 0.00 0.00 0.00 NA -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS NA NA NA NA NA 09 NON -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS NA NA NA NA NA 09 NON
¥¥<8>¥¥<> 0051✓, ¥¥<82310>¥¥<> ▲, ¥¥<82374>¥¥<> ▲, ¥¥<82435>¥¥<> ▲, ¥¥<82565>¥¥<> ▲, ¥¥<82947>¥¥<> ▲, ¥¥<84132>¥¥<> ▲, ¥¥<84295>¥¥<> ▲, ¥¥<84520>¥¥<> ▲ CORRECT CODING EDITS 80048◆, ¥¥<8>¥¥<> 0051◆, ¥¥<82>¥¥<> 040▲, ¥¥<82310>¥¥<> ▲, ¥¥<82374>¥¥<> ▲, ¥¥<82435>¥¥<> ▲, ¥¥<82565>¥¥<> ▲, ¥¥<82947>¥¥<> ▲, ¥¥<84100>¥¥<> ▲, ¥¥<84132>¥¥<> ▲, ¥¥<84295>¥¥<> ▲, ¥¥<84520>¥¥<> ▲ 80051 Electrolyte panel This panel must include the following: Carbon diox- ide (82374) Chloride (82435) Potassium (84132) Sodium (84295) RELATIVE VALUE UNITS 80074 Acute hepatitis panel This panel must include the following: Hepati- tis A antibody (HAAb), IgM antibody (86709) Hepatitis B core anti- Work MP PE–nf PE–f Total–nf Total–f Global P body (HBcAb), IgM antibody (86705) Hepatitis B surface antigen 0.00 0.00 0.00 0.00 0.00 0.00 NA (HBsAg) (87340) Hepatitis C antibody (86803) MODIFIERS INDICATORS RELATIVE VALUE UNITS -50 -51 -62 -66 -80, -82 Suprv Status Work MP PE–nf PE–f Total–nf Total–f Global P NA NA NA NA NA 09 NON 0.00 0.00 0.00 0.00 0.00 0.00 NA CORRECT CODING EDITS MODIFIERS INDICATORS ¥¥<82374>¥¥<> ▲, ¥¥<82435>¥¥<> ▲, ¥¥<84132>¥¥<> ▲, ¥¥<84295>¥¥<> ▲ -50 -51 -62 -66 -80, -82 Suprv Status NA NA NA NA NA 09 NON 80053 Comprehensive metabolic panel This panel must include the follow- CORRECT CODING EDITS ing: Albumin (82040) Bilirubin, total (82247) Calcium (82310) Car- ¥¥<86705>¥¥<> ▲, ¥¥<86709>¥¥<> ▲, ¥¥<86803>¥¥<> ▲, ¥¥<8>¥¥<> 7340▲ bon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potas- sium (84132) Protein, total (84155) Sodium (84295) Transferase, 80076 Hepatic function panel This panel must include the following: Albu- alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino min (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phos- (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520) phatase, alkaline (84075) Protein, total (84155) Transferase, RELATIVE VALUE UNITS alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 0.00 0.00 0.00 0.00 0.00 0.00 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 0.00 0.00 0.00 0.00 0.00 0.00 NA -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS NA NA NA NA NA 09 NON -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS NA NA NA NA NA 09 NON 80048▲, ¥¥<8>¥¥<> 0051◆, 80069■, 80076■, ¥¥<82>¥¥<> 040▲, ¥¥<82247>¥¥<> ▲, ¥¥<82310>¥¥<> ▲, ¥¥<82374>¥¥<> ▲, ¥¥<82435>¥¥<> ▲, ¥¥<82565>¥¥<> ▲, ¥¥<82947>¥¥<> ▲, ¥¥<84075>¥¥<> ▲, ¥¥<84132>¥¥<> ▲, ¥¥<84155>¥¥<> ▲, ¥¥<84295>¥¥<> ▲, ¥¥<84450>¥¥<> ▲, ¥¥<84>¥¥<> 460▲, ¥¥<84520>¥¥<> ▲ CORRECT CODING EDITS ¥¥<82>¥¥<> 040▲, ¥¥<82247>¥¥<> ▲, ¥¥<82248>¥¥<> ▲, ¥¥<84075>¥¥<> ▲, ¥¥<84155>¥¥<> ▲, ¥¥<84450>¥¥<> ▲, ¥¥<84>¥¥<> 460▲ 80061 Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density 80100 Drug screen, qualitative; multiple drug classes chromatographic cholesterol (HDL cholesterol) (83718) Triglycerides (84478) method, each procedure RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status NA NA NA NA NA 09 NON NA NA NA NA NA 09 NON CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<80500>¥¥<> ❆, ¥¥<80502>¥¥<> ❆, ¥¥<82465>¥¥<> ▲, ¥¥<83718>¥¥<> ▲, ¥¥<83721>¥¥<> ■, ¥¥<84>¥¥<> 478▲ ¥¥<8>¥¥<> 0101◆, ¥¥<80500>¥¥<> ❆, ¥¥<80502>¥¥<> ❆, ¥¥<82>¥¥<> 486◆, ¥¥<82487>¥¥<> ◆, ¥¥<82>¥¥<> 488◆, ¥¥<82>¥¥<> 489◆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Pathology–3 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI Version 10.0)
89100 Duodenal intubation and aspiration; single specimen (eg, simple 89135 Gastric intubation, aspiration, and fractional collections (eg, gastric bile study or afferent loop culture) plus appropriate test procedure secretory study); one hour RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.60 0.02 1.62 0.22 2.24 0.84 NA 0.79 0.04 1.61 0.25 2.44 1.08 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A 2NANPDNPDDOC 09 A CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<43752>¥¥<> ■, ¥¥
89105 Duodenal intubation and aspiration; collection of multiple fractional 89136 Gastric intubation, aspiration, and fractional collections (eg, gastric specimens with pancreatic or gallbladder stimulation, single or dou- secretory study); two hours ble lumen tube RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.21 0.01 1.66 0.09 1.88 0.31 NA 0.50 0.02 2.26 0.17 2.78 0.69 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A 2NANPDNPDDOC 09 A CORRECT CODING EDITS
CORRECT CODING EDITS ¥¥<43752>¥¥<> ■, ¥¥<8>¥¥<> 9135◆, ¥¥
89130 Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology; 89141 Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); three hours, including gastric stimulation RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.45 0.02 1.76 0.13 2.23 0.60 NA 0.85 0.04 2.75 0.34 3.64 1.23 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A 2NANPDNPDDOC 09 A CORRECT CODING EDITS CORRECT CODING EDITS ¥¥<43752>¥¥<> ■, ¥¥
89132 Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology; after stimulation 89160 Meat fibers, feces RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.19 0.01 1.51 0.06 1.71 0.26 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A NA NA NA NA NA 09 NON CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<43752>¥¥<> ■, ¥¥
★ Sequential Procedures ✓ Mutually Exclusive Procedures ✰ Standard Preparation/Monitoring Services ❐ “With” versus “Without” Procedures ■ Misuse of Column 2 with Column 1 <¥¥>¥¥<> Modifier use may allow separate payment ▲ Laboratory Panels Pathology–70 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Medicine, Evaluation and Management Services (CPT Codes 90000–99999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction C. Psychiatric Services The Medicine section of the CPT Manual includes codes for non-invasive or CPT codes for psychiatric services include general and special diagnostic minimally invasive (primarily percutaneous access) services that would not services as well as a variety of therapeutic services. By CPT Manual defini- be considered open surgical procedures or evaluation and management ser- tion, therapeutic services (e.g. HCPCS/CPT codes 90804-90829) include vices. In keeping with the general principles of correct CPT coding, the ser- psychotherapy and continuing medical diagnostic evaluation; therefore, CPT vices required to accomplish an evaluation or procedure as described by a codes 90801 and 90802 are not reported with these services. medicine code descriptor are included in the code and cannot be separately reported even if other specific CPT codes exist to describe these supplemen- Interactive services (diagnostic or therapeutic) are distinct forms of services tal services. These principles are described in depth in the general policies for patients who have “lost, or have not yet developed either the expressive of Chapter I. language communication skills to explain his/her symptoms and response to treatment...”