NOTE: CLICK PAGE DOWN TO VIEW NEXT PAGE DROP IN BLACK AND WHITE COVER ON THIS PAGE NOTE: CLICK PAGE DOWN TO VIEW NEXT PAGE CONTENTS FOREWORD ................................................................................................................................................................................................. iii DISCLAIMER .............................................................................................................................................................................................. iv INTRODUCTION ......................................................................................................................................................................................... 1 Linking Diagnosis Codes to Procedure Codes .......................................................................................................................................... 1 Sources of the Data and Data Analysis ..................................................................................................................................................... 1 Format of the Listings ............................................................................................................................................................................... 1 CPT CODING ......................................................................................................................................................................................... 2 Key points regarding CPT ........................................................................................................................................................................ 2 Structure of the CPT Coding System ........................................................................................................................................................ 3 How to use the CPT Coding System ......................................................................................................................................................... 3 CPT Modifiers .......................................................................................................................................................................................... 3 Unlisted Procedures or Services ............................................................................................................................................................... 4 CPT Changes, Additions, and Deletions .................................................................................................................................................. 4 Place (Location) of Service ....................................................................................................................................................................... 4 Procedure Down-Coding .......................................................................................................................................................................... 4 Down-Coding Due to Lack of Documentation ......................................................................................................................................... 4 ICD-10--CM Coding ............................................................................................................................................................................... 5 Key Points Regarding ICD-9-CM ............................................................................................................................................................. 5 General ICD-10-CM Coding Guidelines .................................................................................................................................................. 5 Important Diagnosis Coding Issues .......................................................................................................................................................... 8 Nine Steps for Accurate and Precise ICD-9-CM Coding .......................................................................................................................... 9 DOCUMENTATION GUIDELINES .......................................................................................................................................................... 11 What is Documentation and Why is it Important? .................................................................................................................................. 11 What Do Payers Want and Why? ........................................................................................................................................................... 11 General Principles of Medical Record Documentation ........................................................................................................................... 11 Musculoskeletal Examination ................................................................................................................................................................ 12 Documentation of the Complexity of Medical Decision Making ........................................................................................................... 13 NATIONAL CORRECT CODING POLICY ............................................................................................................................................ 17 Introduction ............................................................................................................................................................................................ 17 Coding Based on Standards of Medical/Surgical Practice ...................................................................................................................... 18 Medical/Surgical Package ....................................................................................................................................................................... 20 Evaluation and Management Services .................................................................................................................................................... 22 Modifiers and Modifier Indicators .......................................................................................................................................................... 22 Standard Preparation/Monitoring Services ............................................................................................................................................. 26 Anesthesia Service Included in Surgical Procedure ................................................................................................................................ 26 HCPCS/CPT Procedure Code Definition ................................................................................................................................................ 26 CPT Coding System and CMS Coding Manual Instructions .................................................................................................................. 27 CPT "Separate Procedure" Definition ..................................................................................................................................................... 27 Family of Codes ...................................................................................................................................................................................... 27 More Extensive Procedure ...................................................................................................................................................................... 28 Sequential Procedure .............................................................................................................................................................................. 28 Laboratory Panel ..................................................................................................................................................................................... 28 Misuse of Column Two Code with Column One Code .......................................................................................................................... 29 Mutually Exclusive Procedures .............................................................................................................................................................. 29 Gender-Specific Procedures .................................................................................................................................................................... 29 Add-On Codes ........................................................................................................................................................................................ 29 CPT codes and descriptions copyright American Medical Association v NOTE: CLICK PAGE DOWN TO VIEW NEXT PAGE CODING GUIDE – ORTHOPEDICS Excluded Service .................................................................................................................................................................................... 30 Unlisted Procedure Codes ....................................................................................................................................................................... 30 Medically Unlikely Edits (MUEs) .........................................................................................................................................................