Coding Companion

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Coding Companion

A comprehensive illustrated guide to coding and reimbursement 00 ASPC TOC.fm Page i Monday, December 1, 2014 1:24 PM

Contents

2015 2015 Coding Companion Contents M71.052 Abscess of bursa, left hip 20005 M71.061 Abscess of bursa, right knee M71.062 Abscess of bursa, left knee 20005 Incision and drainage of soft tissue abscess, subfascial (ie, involves M71.071 Abscess of bursa, right ankle and foot the soft tissue below the deep fascia) M71.072 Abscess of bursa, left ankle and foot M71.08 Abscess of bursa, other site M71.09 Abscess of bursa, multiple sites M72.2 Plantar fascial fibromatosis M72.6 Necrotizing fasciitis M72.8 Other fibroblastic disorders N61 Inflammatory disorders of breast HCPCS Equivalent Codes N/A Terms To Know abscess. Circumscribed collection of pus resulting from bacteria, frequently Musculoskeletal associated with swelling and other signs of inflammation. osteomyelitis. Inflammation of bone that may remain localized or spread to the marrow, cortex, or periosteum, in response to an infecting organism,

General usually bacterial and pyogenic. psoas. Muscles of the loins, the part of the side and back between the ribs and the pelvis. Explanation soft tissue. Nonepithelial tissues outside of the skeleton that includes subcutaneous adipose tissue, fibrous tissue, fascia, muscles, blood and lymph The physician makes an incision through skin and fascia directly over an vessels, and peripheral nervous system tissue. abscessed area involving the soft tissue below the deep fascia. The abscess cavity is explored, debrided, and drained. Depending on the appearance of subfascial. Beneath the band of fibrous tissue that lies deep to the skin, the area, the physician may place a drain or packing after copious irrigation encloses muscles, and separates their layers. of the area. Medicare Edits Coding Tips Fac RVU Non-Fac RVU FUD Status MUE For incision and drainage of an abscess of the skin and subcutaneous tissue, 20005 6.69 8.76 10 A 4(3) simple or single, see 10060; complicated or multiple, see 10061. It is inappropriate to report supplies when these services are performed in an emergency room. For physician office, supplies may be reported with the appropriate HCPCS Level II code. Check with the specific payer to determine Modifiers Medicare Reference coverage. 20005 51 N/A N/A N/A None * with documentation ICD-10-CM Diagnostic Codes K61.0 Anal abscess K61.1 Rectal abscess K61.2 Anorectal abscess K61.3 Ischiorectal abscess K65.1 Peritoneal abscess K68.12 Psoas muscle abscess M71.011 Abscess of bursa, right shoulder M71.012 Abscess of bursa, left shoulder M71.021 Abscess of bursa, right elbow M71.022 Abscess of bursa, left elbow M71.031 Abscess of bursa, right wrist M71.032 Abscess of bursa, left wrist M71.041 Abscess of bursa, right hand M71.042 Abscess of bursa, left hand M71.051 Abscess of bursa, right hip

© 2015 Optum360, LLC CPT © 2015 American Medical Association. All Rights Reserved. 2 — General Musculoskeletal Coding Companion I09.2 Chronic rheumatic pericarditis 33010-33011 I24.1 Dressler's syndrome I30.0 Acute nonspecific idiopathic pericarditis 33010 Pericardiocentesis; initial I30.1 Infective pericarditis 33011 subsequent I30.8 Other forms of acute pericarditis I31.0 Chronic adhesive pericarditis Trachea I31.1 Chronic constrictive pericarditis I31.2 Hemopericardium, not elsewhere classified I31.3 Pericardial effusion (noninflammatory) I31.4 Cardiac tamponade I31.8 Other specified diseases of pericardium I32 Pericarditis in diseases classified elsewhere I51.7 Cardiomegaly M32.12 Pericarditis in systemic lupus erythematosus S26.01XA Contusion of heart with hemopericardium, initial encounter S26.09XA Other injury of heart with hemopericardium, initial encounter T86.31 Heart-lung transplant rejection T86.32 Heart-lung transplant failure T86.33 Heart-lung transplant infection T86.39 Other complications of heart-lung transplant HCPCS Equivalent Codes N/A