. Accordingly, non-interactive services would not be possible B. Therapeutic or Diagnostic Infusions/Injections at the same session as interactive services and are not to be reported The CPT codes 90780-90799 describe services involving therapeutic or together with interactive services. diagnostic injections and infusions. The CPT codes 96400-96549 describe Drug management is included in some therapeutic services (e.g. HCPCS/ administration of chemotherapeutic (primarily antineoplastic) agents; issues CPT codes 90801-90829, 90845, 90847-90853, 90865-90870) and referable to chemotherapy administration will be discussed in this section therefore CPT code 90862 (pharmacologic management) is not to be due to the frequent similarities in administration. reported with these codes. Because the placement of peripheral vascular access devices is integral to When medical services, other than psychiatric services, are provided in vascular (intravenous, intra-arterial) infusions and injections, the CPT codes addition to psychiatric services, separate evaluation and management codes for placement of these devices are not to be separately reported. Accord- cannot be reported. The psychiatric service includes the evaluation and ingly, routine insertion of an intravenous catheter (e.g. CPT codes 36000, management services provided according to CMS policy. 36410) for intravenous infusion, injection or chemotherapy administration (e.g. CPT codes 90780, 90781, 90784, 96408-96412) would be inappro- D. Biofeedback priate. Insertion of central venous access is not routinely necessary to Biofeedback services involve the use of electromyographic techniques to accomplish these services and therefore, could be separately reported. detect and record muscle activity. The CPT codes 95860-95872 (EMG) Because intra-arterial infusion usually involves selective catheterization of should not be reported with biofeedback services based on the use of elec- an arterial supply to a specific organ, there is no routine arterial catheteriza- tromyography during a biofeedback session. If an EMG is performed as a tion common to all arterial infusions; selective arterial catheterization codes separate medically necessary service for diagnosis or follow-up of organic could be separately reported. muscle dysfunction, the appropriate EMG codes (e.g. CPT codes 95860- The administration of drugs, such as growth factors, saline, and diuretics, 95872) may be reported. The -59 modifier should be added to indicate that and other than antineoplastic drugs are reported with CPT codes 90780- the service performed was a separately identifiable diagnostic service. 90784. When the sole purpose of fluid administration (e.g. saline, D5W, Reporting only an objective electromyographic response to biofeedback is etc.) is to maintain patency of the access device, the infusion is neither diag- not sufficient to bill the codes referable to diagnostic EMG. nostic nor therapeutic; therefore, the injection, infusion or chemotherapy E. Gastroenterology administration codes are not to be separately reported. In the case of trans- Gastroenterological tests included in CPT codes 91000-91299 are fre- fusion of blood or blood products, the insertion of a peripheral IV (e.g. CPT quently complementary to endoscopic procedures. Esophageal and gastric codes 36000, 36410) is routinely necessary and is not separately reported. washings for cytology are described as part of upper endoscopy (e.g. CPT Administration of fluid in the course of transfusions to maintain line patency code 43235); therefore, CPT codes 91000 (esophageal intubation) and or between units of blood products is, likewise, not to be separately 91055 (gastric intubation) are not separately reported when performed as reported. If fluid administration is medically necessary for therapeutic rea- part of an upper endoscopy. Provocative testing (CPT code 91052) can be sons (e.g. to correct dehydration, to prevent nephrotoxicity, etc.) in the expedited during GI endoscopy (procurement of gastric specimens). When course of a transfusion or chemotherapy, this could be separately reported performed at the same time as GI endoscopy, CPT code 91052 is reported with the -59 modifier as this is being administered as medically necessary with the -52 modifier indicating that a reduced level of service was per- for a different diagnosis. formed.
©2004 Ingenix, Inc. Jan. 04 Medicine–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI—Version 10.0) F. Ophthalmology tified in the CPT Manual for a given procedure, these can be sepa- General ophthalmological services (e.g. CPT codes 92002-92014) describe rately reported. components of the ophthalmologic examination. When evaluation and management codes are reported, these general ophthalmological service 3. Cardiac output measurement (e.g. CPT codes 93561-93562) is rou- codes (e.g. CPT codes 92002-92014) are not to be reported; the same ser- tinely performed during cardiac catheterization procedures per CPT vices would be represented by both series of codes. definition and, therefore, CPT codes 93561-93562 are not to be reported with cardiac catheterization codes. Special ophthalmologic services represent specific services not described as part of a general or routine ophthalmological examination. Special ophthal- 4. CPT codes 93797 and 93798 describe comprehensive services pro- mological services are recognized as significant, separately identifiable ser- vided by a physician for cardiac rehabilitation. As this includes all vices. services referable to cardiac rehabilitation, it would be inappropriate to bill a separate evaluation and management service code unless For procedures requiring intravenous injection of dye or other diagnostic an unrelated, separately identifiable, service is performed and docu- agent, insertion of an intravenous catheter and dye injection are necessary mented in the medical record. to accomplish the procedure and are included in the procedure. Accordingly, HCPCS/CPT codes 36000 (introduction of a needle or catheter),36410 5. When a physician who is in attendance for a cardiac stress test (venipuncture),90780 (IV infusion),and 90784 (IV injection)as well as selec- obtains a history, and performs a limited examination referable spe- tive vascular catheterization codes are not to be separately reported with cifically to the cardiac stress test, a separate evaluation and manage- services requiring intravenous injection (e.g. CPT codes 92230, 92235, ment service is not reported unless a significant, separately 92240, 92287, for angioscopy and angiography). identifiable service is performed unrelated to the performance of the cardiac stress test and in accordance with the