Military Health System Coding Guidance: Professional Services and Specialty Coding Guidelines Version 3.6 Unified Biostatistical Utility Effective date for this guide version: 1 March 2013 Effective date for audit use: 1 April 2013 1 CHAPTER 1 OVERVIEW ..................................................................................................................................... 1-1 2 1.1. PURPOSE ......................................................................................................................................................... 1-1 3 1.2. DIAGNOSTIC CODING ...................................................................................................................................... 1-2 4 1.3. PROCEDURAL CODING .................................................................................................................................... 1-2 5 1.4. EVALUATION AND MANAGEMENT (E&M) CODING ........................................................................................ 1-3 6 1.5. CODING TABLE UPDATES ............................................................................................................................... 1-3 7 1.6. LEGAL REFERENCE ......................................................................................................................................... 1-4 8 1.7. GETTING HELP ON CODING QUESTIONS .......................................................................................................... 1-4 9 1.8. USE OF THE TERM CAPER .............................................................................................................................. 1-4 10 CHAPTER 2 DIAGNOSTIC CODING ................................................................................................................. 2-1 11 2.1. CODE TAXONOMY (STRUCTURE) .................................................................................................................... 2-1 12 2.2. SPECIFIC DIAGNOSTIC GUIDELINES ................................................................................................................ 2-2 13 CHAPTER 3 EVALUATION AND MANAGEMENT (E&M) CODING ......................................................... 3-1 14 3.1. EVALUATION AND MANAGEMENT CODING – 99201-99499 ............................................................................ 3-1 15 3.2. OFFICE OUTPATIENT SERVICES, 99201–99215 ............................................................................................... 3-6 16 3.3. HOSPITAL OBSERVATION SERVICES ............................................................................................................... 3-6 17 3.4. EMERGENCY DEPARTMENT ............................................................................................................................ 3-6 18 3.5.CONSULTATION ...................................................................................... ERROR! BOOKMARK NOT DEFINED. 19 3.6. MEDICAL EVALUATION BOARDS (MEB) .................................................... ERROR! BOOKMARK NOT DEFINED. 20 3.7. TOBACCO CESSATION COUNSELING ........................................................... ERROR! BOOKMARK NOT DEFINED. 21 CHAPTER 4 PATIENT TO PROVIDER COMMUNICATION VIA TELEPHONE SERVICES AND 22 ELECTRONIC MEDIA ......................................................................................................................................... 4-1 23 4.1. TELEPHONE AND ONLINE (EMAIL) ENCOUNTERS ........................................ ERROR! BOOKMARK NOT DEFINED. 24 4.2. TELEHEALTH SERVICES ............................................................................... ERROR! BOOKMARK NOT DEFINED. 25 4.3. E&M CODING……………………………………………………………………………………………….…4-1 26 4.4. DIAGNOSIS CODING ..................................................................................... ERROR! BOOKMARK NOT DEFINED. 27 4.5. PROCEDURAL CODING…………………………………………………………………………….…….4-2 28 4.6. MODIFIERS……………………………………………………………………………………………..….4-2 29 30 CHAPTER 5 PROCEDURAL CODING .............................................................................................................. 5-1 31 5.1. PROCEDURES .................................................................................................................................................. 5-1 32 5.2. MODIFIERS ...................................................................................................................................................... 5-2 33 5.3. BUNDLED PROCEDURES AND GLOBAL PROCEDURES .................................. ERROR! BOOKMARK NOT DEFINED. 34 5.4. CLINICAL PHARMACISTS ................................................................................................................................. 5-4 35 5.5. CHAPLAINS AND PASTORAL COUNSELOR ....................................................................................................... 5-5 36 5.6. ELECTROCARDIOGRAM (ECG OR EKG) SERVICES 93000–93042 ................................................................... 5-5 37 5.7. LASER TATTOO AND HAIR REMOVAL ............................................................................................................. 5-6 38 5.8. ON CALL ......................................................................................................................................................... 5-6 39 5.9. RECORDS REVIEW ........................................................................................................................................... 5-6 40 5.10. INJECTIONS AND INFUSIONS .......................................................................................................................... 5-6 41 5.11. CAST OR SPLINT APPLICATION ..................................................................................................................... 5-7 42 CHAPTER 6 SPECIALTY CODING.................................................................................................................... 6-1 43 6.1. ANESTHESIA ................................................................................................................................................... 6-1 44 6.2. AUDIOLOGY .................................................................................................................................................... 6-7 45 6.3. CHIROPRACTIC SERVICES ............................................................................................................................. 6-12 46 6.4. DIALYSIS ...................................................................................................................................................... 6-14 47 6.5. END STAGE RENAL DISEASE SERVICES (ESRD) (90951–90970) .................................................................. 6-16 48 6.6. FLIGHT MEDICINE SERVICES ........................................................................................................................ 6-19 49 6.7. GYNECOLOGY ............................................................................................................................................... 6-23 50 6.8. MENTAL HEALTH ......................................................................................................................................... 6-26 51 6.9. NUTRITIONAL MEDICINE ENCOUNTERS ...................................................................................................... 6-30 52 6.10. OBSTETRICS SERVICES ................................................................................................................................ 6-37 53 6.11. OCCUPATIONAL THERAPY (OT) .................................................................................................................. 6-49 54 6.12. OPHTHALMOLOGY/OPTOMETRY ................................................................................................................. 6-53 55 6.13. PHYSICAL THERAPY (PT)—CODING FOR PHYSICAL THERAPIST OR TECHNICIAN ....................................... 6-62 56 6.14. PREVENTIVE MEDICINE SERVICES .............................................................................................................. 6-66 57 6.15. RADIATION ONCOLOGY SERVICES .............................................................................................................. 6-72 58 6.16. RADIOLOGY, INTERVENTIONAL .................................................................................................................. 6-76 59 6.17. HEALTH EXAMS OF DEFINED SUBPOPULATIONS, V 70.5_X ........................................................................ 6-78 60 6.18. RECONSTRUCTIVE AND COSMETIC SURGERY .............................................................................................. 6-82 61 6.19. SOCIAL WORK AND FAMILY ADVOCACY SERVICES .................................................................................... 6-84 62 6.20. SUBSTANCE ABUSE PROGRAM SERVICES.................................................................................................... 6-88 63 CHAPTER 7 CODING AMBULATORY PROCEDURE VISIT (APV) ENCOUNTERS ............................... 7-1 64 7.1. DEFINITIONS ................................................................................................................................................... 7-1 65 7.2. CODING PRE- AND POST-PROCEDURE APV ENCOUNTERS .............................................................................. 7-2 66 7.3. PATIENT ADMITTED FROM APV ....................................................................................................................