Explanation Terms To Know The physician drains fluid from the pericardial space. The physician may cardiomegaly. Enlargement of the heart due to a thickened heart muscle or perform this procedure using anatomic landmarks or under fluoroscopic or an enlarged heart chamber, usually as a result of the heart having to work echocardiographic (ultrasound) guidance (separately reported). The physician harder than normal. places a long needle below the sternum and directs it into the pericardial space. When pericardial fluid is aspirated, the physician may advance a echography. Radiographic imaging that uses sound waves reflected off the guidewire through the needle into the pericardial space and exchange the different densities of anatomic structures to create images. needle over the guidewire for a drainage catheter. The physician removes as Arteries pericarditis. Inflammation affecting the pericardium. much pericardial fluid as is required, removes the needle or catheter, and dresses the wound. Report 33011 for each subsequent pericardiocentesis. pericardium. Thin and slippery case in which the heart lies that is lined with fluid so that the heart is free to pulse and move as it beats.

Coding Tips and tamponade heart. Interference with the venous return of blood to the heart Moderate (conscious) sedation performed with 33010–33011 is considered due to an extensive accumulation of blood in the pericardium (pericardial to be an integral part of the procedure and is not reported separately. However, Veins effusion). Tamponade may occur as a complication of dissecting thoracic anesthesia services (00100–01999) may be billed separately when performed by a physician (or other qualified provider) other than the physician performing aneurysm, pericarditis, renal failure, acute myocardial infarction, chest trauma, the procedure. Note that these codes include any ECG monitoring or a malignancy. Treatment involves the emergent removal of the fluid. (93040–93042) the physician may perform. Local anesthesia is included in these services. For radiology supervision and interpretation, see 76930. Medicare Edits Fac RVU Non-Fac RVU FUD Status MUE ICD-10-CM Diagnostic Codes 33010 3.49 3.49 0 A 1(2) A18.84 Tuberculosis of heart 33011 3.52 3.52 0 A 1(3) A39.53 Meningococcal pericarditis A43.8 Other forms of nocardiosis A52.06 Other syphilitic heart involvement Modifiers Medicare Reference A54.83 Gonococcal heart infection 33010 51 N/A N/A N/A None A93.8 Other specified arthropod-borne viral fevers 33011 51 N/A N/A 80* B33.23 Viral pericarditis * with documentation C45.2 Mesothelioma of pericardium D15.1 Benign neoplasm of heart D48.7 Neoplasm of uncertain behavior of other specified sites I01.0 Acute rheumatic pericarditis