evaluation and man- G. Otorhinolaryngologic Services agement guidelines. The evaluation and management service CPT coding for otorhinolaryngologic services involves a number of tests that would be reported with the -25 modifier in this instance. can be performed qualitatively by confrontation during physical examina- tion or quantitatively with electrical recording equipment. CPT definition 6. Routine monitoring of EKG rhythm and review of daily hemody- specifies which is the case for each code. CPT codes 92552-92557, and namics, including cardiac outputs, is a part of critical care evaluation 92561-92589 can be performed qualitatively or quantitatively but accord- and management. Separate billing for review of EKG rhythm strips ing to CPT definition these can be reported only if calibrated electronic and cardiac output measurements (e.g. CPT codes 93040-93042, equipment is used. Confrontational estimation of these tests by the physi- 93561, 93562) and critical care services is inappropriate. An cian is part of the evaluation and management service. exception to this may include a sudden change in patient status associated with a change in cardiac rhythm requiring a return to the H. Cardiovascular Services ICU or telephonic transmission to review a rhythm strip. If reported Cardiovascular medicine services include non-invasive and invasive diag- separately, time included for this service is not included in the criti- nostic testing (including intracardiac testing) as well as therapeutic services cal care time calculated for the critical care service. (e.g. electrophysiological procedures). Several unique issues arise due to the spectrum of cardiovascular codes included in this section. I. Pulmonary Services 1. When cardiopulmonary resuscitation is performed without other CPT coding for pulmonary function tests includes both comprehensive and evaluation and management services (e.g. a physician responds to component codes to accommodate variation among pulmonary function lab- a “code blue” and directs cardiopulmonary resuscitation with the oratories. As a result of these code combinations, several issues are patient's attending physician then resuming the care of the patient addressed in this policy section. after the patient has been revived), only the CPT code 92950 for 1. Alternate methods of reporting data obtained during a spirometry CPR should be reported. Levels of critical care services and pro- or other pulmonary function session cannot be separately reported. longed management services are determined by time; when CPT Specifically, the flow volume loop is an alternative method of calcu- code 92950 is reported, the time required to perform CPR is not lating a standard spirometric parameter. The CPT code 94375 is included in critical care or other timed evaluation and management included in standard spirometry (rest and exercise) studies. services. 2. When a physician who is in attendance for a pulmonary function 2. In keeping with the policies outlined previously, procedures rou- study, obtains a limited history, and performs a limited examination tinely performed as part of a comprehensive service are included in referable specifically to the pulmonary function testing, separately the comprehensive service and not separately reported. A number coding for an evaluation and management service is not appropri- of therapeutic and diagnostic cardiovascular procedures (e.g. CPT ate. If a significant, separately identifiable service is performed codes 92950-92998, 93501-93545, 93600-93624, 93640- unrelated to the technical performance of the pulmonary function 93652) routinely utilize intravenous or intra-arterial vascular test, an evaluation and management service may be reported. access, routinely require electrocardiographic monitoring, and fre- quently require agents administered by injection or infusion tech- 3. When multiple spirometric determinations are necessary (e.g. CPT niques; accordingly, separate codes for routine access, monitoring, code 94070) to complete the service described in the CPT code, injection or infusion services are not to be reported. Fluoroscopic only one unit of service is reported. guidance procedures are integral to invasive intravascular proce- dures and are included in those services. In unique circumstances, 4. Pulmonary stress testing (e.g. CPT code 94620) is a comprehensive where these services are performed, not as an integral part of the stress test with a number of component tests separately defined in procedure, the appropriate code can be separately reported with the the CPT Manual. It is inappropriate to separately code venous -59 modifier. When supervision and interpretation codes are iden- access, EKG monitoring, spirometric parameters performed before,
Medicine–2 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Evaluation and Management Services
99201 Office or other outpatient visit for the evaluation and management of 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a prob- a new patient, which requires these three key components: a com- lem focused history; a problem focused examination; and straight- prehensive history; a comprehensive examination; and medical deci- forward medical decision making. Counseling and/or coordination of sion making of moderate complexity. Counseling and/or care with other providers or agencies are provided consistent with coordination of care with other providers or agencies are provided the nature of the problem(s) and the patient's and/or family's needs. consistent with the nature of the problem(s) and the patient's and/or Usually, the presenting problems are self limited or minor. Physi- family's needs. Usually, the presenting problem(s) are of moderate to cians typically spend 10 minutes face-to-face with the patient and/or high severity. Physicians typically spend 45 minutes face-to-face family. with the patient and/or family. RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.45 0.02 0.51 0.16 0.98 0.63 NA 1.99 0.12 1.54 0.71 3.65 2.82 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A 2NANPDNPDDOC 09 A CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<43752>¥¥<> ■, 80500❆, 80502❆, 90862❆, 90940❆, 92002▼, 92004▼, 92012▼, 92014▼, ¥¥<43752>¥¥<> ■, 80500❆, 80502❆, 90862❆, 90940❆, 92002▼, 92004▼, 92012▼, 92014▼, 94656❆, 94657❆, 94660❆, 94662❆, 95831❆, 95832❆, 95833❆, 95834❆, 95851❆, 94656❆, 94657❆, 94660❆, 94662❆, 95831❆, 95832❆, 95833❆, 95834❆, 95851❆, 95852❆, ¥¥<9>¥¥<> 6115✚, 96150✚, 96151✚, 96152✚, 96153✚, 96154✚, 97802■, 97803■, 95852❆, ¥¥<9>¥¥<> 6115✚, 96150✚, 96151✚, 96152✚, 96153✚, 96154✚, 97802■, 97803■, 97804■, 99239✓, 99435✓, G0102❆, G0117❆, G0118❆, G0245❆, G0246❆, ¥¥
99202 Office or other outpatient visit for the evaluation and management of 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an a new patient, which requires these three key components: a com- expanded problem focused history; an expanded problem focused prehensive history; a comprehensive examination; and medical deci- examination; and straightforward medical decision making. Coun- sion making of high complexity. Counseling and/or coordination of seling and/or coordination of care with other providers or agencies care with other providers or agencies are provided consistent with are provided consistent with the nature of the problem(s) and the the nature of the problem(s) and the patient's and/or family's needs. patient's and/or family's needs. Usually, the presenting problem(s) Usually, the presenting problem(s) are of moderate to high severity. are of low to moderate severity. Physicians typically spend 20 min- Physicians typically spend 60 minutes face-to-face with the patient utes face-to-face with the patient and/or family. and/or family. RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.87 0.06 0.79 0.32 1.72 1.25 NA 2.65 0.14 1.82 0.93 4.61 3.72 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 A 2NANPDNPDDOC 09 A CORRECT CODING EDITS CORRECT CODING EDITS
¥¥<43752>¥¥<> ■, 80500❆, 80502❆, 90862❆, 90940❆, 92002▼, 92004▼, 92012▼, 92014▼, ¥¥<43752>¥¥<> ■, 80500❆, 80502❆, 90862❆, 90940❆, 92002▼, 92004▼, 92012▼, 92014▼, 94656❆, 94657❆, 94660❆, 94662❆, 95831❆, 95832❆, 95833❆, 95834❆, 95851❆, 94656❆, 94657❆, 94660❆, 94662❆, 95831❆, 95832❆, 95833❆, 95834❆, 95851❆, 95852❆, ¥¥<9>¥¥<> 6115✚, 96150✚, 96151✚, 96152✚, 96153✚, 96154✚, 97802■, 97803■, 95852❆, ¥¥<9>¥¥<> 6115✚, 96150✚, 96151✚, 96152✚, 96153✚, 96154✚, 97802■, 97803■, 97804■, 99239✓, 99435✓, G0102❆, G0117❆, G0118❆, G0245❆, G0246❆, ¥¥
99203 Office or other outpatient visit for the evaluation and management of 99211 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a an established patient, that may not require the presence of a physi- detailed history; a detailed examination; and medical decision mak- cian. Usually, the presenting problem(s) are minimal. Typically, 5 ing of low complexity. Counseling and/or coordination of care with minutes are spent performing or supervising these services. other providers or agencies are provided consistent with the nature RELATIVE VALUE UNITS of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typi- Work MP PE–nf PE–f Total–nf Total–f Global P cally spend 30 minutes face-to-face with the patient and/or family. 0.17 0.01 0.41 0.06 0.59 0.24 NA RELATIVE VALUE UNITS MODIFIERS INDICATORS Work MP PE–nf PE–f Total–nf Total–f Global P -50 -51 -62 -66 -80, -82 Suprv Status 1.33 0.10 1.15 0.49 2.58 1.92 NA 2NANPDNPDDOC 09 A MODIFIERS INDICATORS CORRECT CODING EDITS -50 -51 -62 -66 -80, -82 Suprv Status ¥¥<43752>¥¥<> ■, 80500❆, 80502❆, 90862❆, 90940❆, 92002▼, 92004▼, 92012▼, 92014▼, 94656❆, 94657❆, 94660❆, 94662❆, 95831❆, 95832❆, 95833❆, 95834❆, 95851❆, 2NANPDNPDDOC 09 A 95852❆, ¥¥<9>¥¥<> 6115✚, 96150✚, 96151✚, 96152✚, 96153✚, 96154✚, 97802■, 97803■, CORRECT CODING EDITS 97804■, 99239✓, 99435✓, G0102❆, G0117❆, G0118❆, G0245❆, G0246❆, ¥¥
Medicine Services
90375 Rabies immune globulin (RIg), human, for intramuscular and/or sub- 90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for per- cutaneous use cutaneous use RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status NA NA NA NA NA 09 EXC NA NA NA NA NA 09 EXC CORRECT CODING EDITS CORRECT CODING EDITS 90376✓ 90586✓, 90782✚
90378 Respiratory syncytial virus immune globulin (RSV-IgIM), for intra- 90632 Hepatitis A vaccine, adult dosage, for intramuscular use muscular use, 50 mg, each RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status NA NA NA NA NA 09 EXC NA NA NA NA NA 09 NON CORRECT CODING EDITS CORRECT CODING EDITS 90633✓, 90634✓, 90636✓, 90782✓ ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<9>¥¥<> 0780■, 90783■, 90784■, 90788■
90471 Immunization administration (includes percutaneous, intradermal, 90633 Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, subcutaneous, intramuscular and jet injections); one vaccine (single for intramuscular use or combination vaccine/toxoid) RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.01 0.20 0.20 0.21 0.21 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status NA NA NA NA NA 09 EXC 2NANPDNPDDOC 09 A CORRECT CODING EDITS CORRECT CODING EDITS 90634✓, 90636✓, 90782✓ 90782✓, 90784✓ 90634 Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, 90472 Immunization administration (includes percutaneous, intradermal, for intramuscular use subcutaneous, intramuscular and jet injections); each additional vac- RELATIVE VALUE UNITS cine (single or combination vaccine/toxoid) (List separately in addi- Work MP PE–nf PE–f Total–nf Total–f Global P tion to code for primary procedure) 0.00 0.00 0.00 0.00 0.00 0.00 NA RELATIVE VALUE UNITS MODIFIERS INDICATORS Work MP PE–nf PE–f Total–nf Total–f Global P -50 -51 -62 -66 -80, -82 Suprv Status 0.00 0.01 0.14 0.14 0.15 0.15 INC NA NA NA NA NA 09 EXC MODIFIERS INDICATORS CORRECT CODING EDITS -50 -51 -62 -66 -80, -82 Suprv Status 90636✓, 90782✓ 2NANPDNPDDOC 09 A CORRECT CODING EDITS 90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for NA intramuscular use RELATIVE VALUE UNITS 90581 Anthrax vaccine, for subcutaneous use Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA RELATIVE VALUE UNITS MODIFIERS INDICATORS Work MP PE–nf PE–f Total–nf Total–f Global P -50 -51 -62 -66 -80, -82 Suprv Status 0.00 0.00 0.00 0.00 0.00 0.00 NA NA NA NA NA NA 09 EXC MODIFIERS INDICATORS CORRECT CODING EDITS -50 -51 -62 -66 -80, -82 Suprv Status 90782✚ NA NA NA NA NA 09 EXC CORRECT CODING EDITS 90782✚
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Medicine–7 CPT only ©2003 American Medical Association. All Rights Reserved.
Category III Codes CPT Codes (0001T – 0099T)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction dures in the related section of the CPT Manual. For example, if the XXXXT The CPT Manual contains Category III codes, XXXXT, that represent emerg- code describes a laboratory procedure, the coding policies that apply are ing technologies, services, and procedures. Each Category III code is refer- those found in Chapter I (General Correct Coding Policies) and Chapter X enced in another section of the CPT Manual that contains related (Pathology and Laboratory Services (CPT Codes 80000-89999)) of the procedures. CCI contains edits for many of these codes. The coding policies “National Correct Coding Policy Manual for Part B Medicare Carriers.” used to establish these edits are the same as those used for other proce-
©2004 Ingenix, Inc. Jan. 04 Category III–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Category III Codes