CPT © 2015 American Medical Association. All Rights Reserved. © 2015 Optum360, LLC Coding Companion Arteries and Veins — 185 K51.512 Left sided colitis with intestinal obstruction 45340 K51.812 Other ulcerative colitis with intestinal obstruction K51.912 Ulcerative colitis, unspecified with intestinal obstruction 45340 Sigmoidoscopy, flexible; with transendoscopic balloon dilation K56.5 Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection) K56.60 Unspecified intestinal obstruction K56.69 Other intestinal obstruction K91.3 Postprocedural intestinal obstruction Q42.0 Congenital absence, atresia and stenosis of rectum with fistula Q42.1 Congenital absence, atresia and stenosis of rectum without fistula Q42.2 Congenital absence, atresia and stenosis of anus with fistula Q42.3 Congenital absence, atresia and stenosis of anus without fistula Q42.8 Congenital absence, atresia and stenosis of other parts of large intestine Q42.9 Congenital absence, atresia and stenosis of large intestine, part unspecified HCPCS Equivalent Codes N/A Terms To Know atresia. Congenital closure or absence of a tubular organ or an opening to the body surface. Explanation balloon catheter. Any catheter equipped with an inflatable balloon at the The physician performs flexible sigmoidoscopy and dilates strictures by balloon end to hold it in place in a body cavity or to be used for dilation of a vessel catheter. The physician inserts the sigmoidoscope into the anus and advances lumen. the scope through the rectum and into the sigmoid colon. The lumen of the complication. Condition arising after the beginning of observation and sigmoid colon and rectum are visualized. Areas of stenosis are identified and treatment that modifies the course of the patient's illness or the medical care a balloon catheter is passed to the point of constriction and a little beyond. required, or an undesired result or misadventure in medical care. The balloon is inflated to the appropriate diameter and gradually withdrawn through the stenosed area, stretching the walls of the bowel at the strictured congenital. Present at birth, occurring through heredity or an influence during area. The scope is withdrawn at the completion of the procedure. gestation up to the moment of birth. Coding Tips dilation. Artificial increase in the diameter of an opening or lumen made by medication or by instrumentation. Moderate (conscious) sedation performed with 45340 is considered to be an integral part of the procedure and is not reported separately. However, intestinal or peritoneal adhesions with obstruction. Abnormal fibrous anesthesia services (00100–01999) may be billed separately when performed band growths joining separate tissues in the peritoneum or intestine, causing by a physician (or other qualified provider) other than the physician performing blockage. the procedure. Report the appropriate endoscopy for each anatomic site examined. Surgical endoscopy includes a diagnostic endoscopy; however, obstruction. Act or state of being clogged or blocked from allowing through diagnostic endoscopy can be identified separately when performed at the passage. same surgical session as an open procedure. If multiple balloon dilations are stenosis. Narrowing or constriction of a passage. performed on several strictures during the same session, report modifier 59 on each subsequent dilation. For fluoroscopic guidance, see 74360. For stricture. Narrowing of an anatomical structure. colonoscopy, flexible, with transendoscopic balloon dilation, see 45386. Do not report 45340 in conjunction with 45330, 45346, or 45347. Medicare Edits Fac RVU Non-Fac RVU FUD Status MUE

Digestive ICD-10-CM Diagnostic Codes 45340 3.33 13.86 0 A 1(2) K50.112 Crohn's disease of large intestine with intestinal obstruction K50.812 Crohn's disease of both small and large intestine with intestinal obstruction Modifiers Medicare Reference K50.912 Crohn's disease, unspecified, with intestinal obstruction K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction 45340 51 N/A N/A N/A None K51.212 Ulcerative (chronic) proctitis with intestinal obstruction * with documentation K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction K51.412 Inflammatory polyps of colon with intestinal obstruction