0002T Transcatheter placement of extracranial cerebrovascular artery stent(s), 0009T Endometrial cryoablation with ultrasonic guidance percutaneous; initial vessel RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 C NA NA NPD NPD NPD 09 NA CORRECT CODING EDITS CORRECT CODING EDITS ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<5>¥¥<> 7100❍, ¥¥<5>¥¥<> 7180❍, ¥¥<57400>¥¥<> ❆, ¥¥<57>¥¥<> 410❆, ¥¥<57>¥¥<> 452■, ¥¥<57500>¥¥<> ❍, ¥¥<5>¥¥<> 7530❍, ¥¥<3>¥¥<> 4800✓, ¥¥<3>¥¥<> 4802✓, ¥¥<3>¥¥<> 4804✓, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<9>¥¥<> 0780❆ ¥¥<57800>¥¥<> ❆, ¥¥<5>¥¥<> 8100■, ¥¥<5>¥¥<> 8120▼, ¥¥<5>¥¥<> 8353✓, ¥¥<5>¥¥<> 8558▼, ¥¥<58563>¥¥<> ✓, ¥¥<64435>¥¥<> ●, ¥¥<69990>¥¥<> ■, 76362◆, 76394◆, 76490◆, 76940◆, ¥¥<76>¥¥<> 942■, ¥¥<7>¥¥<> 6986■, ¥¥<9>¥¥<> 0780❆ 0005T Transcatheter placement of extracranial cerebrovascular artery stent(s), percutaneous; initial vessel 0012T Arthroscopy, knee, surgical, implantation of osteochondral graft(s) for RELATIVE VALUE UNITS treatment of articular surface defect; autografts Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 0.00 0.00 0.00 0.00 0.00 0.00 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 0.00 0.00 0.00 0.00 0.00 0.00 NA -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 1NANPDNPDDOC 09 C -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 1NANPDNPDDOC 09 C
¥¥<35201>¥¥<> ❆, ¥¥<35206>¥¥<> ❆, ¥¥<35226>¥¥<> ❆, ¥¥<35261>¥¥<> ❆, ¥¥<35266>¥¥<> ❆, ¥¥<35>¥¥<> 286❆, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<36620>¥¥<> ❍, CORRECT CODING EDITS ¥¥<36625>¥¥<> ❍, ¥¥<3>¥¥<> 7202❆, ¥¥<3>¥¥<> 7205✓, ¥¥<69990>¥¥<> ■, ¥¥<76>¥¥<> 000■, ¥¥<76>¥¥<> 003■, ¥¥<76>¥¥<> 360■, ¥¥<76393>¥¥<> ■, ¥¥<76>¥¥<> 942■, ¥¥<29870>¥¥<> ❍, ¥¥<29871>¥¥<> ❆, ¥¥<29874>¥¥<> ❆, ¥¥<29875>¥¥<> ❍, ¥¥<29>¥¥<> 877❆, ¥¥<29879>¥¥<> ❆, ¥¥<2>¥¥<> 9884❍, ¥¥<2>¥¥<> 9886▼, ¥¥<2>¥¥<> 9887▼, ¥¥<9>¥¥<> 0780❆ ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<9>¥¥<> 0780❆ 0007T Transcatheter placement of extracranial cerebrovascular artery stent(s), percutaneous, radiological supervision and interpretation, each vessel 0013T Arthroscopy, knee, surgical, implantation of osteochondral graft(s) for RELATIVE VALUE UNITS treatment of articular surface defect; allografts Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 0.00 0.00 0.00 0.00 0.00 0.00 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 0.00 0.00 0.00 0.00 0.00 0.00 NA -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 1NANPDNPDDOC 09 C -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 1NANPDNPDDOC 09 C
¥¥<35201>¥¥<> ■, ¥¥<35206>¥¥<> ■, ¥¥<35226>¥¥<> ■, ¥¥<35261>¥¥<> ■, ¥¥<35266>¥¥<> ■, ¥¥<35>¥¥<> 286■, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, CORRECT CODING EDITS ¥¥<76>¥¥<> 360✓, ¥¥<9>¥¥<> 0780❆ ¥¥<0012T>¥¥<> ✓, ¥¥<29870>¥¥<> ❍, ¥¥<29871>¥¥<> ❆, ¥¥<29874>¥¥<> ❆, ¥¥<29875>¥¥<> ❍, ¥¥<29>¥¥<> 877❆, ¥¥<29879>¥¥<> ❆, ¥¥<2>¥¥<> 9884❍, ¥¥<2>¥¥<> 9886▼, ¥¥<2>¥¥<> 9887▼, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<9>¥¥<> 0780❆ 0008T Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with suturing of the esophagogastric junction 0014T Meniscal transplantation, medial or lateral, knee (any method) RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 C 1NANPDNPDDOC 09 C CORRECT CODING EDITS CORRECT CODING EDITS 00740●, 00810●, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<43200>¥¥<> ❍, ¥¥<43202>¥¥<> ▼, ¥¥<43204>¥¥<> ▼, ¥¥<43205>¥¥<> ▼, ¥¥<43215>¥¥<> ▼, ¥¥<29870>¥¥<> ❍, ¥¥<29871>¥¥<> ❆, ¥¥<29874>¥¥<> ❆, ¥¥<29875>¥¥<> ❍, ¥¥<29>¥¥<> 877❆, ¥¥<2>¥¥<> 9880▼, ¥¥<2>¥¥<> 9881▼, ¥¥<2>¥¥<> 9882■, ¥¥<2>¥¥<> 9883■, ¥¥<43216>¥¥<> ▼, ¥¥<43217>¥¥<> ▼, ¥¥<43219>¥¥<> ▼, ¥¥<43220>¥¥<> ▼, ¥¥<43226>¥¥<> ▼, ¥¥<43227>¥¥<> ▼, ¥¥<43228>¥¥<> ▼, ¥¥<43231>¥¥<> ▼, ¥¥<43232>¥¥<> ▼, ¥¥<2>¥¥<> 9884❍, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202■, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64416>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<43234>¥¥<> ▼, ¥¥<43235>¥¥<> ❍, ¥¥<43255>¥¥<> ❆, ¥¥<69990>¥¥<> ■, ¥¥<8>¥¥<> 9130❆, ¥¥<9>¥¥<> 0780❆, ¥¥<9>¥¥<> 0781❆, 90782❆, 90783❆, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, ¥¥<9>¥¥<> 0780❆ 90784❆, ¥¥<91105>¥¥<> ■, ¥¥<9>¥¥<> 4760❆, ¥¥<9>¥¥<> 4761❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Category III–3 CPT only ©2003 American Medical Association. All Rights Reserved.
Category III Codes
0032T Speculoscopy; with directed sampling 0037T Open subclavian to carotid artery transposition performed in conjunction with endovascular thoracic aneurysm repair, by neck incision, unilateral RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 C 2NANPDNPDDOC 09 C CORRECT CODING EDITS CORRECT CODING EDITS ¥¥<0031T>¥¥<> ◆ ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 0033T Endovascular repair of descending thoracic aortic aneurysm, pseudoan- eurysm or dissection; involving coverage of left subclavian artery origin, 0038T Endovascular repair of descending thoracic aortic aneurysm, pseudoan- initial endoprosthesis eurysm or dissection involving coverage of left subclavian artery origin, RELATIVE VALUE UNITS initial endoprosthesis, radiological supervision and interpretation Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 0.00 0.00 0.00 0.00 0.00 0.00 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 0.00 0.00 0.00 0.00 0.00 0.00 NA -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 2NANPDNPDDOC 09 C -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 2NANPDNPDDOC 09 C 01926●, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, CORRECT CODING EDITS ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆ 01916●
0034T Endovascular repair of descending thoracic aortic aneurysm, pseudoan- eurysm or dissection; not involving coverage of left subclavian artery ori- 0039T Endovascular repair of descending thoracic aortic aneurysm, pseudoan- gin, initial endoprosthesis eurysm or dissection not involving coverage of left subclavian artery ori- gin, initial endoprosthesis, radiological supervision and interpretation RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 C 2NANPDNPDDOC 09 C CORRECT CODING EDITS CORRECT CODING EDITS 01926●, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, 01916● ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
0035T Placement of proximal or distal extension prosthesis for endovascular 0040T Placement of proximal or distal extension prosthesis for endovascular repair of descending thoracic aortic aneurysm, pseudoaneurysm or dis- repair of descending thoracic aortic aneurysm, pseudoaneurysm or dis- section; initial extension section, each extension, radiological supervision and interpretation RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 C 2NANPDNPDDOC 09 C CORRECT CODING EDITS CORRECT CODING EDITS 01916● 01926●, ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<3>¥¥<> 7202❆, ¥¥<6>¥¥<> 2318■, ¥¥<6>¥¥<> 2319■, ¥¥<64415>¥¥<> ■, ¥¥<64417>¥¥<> ■, ¥¥<64450>¥¥<> ■, ¥¥<64>¥¥<> 470■, ¥¥<64475>¥¥<> ■, 69990■, ¥¥<9>¥¥<> 0780❆
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 Category III–5 CPT only ©2003 American Medical Association. All Rights Reserved.