© 2015 Optum360, LLC CPT © 2015 American Medical Association. All Rights Reserved. 276 — Digestive Coding Companion D30.11 Benign neoplasm of right renal pelvis 52351 D30.12 Benign neoplasm of left renal pelvis D30.21 Benign neoplasm of right ureter 52351 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic D30.22 Benign neoplasm of left ureter D30.3 Benign neoplasm of bladder D41.11 Neoplasm of uncertain behavior of right renal pelvis D41.12 Neoplasm of uncertain behavior of left renal pelvis D41.21 Neoplasm of uncertain behavior of right ureter D41.22 Neoplasm of uncertain behavior of left ureter D41.4 Neoplasm of uncertain behavior of bladder N11.0 Nonobstructive reflux-associated chronic pyelonephritis N11.1 Chronic obstructive pyelonephritis N11.8 Other chronic tubulo-interstitial nephritis N13.1 Hydronephrosis with ureteral stricture, not elsewhere classified N13.2 Hydronephrosis with renal and ureteral calculous obstruction N13.39 Other hydronephrosis N13.4 Hydroureter N13.5 Crossing vessel and stricture of ureter without hydronephrosis N13.8 Other obstructive and reflux uropathy N20.0 Calculus of kidney N20.1 Calculus of ureter N20.2 Calculus of kidney with calculus of ureter N21.0 Calculus in bladder Explanation N22 Calculus of urinary tract in diseases classified elsewhere The physician examines the urinary collecting system for diagnostic purposes N28.82 Megaloureter with endoscopes passed through the urethra into the bladder N28.89 Other specified disorders of kidney and ureter (cystourethroscope), ureter (ureteroscope), and renal pelvis (pyeloscope). N30.10 Interstitial cystitis (chronic) without hematuria After examination, the physician removes the endoscopes. N30.11 Interstitial cystitis (chronic) with hematuria Coding Tips N30.20 Other chronic cystitis without hematuria A surgical cystourethroscopy always includes a diagnostic cystourethroscopy. N30.21 Other chronic cystitis with hematuria Do not report this code with 52341–52346 or 52352–52356. For radiology N30.30 Trigonitis without hematuria supervision and interpretation, see 74485. N30.31 Trigonitis with hematuria N30.40 Irradiation cystitis without hematuria ICD-10-CM Diagnostic Codes N30.41 Irradiation cystitis with hematuria C65.1 Malignant neoplasm of right renal pelvis N30.80 Other cystitis without hematuria C65.2 Malignant neoplasm of left renal pelvis N30.81 Other cystitis with hematuria C66.1 Malignant neoplasm of right ureter N31.0 Uninhibited neuropathic bladder, not elsewhere classified C66.2 Malignant neoplasm of left ureter N31.1 Reflex neuropathic bladder, not elsewhere classified C67.0 Malignant neoplasm of trigone of bladder N31.2 Flaccid neuropathic bladder, not elsewhere classified C67.1 Malignant neoplasm of dome of bladder N31.8 Other neuromuscular dysfunction of bladder C67.2 Malignant neoplasm of lateral wall of bladder N32.0 Bladder-neck obstruction C67.3 Malignant neoplasm of anterior wall of bladder N32.1 Vesicointestinal fistula C67.4 Malignant neoplasm of posterior wall of bladder N32.2 Vesical fistula, not elsewhere classified C67.5 Malignant neoplasm of bladder neck N32.3 Diverticulum of bladder C67.6 Malignant neoplasm of ureteric orifice N32.81 Overactive bladder C67.7 Malignant neoplasm of urachus N32.89 Other specified disorders of bladder C67.8 Malignant neoplasm of overlapping sites of bladder N33 Bladder disorders in diseases classified elsewhere C79.01 Secondary malignant neoplasm of right kidney and renal pelvis N39.0 Urinary tract infection, site not specified Urinary C79.02 Secondary malignant neoplasm of left kidney and renal pelvis N39.3 Stress incontinence (female) (male) C79.11 Secondary malignant neoplasm of bladder N39.41 Urge incontinence C79.19 Secondary malignant neoplasm of other urinary organs N39.42 Incontinence without sensory awareness D09.0 Carcinoma in situ of bladder N39.43 Post-void dribbling D09.19 Carcinoma in situ of other urinary organs N39.44 Nocturnal enuresis