HCPCS Level II [Supplemental Services] (Codes A0000–V9999)
IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.
Correct Coding Policies
A. Introduction prescriptions used in the treatment of mental psychoneurotic and The HCPCS Level II codes are alpha-numeric codes that have been devel- personality disorders. oped by the Centers for Medicare and Medicaid Services (CMS) as a comple- mentary coding system to the CPT Manual. These codes describe non- 2. HCPCS code Q0091, for screening pap smears includes the services physician services and supplies such as drugs, durable medical equipment, necessary to procure and transport the specimen to the laboratory. ambulance, manipulations, etc. The general correct coding policies previ- If an evaluation and management service is performed at the same ously outlined in Chapter I apply to these codes as well as CPT codes. The visit solely for the purpose of performing a screening pap smear, correct coding edits and policy statements that follow address only those then the evaluation and management service is not reported sepa- HCPCS Level II codes that are to be reported to the Medicare Part B carriers. rately. If a significant, separately identifiable evaluation and man- agement service is performed to evaluate other medical problems, B. General Policy Statements then both the screening pap smear and the evaluation and manage- 1. HCPCS code M0064 is not to be reported separately from CPT ment service are reported. By appending the -25 modifier to the codes 90801-90857 (psychiatric services). This code describes a evaluation and management code, the provider is indicating that a brief office visit for the sole purpose of monitoring or changing drug significant, separately identifiable service was rendered.
©2004 Ingenix, Inc. Jan. 04 HCPCS–1 CPT only ©2003 American Medical Association. All Rights Reserved.
HCPCS Level II Supplemental Services
G0239 Therapeutic procedures to improve respiratory function or increase G0245 Initial physician evaluation and management of a diabetic patient strength or endurance of respiratory muscles, two or more individu- with diabetic sensory neuropathy resulting in a loss of protective als (includes monitoring) sensation (lops) which must include: (1) the diagnosis of lops, (2) a RELATIVE VALUE UNITS patient history, (3) a physical examination that con Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 0.00 0.00 0.00 0.00 0.00 0.00 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS 0.87 0.06 0.79 0.32 1.72 1.25 NA -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS 2NANPDNPDDOC 09 C -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS 2NANPDNPDDOC 09 C
¥¥
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 HCPCS–19 CPT only ©2003 American Medical Association. All Rights Reserved.
HCPCS Level II Supplemental Services
A4644 Supply of low osmolar contrast material (200-299 mgs of iodine) G0001 Routine venipuncture for collection of specimen(s) RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status NA NA NPD NPD NPD 09 NA NA NA NA NA NA 09 NON CORRECT CODING EDITS CORRECT CODING EDITS
¥¥
A4645 Supply of radiopharmaceurical diagnostic imaging agent, I-131 tosi- G0008 Administration of influenza virus vaccine tumomab, per dose RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA 0.00 0.00 0.00 0.00 0.00 0.00 NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status NA NA NA NA NA 09 NON NA NA NPD NPD NPD 09 NA CORRECT CODING EDITS CORRECT CODING EDITS ¥¥<90471>¥¥<> ✓ ¥¥
C1080 Supply of radiopharmaceutical therapeutic imaging agent, I-131 G0009 Administration of pneumococcal vaccine tositumomab, per dose RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA NA NA NA NA NA NA NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status NA NA NA NA NA 09 NON NA NA NA NA NA NA NA NA CORRECT CODING EDITS
CORRECT CODING EDITS ¥¥<90471>¥¥<> ✓
¥¥<7>¥¥<> 8999■, ¥¥<7>¥¥<> 9900◆, A4641◆, A9699◆ G0010 Administration of hepatitis b vaccine Ambulatory infusion pump, single or multiple channels, electric or C1081 RELATIVE VALUE UNITS battery operated, with administrative equipment, worn by patient Work MP PE–nf PE–f Total–nf Total–f Global P RELATIVE VALUE UNITS 0.00 0.00 0.00 0.00 0.00 0.00 NA Work MP PE–nf PE–f Total–nf Total–f Global P MODIFIERS INDICATORS NA NA NA NA NA NA NA NA -50 -51 -62 -66 -80, -82 Suprv Status MODIFIERS INDICATORS NA NA NA NA NA 09 NON -50 -51 -62 -66 -80, -82 Suprv Status CORRECT CODING EDITS NA NA NA NA NA NA NA NA ¥¥<90471>¥¥<> ✓ CORRECT CODING EDITS
¥¥<7>¥¥<> 8999■, ¥¥<7>¥¥<> 9900◆, A4641◆, A9699◆ G0030 Pet myocardial perfusion imaging, (following previous pet, g0030- g0047); single study, rest or stress (exercise and/or pharmacologic) Routine venipuncture for collection of specimen(s) E0781 RELATIVE VALUE UNITS RELATIVE VALUE UNITS Work MP PE–nf PE–f Total–nf Total–f Global P Work MP PE–nf PE–f Total–nf Total–f Global P 0.00 0.00 0.00 0.00 0.00 0.00 NA NA NA NA NA NA NA NA NA MODIFIERS INDICATORS MODIFIERS INDICATORS -50 -51 -62 -66 -80, -82 Suprv Status -50 -51 -62 -66 -80, -82 Suprv Status 2NANPDNPDDOC 09 C NA NA NA NA NA NA NA NA CORRECT CODING EDITS
CORRECT CODING EDITS ¥¥<36>¥¥<> 000❆, ¥¥<3>¥¥<> 6410❆, ¥¥<9>¥¥<> 0780❆, ¥¥
● Anesthesia Included in Surgical Procedure ✚ CPT/HCPCS Coding Manual Guideline ♠ Designation of Gender-specific Procedures ❆ Standards of Medical/Surgical Practice ❍ CPT Separate Procedure Definition ▼ Most Extensive Procedure ◆ CPT/HCPCS Procedure Code Definition ©2004 Ingenix, Inc. Jan. 04 HCPCS–3 CPT only ©2003 American Medical Association. All Rights Reserved.
Appendix A: Geographic Practice Cost Indices by Medicare Locality
Note: At the time of printing there was legislation pending that may affect the GPCIs for 2004. If changes are made to the GPCI, you will be notified via e-mail of the changes and given instructions as to where to locate the revised information on the Ingenix Web site.