CPT © 2015 American Medical Association. All Rights Reserved. © 2015 Optum360, LLC Coding Companion Urinary — 337 N39.45 Continuous leakage N39.46 Mixed incontinence 53040-53060 N39.490 Overflow incontinence 53040 Drainage of deep periurethral abscess N39.498 Other specified urinary incontinence 53060 Drainage of Skene's gland abscess or cyst N39.8 Other specified disorders of urinary system N82.0 Vesicovaginal fistula N82.1 Other female urinary-genital tract fistulae Q62.0 Congenital hydronephrosis Q62.11 Congenital occlusion of ureteropelvic junction Q62.12 Congenital occlusion of ureterovesical orifice Q62.2 Congenital megaureter Q62.31 Congenital ureterocele, orthotopic Q62.32 Cecoureterocele Q62.39 Other obstructive defects of renal pelvis and ureter Q64.11 Supravesical fissure of urinary bladder Q64.12 Cloacal extrophy of urinary bladder Q64.19 Other exstrophy of urinary bladder Q64.31 Congenital bladder neck obstruction Q64.33 Congenital stricture of urinary meatus Q64.39 Other atresia and stenosis of urethra and bladder neck Q64.5 Congenital absence of bladder and urethra Q64.6 Congenital diverticulum of bladder Q64.72 Congenital prolapse of urinary meatus Q64.73 Congenital urethrorectal fistula Explanation Q64.79 Other congenital malformations of bladder and urethra The physician drains an abscess in the urethra resulting from a urethral S37.19XA Other injury of ureter, initial encounter infection or traumatic injury. The physician makes an incision through the S37.29XA Other injury of bladder, initial encounter skin, subcutaneous tissue, and overlaying layers of muscle, fat, and tissue T19.1XXA Foreign body in bladder, initial encounter (fascia) over the site of the abscess. By blunt or sharp dissection, the incision is carried into the abscess. Several drains are inserted and the incision is closed HCPCS Equivalent Codes in layers. Report 53040 for drainage of a deep periurethral abscess. For an N/A abscess or cyst in Skene's or paraurethral glands in the female, report 53060. Terms To Know Coding Tips congenital. Present at birth, occurring through heredity or an influence during The physician usually performs these services under local anesthesia. However, gestation up to the moment of birth. these procedures may be performed under general anesthesia, depending on the age and/or condition of the patient. cystitis. Inflammation of the urinary bladder. Symptoms include dysuria, frequency of urination, urgency, and hematuria. ICD-10-CM Diagnostic Codes diverticulum. Pouch or sac in the walls of an organ or canal. N34.0 Urethral abscess N36.8 Other specified disorders of urethra hematuria. Blood in urine, which may present as gross visible blood or as the presence of red blood cells visible only under a microscope. HCPCS Equivalent Codes N/A Medicare Edits Fac RVU Non-Fac RVU FUD Status MUE Medicare Edits 52351 8.72 8.72 0 A 1(3) Fac RVU Non-Fac RVU FUD Status MUE 53040 11.24 11.24 90 A 1(3) 53060 4.74 5.26 10 A 1(3) Modifiers Medicare Reference 52351 51 N/A N/A N/A None * with documentation Modifiers Medicare Reference 53040 51 N/A N/A 80* None Urinary 53060 51 N/A N/A N/A * with documentation