Carrier No. Locality No. Locality Name Work Practice expense Malpractice 00510 00 Alabama 0.978 0.870 0.779 00831 01 Alaska 1.064 1.172 1.126 00832 00 Arizona 0.994 0.978 1.090 00520 13 Arkansas 0.953 0.847 0.389 31146 26 Anaheim/Santa Ana, CA 1.037 1.184 0.955 31146 18 Los Angeles, CA 1.056 1.139 0.955 31140 03 Marin/Napa/Solano, CA 1.015 1.248 0.669 31140 07 Oakland/Berkeley, CA 1.041 1.235 0.669 31140 05 San Francisco, CA 1.068 1.458 0.669 31140 06 San Mateo, CA 1.048 1.432 0.663 31140 09 Santa Clara, CA 1.063 1.380 0.622 31146 17 Ventura, CA 1.028 1.125 0.763 31146 99 Rest of California* 1.007 1.034 0.740 31140 99 Rest of California* 1.007 1.034 0.740 00824 01 Colorado 0.985 0.992 0.821 00591 00 Connecticut 1.050 1.156 0.933 00902 01 Delaware 1.019 1.035 0.802 00903 01 DC + MD/VA Suburbs 1.050 1.166 0.917 00590 03 Fort Lauderdale, FL 0.996 1.018 1.790 00590 04 Miami, FL 1.015 1.052 2.399 00590 99 Rest of Florida 0.975 0.946 1.268 00511 01 Atlanta, GA 1.006 1.059 0.951 00511 99 Rest of Georgia 0.970 0.892 0.951 00833 01 Hawaii/Guam 0.997 1.124 0.817 05130 00 Idaho 0.960 0.881 0.478 00952 16 Chicago, IL 1.028 1.092 1.832 00952 12 East St. Louis, IL 0.988 0.924 1.720 00952 15 Suburban Chicago, IL 1.006 1.071 1.648 00952 99 Rest of Illinois 0.964 0.889 1.175 00630 00 Indiana 0.981 0.922 0.459 00826 00 Iowa 0.959 0.876 0.593 00650 00 Kansas* 0.963 0.895 0.738 00740 04 Kansas* 0.963 0.895 0.738 00660 00 Kentucky 0.970 0.866 0.875 00528 01 New Orleans, LA 0.998 0.945 1.240 00528 99 Rest of Louisiana 0.968 0.870 1.066 31142 03 Southern Maine 0.979 0.999 0.652 31142 99 Rest of Maine 0.961 0.910 0.652 00901 01 Baltimore/Surr. Cntys, MD 1.021 1.038 0.931
©2004 Ingenix, Inc. Jan. 04 Appendix A–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Medicare Correct Coding Guide (CCI—Version 10.0)
Carrier No. Locality No. Locality Name Work Practice expense Malpractice 00901 99 Rest of Maryland 0.984 0.972 0.767 31143 01 Metropolitan Boston 1.041 1.239 0.803 31143 99 Rest of Massachusetts 1.010 1.129 0.803 00953 01 Detroit, MI 1.043 1.038 2.741 00953 99 Rest of Michigan 0.997 0.938 1.545 00954 00 Minnesota 0.990 0.974 0.431 00512 00 Mississippi 0.957 0.837 0.750 00740 02 Metropolitan Kansas City, MO 0.988 0.967 0.896 00523 01 Metropolitan St. Louis, MO 0.994 0.938 0.893 00740 99 Rest of Missouri* 0.946 0.825 0.842 00523 99 Rest of Missouri* 0.946 0.825 0.842 00751 01 Montana 0.950 0.876 0.815 00655 00 Nebraska 0.948 0.877 0.442 00834 00 Nevada 1.005 1.039 1.138 31144 40 New Hampshire 0.986 1.030 0.883 00805 01 Northern NJ 1.058 1.193 0.916 00805 99 Rest of New Jersey 1.029 1.110 0.916 00521 05 New Mexico 0.973 0.900 0.898 00803 01 Manhattan, NY 1.094 1.351 1.586 00803 02 Nyc Suburbs/Long I., NY 1.068 1.251 1.869 00803 03 Poughkpsie/N Nyc Suburbs, NY 1.011 1.075 1.221 14330 04 Queens, NY 1.058 1.228 1.791 00801 99 Rest of New York 0.998 0.944 0.720 05535 00 North Carolina 0.970 0.931 0.618 00820 01 North Dakota 0.950 0.880 0.630 00883 00 Ohio 0.988 0.944 0.967 00522 00 Oklahoma 0.968 0.876 0.413 00835 01 Portland, OR 0.996 1.049 0.438 00835 99 Rest of Oregon 0.961 0.933 0.438 00865 01 Metropolitan Philadelphia, PA 1.023 1.092 1.400 00865 99 Rest of Pennsylvania 0.989 0.929 0.790 00973 20 Puerto Rico 0.881 0.712 0.268 00870 01 Rhode Island 1.017 1.065 0.896 00880 01 South Carolina 0.974 0.904 0.336 00820 02 South Dakota 0.935 0.878 0.385 05440 35 Tennessee 0.975 0.900 0.612 00900 31 Austin, TX 0.986 0.996 0.922 00900 20 Beaumont, TX 0.992 0.890 1.318 00900 09 Brazoria, TX 0.992 0.978 1.318 00900 11 Dallas, TX 1.010 1.065 0.996 00900 28 Fort Worth, TX 0.987 0.981 0.996 00900 15 Galveston, TX 0.988 0.969 1.318 00900 18 Houston, TX 1.020 1.007 1.316 00900 99 Rest of Texas 0.966 0.880 1.047
Appendix A–2 Jan. 04 ©2004 Ingenix, Inc. CPT only ©2003 American Medical Association. All Rights Reserved.
Appendix B: CPT Modifiers
Before assigning a final code, it is important to decide whether a modifier -27 Multiple Outpatient Hospital E/M Encounters on the Same should be assigned to indicate that a service or procedure has been altered Date or modified by specific circumstance. Keep in mind that assignment of mod- For hospital outpatient reporting purposes, utilization of hospital ifiers often requires submission of substantiating documentation. Each resources related to separate and distinct E/M encounters performed in modifier has a two digit or five digit format. The five digit format begins multiple outpatient hospital settings on the same date may be reported with 099 and maybe used instead of the two digit format (e.g., -50 or by adding the modifier -27 to each appropriate level outpatient and/or 09950). emergency department (E/M) code(s). This modifier provides a means of reporting circumstances involving management services provided by Because this manual does not cover anesthesia services, the anesthesia physician(s) in more than one (multiple) outpatient hospital setting(s) modifier -23, Unusual Anesthesia, is not included. (e.g., hospital emergency department, clinic). Note: This modifier is Listed below are common modifiers with definitions, coding tips and appli- not to be used for physician reporting of multiple E/M services per- cable Medicare payment policies. formed by the same physician on the same date. For physician report- ing of all outpatient E/M services provided by the same physician on -21 Prolonged Evaluation and Management Services the same date and performed in multiple outpatient setting(s) (e.g., Indicates that the service provided is greater than that usually required hospital emergency department, clinic), see Evaluation and Manage- at the highest level of evaluation and management service within a cat- ment, Emergency Department, or preventive Medicine Services codes. egory. -32 Mandated Services Documentation must be submitted to substantiate use of this modifier. Use when the consultation and/or related services are required by an appropriate source such as a PRO or third-party payer. -22 Unusual Procedural Services Add when the service is more intensive than the accepted range of nor- -47 Anesthesia by Surgeon mal. Range of normal varies from community to community. The anesthesia service is included in the primary procedure under the CMS global surgery policy and no additional payment is made. When Any time the modifier -22 is added to a procedure, the carrier will general or regional anesthesia is provided by the surgeon, the proce- expect thorough documentation to support the increased fee consider- dure code may be reported by adding modifier -47 to the basic service. ation. The standard payment amount will be paid by Medicare without supporting documentation. If it is medically necessary for a separate provider (anesthesiologist/ anesthetist) to provide the anesthesia services, a separate service may -24 Unrelated Evaluation and Management Services by the Same be reported. Physician during a Postoperative Period Indicates that a physician performed an evaluation and management Modifier -47 would not be used as a modifier for the anesthesia proce- service for an reason unrelated to the original procedure. dure codes 00100-01999.