© 2015 Optum360, LLC CPT © 2015 American Medical Association. All Rights Reserved. 338 — Urinary Coding Companion K51.80 Other ulcerative colitis without complications G0104, G0106, G0122 K51.811 Other ulcerative colitis with rectal bleeding K51.812 Other ulcerative colitis with intestinal obstruction G0104 Colorectal cancer screening; flexible sigmoidoscopy K51.813 Other ulcerative colitis with fistula G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema K51.814 Other ulcerative colitis with abscess G0122 Colorectal cancer screening; barium enema K52.0 Gastroenteritis and colitis due to radiation K52.1 Toxic gastroenteritis and colitis Explanation K52.2 Allergic and dietetic gastroenteritis and colitis In G0104, a flexible sigmoidoscopy is performed for colorectal cancer screening. K52.81 Eosinophilic gastritis or gastroenteritis After the patient's bowel has been prepped, the physician inserts the flexible K52.82 Eosinophilic colitis sigmoidoscope through the anus and advances the scope into the sigmoid colon. The lumen of the sigmoid colon and rectum are visualized and brushings K52.89 Other specified noninfective gastroenteritis and colitis or washings may be obtained. The sigmoidoscope is withdrawn. In G0106, a K52.9 Noninfective gastroenteritis and colitis, unspecified colorectal screening for cancer is performed via barium enema as an alternative K55.0 Acute vascular disorders of intestine to a screening sigmoidoscopy (G0104). Both G0106 and G0122 are a K55.1 Chronic vascular disorders of intestine radiological exam of the large intestine carried out after the administration K55.9 Vascular disorder of intestine, unspecified of a barium enema to instill the contrast medium into the colon. Fluoroscopy and x-rays are used to observe the images as the contrast fills the colon and Z12.11 Encounter for screening for malignant neoplasm of colon helps the physician to diagnose cancer, even colitis, and other diseases. After Z86.010 Personal history of colonic polyps the patient has emptied the colon, more films are taken. N/A Coding Tips Terms To Know Medicare covers a flexible sigmoidoscopy for screening of colorectal cancer barium enema. Radiology exam for viewing the intestine that utilizes a once every four years for patients 50 years of age or older. suspension of barium sulfate, a chalk-like substance that appears white on ICD-10-CM Diagnostic Codes x-ray, to delineate the lining of the colon and rectum. The barium is administered via the rectum and held inside the colon while x-rays are taken. K51.00 Ulcerative (chronic) pancolitis without complications Barium enema may also be performed therapeutically in order to relieve K51.011 Ulcerative (chronic) pancolitis with rectal bleeding intussusception or intestinal obstructions. K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction K51.013 Ulcerative (chronic) pancolitis with fistula screening test. Exam or study used by a physician to identify abnormalities, regardless of whether the patient exhibits symptoms. K51.014 Ulcerative (chronic) pancolitis with abscess K51.018 Ulcerative (chronic) pancolitis with other complication sigmoidoscopy. Endoscopic examination of the entire rectum and sigmoid K51.20 Ulcerative (chronic) proctitis without complications colon, often including a portion of the descending colon and usually performed K51.211 Ulcerative (chronic) proctitis with rectal bleeding with a flexible fiberoptic scope in conjunction with a surgical procedure. K51.212 Ulcerative (chronic) proctitis with intestinal obstruction Medicare Edits K51.213 Ulcerative (chronic) proctitis with fistula K51.214 Ulcerative (chronic) proctitis with abscess Fac RVU Non-Fac RVU FUD Status MUE K51.218 Ulcerative (chronic) proctitis with other complication G0104 1.83 3.91 0 A 1(2) K51.30 Ulcerative (chronic) rectosigmoiditis without complications G0106 5.95 5.95 N/A A 1(2) G0122 7.5 7.5 N/A N - K51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction K51.313 Ulcerative (chronic) rectosigmoiditis with fistula Modifiers Medicare Reference K51.314 Ulcerative (chronic) rectosigmoiditis with abscess G0104 51 N/A N/A N/A 100-04,18,60.1 K51.318 Ulcerative (chronic) rectosigmoiditis with other complication G0106 N/A N/A N/A 80* K51.40 Inflammatory polyps of colon without complications G0122 N/A N/A N/A N/A K51.411 Inflammatory polyps of colon with rectal bleeding * with documentation K51.412 Inflammatory polyps of colon with intestinal obstruction HCPCS K51.413 Inflammatory polyps of colon with fistula K51.414 Inflammatory polyps of colon with abscess K51.418 Inflammatory polyps of colon with other complication K51.50 Left sided colitis without complications K51.511 Left sided colitis with rectal bleeding K51.512 Left sided colitis with intestinal obstruction K51.513 Left sided colitis with fistula K51.514 Left sided colitis with abscess K51.518 Left sided colitis with other complication

© 2015 Optum360, LLC CPT © 2015 American Medical Association. All Rights Reserved. 428 — HCPCS Coding Companion Explanation This cervical or vaginal cytopathology screening is done on specimens prepared G0108-G0109 in a smear. The specimen is collected by cervical, endocervical, or vaginal G0108 Diabetes outpatient self-management training services, individual, per scrapings or by aspiration of vaginal fluid and cells. The screening method is 30 minutes microscopy examination of a spray or liquid fixated smear prepared by the physician collecting the specimen. Screening, defined as the careful review of G0109 Diabetes outpatient self-management training services, group session the specimen for abnormal cells, may then be accomplished by different methods (2 or more), per 30 minutes that involve the use of automated systems. Explanation These codes are for diabetes self-management training services, either individually or in a group of two or more. Diabetes self-management training is done to G0179-G0180 teach the diabetic how to control and monitor blood glucose levels with the G0179 Physician re-certification for Medicare-covered home health services proper use of the monitoring device, dietary calculations and restrictions, and under a home health plan of care (patient not present), including correct administration of diabetic medications. These codes are reported per contacts with home health agency and review of reports of patient 30 minute intervals. status required by physicians to affirm the initial implementation of the plan of care that meets patient's needs, per re-certification period G0180 Physician certification for Medicare-covered home health services under G0123-G0124 a home health plan of care (patient not present), including contacts G0123 Screening cytopathology, cervical or vaginal (any reporting system), with home health agency and review of reports of patient status collected in preservative fluid, automated thin layer preparation, required by physicians to affirm the initial implementation of the plan screening by cytotechnologist under physician supervision of care that meets patient's needs, per certification period G0124 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, Explanation requiring interpretation by physician These codes report one period of certification or recertification of a patient's qualifying status for Medicare-covered home health services under a home Explanation health plan of care by a physician, without the patient present. This includes all These cervical or vaginal cytopathology screenings (any reporting system) of contacts made with the home health agency and reviewing of patient status specimens collected in preservative fluid may be identified as "thin prep." The reports required by physicians to affirm the initial implementation of the care specimen is collected by cervical, endocervical, or vaginal scrapings or by plan designed to meet the patient's needs. aspiration of vaginal fluid and cells. This method saves time by eliminating the need for the physician to prepare a smear; the specimen is placed in a preservative suspension instead. At the laboratory, special instruments take the G0181-G0182 cells in the preservative suspension and "plate-out" a monolayer for screening, G0181 Physician supervision of a patient receiving Medicare-covered services which will carefully review the specimen for abnormal cells. provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review G0130 of subsequent reports of patient status, review of laboratory and other G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or studies, communication (including telephone calls) with other health more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) care professionals involved in the patient's care, integration of new information into the medical treatment plan and/or adjustment of Explanation medical therapy, within a calendar month, 30 minutes or more Bone mineral density studies are used to evaluate diseases of bone and/or the G0182 Physician supervision of a patient under a Medicare-approved hospice responses of bone disease to treatment. Densities are measured at the wrist, (patient not present) requiring complex and multidisciplinary care radius, hip, pelvis, spine, or heel. The studies assess bone mass or density modalities involving regular physician development and/or revision of associated with such diseases as osteoporosis, osteomalacia, and renal care plans, review of subsequent reports of patient status, review of osteodystrophy. Single energy x-ray absorptiometry (SEXA) utilizes an x-ray tube as the radiation source that is pulsed at a certain energy level. SEXA is used laboratory and other studies, communication (including telephone to scan bone that is in a superficial location with little adjacent soft tissue, such calls) with other health care professionals involved in the patient's care, as the wrist or heel. There is a differential attenuation between bone and soft integration of new information into the medical treatment plan and/or tissue for the energy beam. Excessive soft tissue renders the measurement adjustment of medical therapy, within a calendar month, 30 minutes incorrect. An attenuation profile of the bony components is calculated and the or more results are given in two scores, which are reported as standard deviations from the normal bone density of a person the same sex, 30 years old, which is the Explanation age of peak bone mass, and from the normal bone density of an "age matched" These codes represent physician supervision of a patient receiving that compares the patient’s bone density to what is expected in someone the Medicare-covered services provided by a participating home health agency or same age, sex, and size. of a patient under a Medicare-approved hospice. This includes complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of G0141 laboratory and other studies, communication with other health care professionals

Appendix involved in the patient's care, including all telephone calls, and integration of G0141 Screening cytopathology smears, cervical or vaginal, performed by new information into the medical treatment plan and/or adjustment of medical automated system, with manual rescreening, requiring interpretation therapy, within a calendar month. The patient is not present for the physician by physician supervision.