Payment for this service will be made in addition to the global surgery -50 Bilateral Procedure payment. Add to the second unilateral surgical procedure code when a bilateral surgical procedure is performed and there is no code for the bilateral -25 Significant, Separately Identifiable Evaluation and Manage- procedure. Some carriers prefer the addition of the -50 modifier to the ment Service by the Same Physician on the Same Day of a first CPT code instead of reporting the code twice. Both procedures Procedure or Other Service must be performed during the same session, and each procedure must Indicates that a physician performed a separately identifiable evalua- have required a separate incision. tion and management service beyond the usual preoperative and post- operative care associated with the procedure performed. The This modifier should not be used with add-on codes, those designated evaluation and management service may be prompted by the symptom with the “+” symbol in the CPT manual and usually contain the phrase or condition for which the service and/or procedure was provided. "each additional" in the code narrative.
This modifier should not be used to report an evaluation and manage- Medicare will allow 150 percent of the approved amount for bilateral ment service that resulted in a decision to perform surgery. procedures.
-26 Professional Component -51 Multiple Procedures Certain procedures are a combination of a technical and a physician or Use when multiple procedures are performed on the same day or dur- professional component. When a physician or professional component ing the same session. List the major procedure first on the claim form; is to be reported separately, the service is identified by modifier -26. then the secondary procedures identified with the -51 modifier.
Separate entries with associated RVUs for codes that may be reported This modifier should not be used with add-on codes, those designated with a -26 modifier are included in this manual. with the “+” symbol in the CPT manual and usually contain the phrase “each additional” in the code narrative. In addition the –51 modifier may not be used with procedures that are usually performed in con- junction with a primary procedure, but are not designated as add-on codes. The CPT manual uses the “ “ symbol to identify these codes.
©2004 Ingenix, Inc. Jan. 04 Appendix B–1 CPT only ©2003 American Medical Association. All Rights Reserved.
Modifiers
–73 Discontinued Out-Patient Hospital/Ambulatory Surgery Cen- Payment is made based on the billed amount or 16 percent of the glo- ter (ASC) Procedure Prior to Administration of Anesthesia bal surgical fee, whichever is lower, for procedures approved for assis- This modifier is used in an outpatient hospital or ambulatory surgery tant surgery. center setting to indicate that a procedure was terminated prior to the administration of anesthesia. A physician may elect to discontinue or Medicare will deny payment for assistant at surgery for surgical proce- terminate a procedure due to extenuating circumstances. The addition dures in which a physician is used as an assistant in less than 5 per- of the –73 modifier to the intended procedure code indicates that the cent of the cases nationally. preparations for the procedure were made but discontinued prior to the administration of anesthesia. -81 Minimum Assistant Surgeon Use to indicate minimum surgical assistant services. –74 Discontinued Out-Patient Hospital/Ambulatory Surgery Cen- ter (ASC) Procedure After Administration of Anesthesia Medicare will deny payment for assistant at surgery for surgical proce- This modifier is used in an outpatient hospital or ambulatory surgery dures in which a physician is used as an assistant in less than 5 per- center setting to indicate that a procedure was terminated after the cent of the cases nationally. administration of anesthesia. A physician may elect to discontinue or -82 Assistant Surgeon (when qualified resident surgeon not terminate a procedure due to extenuating circumstances. The addition available) of the –73 modifier to the intended procedure code indicates that the Used most frequently in teaching hospitals where students and interns preparations for the procedure were made but discontinued after the are on staff. administration of anesthesia. Used for an assistant surgeon when a qualified resident is not avail- -76 Repeat Procedure by Same Physician able. Use when the same physician who performed the original procedure needs to repeat it. Medicare allows 16 percent of the approved amount for surgical assists unless the procedure is listed as one which restricts and pre- The repeat procedure should not be planned. vents payment for surgical assistants. Documentation may be required by the carrier. Medicare will deny payment for assistant at surgery for surgical proce- -77 Repeat Procedure by Another Physician dures in which a physician is used as an assistant in less than 5 per- Use when a physician, other than the one who originally performed the cent of the cases nationally. procedure, repeats it. -90 Reference (Outside) Laboratory The repeat procedure should not be planned. Identify laboratory procedures done by a party other than the treating or reporting physician by using this modifier. Documentation may be required by the carrier. -91 Repeat Clinical Diagnostic Laboratory Test -78 Return to the Operating Room for a Related Procedure in Use to report a repeat lab test on the same day to obtain subsequent the Postoperative Period results. Use when an additional, related procedure requires a return to the operating room during the postoperative period. If a CPT code exists -99 Multiple Modifiers for the procedure, Medicare will pay the full value of the intraoperative When more than one modifier is needed to identify the services or pro- portion of a given procedure. cedures provided, add modifier -99 to the procedure code first, fol- lowed by the other modifiers. If no CPT code exists, assign the correct unlisted procedure code; and Medicare will pay 50 percent of the value of the intraoperative service Medicare will recognize up to two additional modifiers assigned to a originally performed. procedure.
Documentation should be submitted with the claim to describe the clin- -TCTechnical Component ical circumstances. Certain procedures are a combination of a technical and a physician or professional component. When the technical component is to be -79 Unrelated Procedure or Service by the Same Physician Dur- reported separately, the service is identified by modifier -TC. ing the Postoperative Period Use when an unrelated procedure is performed during the postopera- Separate entries with associated RVUs for codes that may be reported tive period. with a -TC modifier are included in this manual.
Specific ICD-9-CM codes will substantiate the medical necessity of the CMS now requires CPT and HCPCS Level II modifiers in reporting outpatient unrelated procedure. services. These modifiers must be reported using the two-digit format. The following modifiers are approved for hospital outpatient services pro- Documentation will be required to describe the clinical circumstances. vided in Ambulatory Surgery Centers (ASC). A new global period begins for any procedure modified by -79. -25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or -80 Assistant Surgeon Other Service Use to indicate surgical assistant services.
©2004 Ingenix, Inc. Jan. 04 Appendix B–3 CPT only ©2003 American Medical Association. All Rights Reserved.