Evaluation and Management Evaluation and Management

This section provides an overview of evaluation and management physicians should practice in “the exact same specialty and exact (E/M) services, tables that identify the documentation elements same subspecialty as the physician.” State licensure guidelines associated with each code, and the federal documentation determine the scope of practice and a qualified health care guidelines with emphasis on the 1997 exam guidelines. This set of professional must practice within these guidelines, even if more guidelines represent the most complete discussion of the elements restrictive than the CPT guidelines. The qualified health care of the currently accepted versions. The 1997 version identifies both professional may report services independently or under incident-to general multi-system physical examinations and single-system guidelines. The professionals within this definition are separate from examinations, but providers may also use the original 1995 version “clinical staff" and are able to practice independently. CPT defines of the E/M guidelines; both are currently supported by the Centers clinical staff as “a person who works under the supervision of a for Medicare and Medicaid Services (CMS) for audit purposes. physician or other qualified health care professional and who is allowed, by law, regulation, and facility policy to perform or assist in Although some of the most commonly used codes by physicians of the performance of a specified professional service, but who does all specialties, the E/M service codes are among the least not individually report that professional service.” Keep in mind that understood. These codes, introduced in the 1992 CPT® manual, there may be other policies, guidance, or payer policies that can were designed to increase accuracy and consistency of use in the affect who may report a specific service. reporting of levels of non-procedural encounters. This was accomplished by defining the E/M codes based on the degree that certain common elements are addressed or performed and reflected Types of E/M Services in the medical documentation. When approaching E/M, the first choice that a provider must make is what type of code to use. The following tables outline the E/M The Office of the Inspector General (OIG) Work Plan for physicians codes for different levels of care for: consistently lists these codes as an area of continued investigative review. This is primarily because Medicare payments for these • Office or other outpatient services—new patient services total approximately $33.5 billion per year and are • Office or other outpatient services—established patient responsible for close to half of Medicare payments for physician services. • Hospital observation services—initial care, subsequent, and discharge The levels of E/M services define the wide variations in skill, effort, • Hospital inpatient services—initial care, subsequent, and and time and are required for preventing and/or diagnosing and discharge treating illness or injury, and promoting optimal health. These codes • Observation or inpatient care (including admission and discharge are intended to represent physician work, and because much of this services) work involves the amount of training, experience, expertise, and knowledge that a provider may bring to bear on a given patient • Consultations—office or other outpatient presentation, the true indications of the level of this work may be • Consultations—inpatient difficult to recognize without some explanation. The specifics of the code components that determine code selection At first glance, selecting an E/M code may appear to be difficult, but are listed in the table and discussed in the next section. Before a the system of coding clinical visits may be mastered once the level of service is decided upon, the correct type of service is requirements for code selection are learned and used. identified.

Providers Office or other outpatient services are E/M services provided in the physician or other qualified health care provider’s office, the The AMA advises coders that while a particular service or procedure outpatient area, or other ambulatory facility. Until the patient is may be assigned to a specific section, the service or procedure itself admitted to a health care facility, he/she is considered to be an is not limited to use only by that specialty group (see paragraphs 2 outpatient. and 3 under “Instructions for Use of the CPT Codebook” on page xii of the CPT Book). Additionally, the procedures and services listed A new patient is a patient who has not received any face-to-face throughout the book are for use by any qualified physician or other professional services from the physician or other qualified health qualified health care professional or entity (e.g., hospitals, care provider within the past three years. An established patient is a laboratories, or home health agencies). patient who has received face-to-face professional services from the physician or other qualified health care provider within the past The use of the phrase “physician or other qualified health care three years. In the case of group practices, if a physician or other professional” (OQHCP) was adopted to identify a health care qualified health care provider of the exact same specialty or provider other than a physician. This type of provider is further subspecialty has seen the patient within three years, the patient is described in CPT as an individual “qualified by education, training, considered established. licensure/regulation (when applicable), and facility privileging (when applicable).” In addition, CPT guidelines indicate that the If a physician or other qualified health care provider is on call or advanced practice nurses and physician assistant who work with covering for another physician or other qualified health care