Coding Notes - Billing & Coding Pocket Guide

Copyright © 2007 by F. A. Davis.
00Andress (F)-FM 4/17/07 3:00 PM Page 3
Provider’s
Coding
Notes Billing and Coding Pocket Guide
Alice Anne Andress, CCS-P, CCP
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01Andress (F)-01 4/17/07 3:00 PM Page 1
1
General Billing and Insurance Guidelines
Patient Registration Form
The patient registration form is one of the most important forms in

a medical practice. It contains all necessary information required
for billing for services and procedures. This form should be updated
yearly. Patient information should be reviewed and verified at each
patient encounter to ensure that the practice has the most current
and accurate information on file.
Each item on the form should be verified by asking the patient, “Do
you still live at . . . ” instead of using a general statement such as
“Has anything changed since your last visit?”
A copy of the patient’s health insurance card, both front and back,
should be copied during each visit.
This form should contain the following information:
Data Reason
Date Required for billing purposes
Patient’s name Required for billing purposes
Patient’s address Required for billing purposes
Patient’s phone number Required for billing purposes and
to contact patient regarding
appointments and testing results
Patient’s date of birth Required for billing purposes
Patient’s age Required for billing purposes
Patient’s social security Required for patient identification
number purposes only
Guarantor’s name, address, Required for billing purposes
and phone number if
patient is not guarantor
Employer’s name, address, Required for billing or if patient
and phone number needs to be contacted during
working hours
(Continued text on following page)
GENERAL
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GENERAL
Data Reason
Spouse’s name May be required for billing
purposes
Spouse’s employer’s name, May be required for billing pur-
address, and phone poses or if spouse needs to be
number contacted during working hours
Insurance company name, Required for billing purposes
address, and phone
number
Insurance identification Required for billing purposes
and group numbers
Person to be notified in Required in case of emergency
case of emergency
Referred by Required for billing purposes and
quality of care purposes
Patient’s signature Required for billing purposes
Some forms will contain
the following:
List of current medications For clinical reasons
Past illnesses/surgeries
Allergies
Review this form for completeness as this information is critical
to the billing process. Any missing information should be
completed by asking the patient questions.
There are some key areas to look for that may be “tell-tale”
for nonpaying patients. These areas are:
■ Incomplete information on the form
■ Questionable employment information
■ No phone number
■ Post office box listed in lieu of a street address
■ Motel address
■ No insurance information
■ No referral information
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01Andress (F)-01 4/17/07 3:00 PM Page 3
3
A potential nonpaying patient may sometimes be identified
by items on the previous list.
If any of the listed elements exist, extra care should be taken
to obtain accurate and complete information.
Patient Encounter Form

One of the most important factors in medical billing is an
accurate billing form. This form has many names, patient
encounter form, superbill, fee slip, charge slip, billing
form, etc. This form is used to communicate the patient
visit charges to the billing personnel. All information on
this form must be accurate and complete and contain the
following information:
■ Patient’s name
■ Patient’s address
■ Patient’s home phone number
■ Patient’s account number/medical record number
■ Guarantor’s name
■ Patient/guarantor’s insurance company and identification
number
■ Date of service
■ Date of birth
■ Provider name
■ Diagnosis section
■ CPT code section
■ Space for next appointment
■ Space for provider to complete with any studies that may
need to be ordered
This form must be reviewed and updated twice a year when
the codes are updated. Deleted codes, new codes, and revised
codes should be updated when necessary.
The patients should be questioned at each visit to identify any
changes that may have occurred since their last visit.
GENERAL
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GENERAL
Life Cycle Of An Insurance Form

New Patient, Office
A new patient is one who has not been seen by the physician or
any physician in that specialty group within the last 3 years. These
visits are reported using codes 99201–99205. Detailed information
regarding these codes can be found in Tab Two.
The steps involved in an office visit for a new patient are:
Step 1 Patient information
The patient arrives at the Patient’s name
office. The patient is either Address
interviewed or completes a
patient registration form to Phone number
obtain information listed to Place of employment
the right. Spouse name, if applicable
If the patient registration form
is not completed in its Emergency contact information
entirety, the office staff Allergies
should question the patient Reason for the visit
in order to obtain all the
necessary information. Type of insurance
Some offices will have the Address of insurance
patient complete a history Sign a record release form,
form in addition to the if applicable
registration form.
OR
The patient calls the office to Patient’s name
make an appointment. Address
Information is collected Phone number
during the phone call to
obtain information as listed Place of employment
to the right. Patient Spouse name, if applicable
*Current Procedural Terminology © 2006 American Medical Association,
All Rights Reserved.
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01Andress (F)-01 4/17/07 3:00 PM Page 5
5
is asked to bring his/her Emergency contact information
insurance card to the office Allergies
visit. Reason for the visit
Type of insurance
Address of insurance
Step 2 Insurance
The patient Patient registration form is completed.
arrives at Both sides of the insurance card are copied.
the office
This copy is placed in the patient’s chart.
with his/her
insurance All patients with insurance must sign an authori-
card. zation of benefits form to allow the practice to
release information necessary for payment of
the claim and to request that payment be made
directly to the physician practice.
Depending on the insurance, verification of
coverage may be necessary.
If this is a specialty office and the patient has
a managed care plan, a referral is necessary for
treatment.
Most managed care plans have co-pays, which
must be paid at the time of the visit.
If the patient has Medicare, a deductible must be
met at the beginning of each calendar year.
If the patient has Medicaid or other insurances,
there may be deductibles and co-pays that are
necessary to be paid. This information can be
found on the insurance card.
If the patient is a child, be aware of the birthday
rule. If both parents carry insurance, the child
will be covered under the parent whose
birthday is first in a calendar year.
GENERAL
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GENERAL
Step 3 Create the chart

A patient chart Place patient registration form and copy of
is created insurance card in chart.
with the Place all other authorization forms in the chart.
forms listed
to the right. Any forms used by the practice to record
clinical information, such as medication
logs, progress note forms, office visit
templates, history forms, problem lists, etc.
Apply appropriate labels to the chart, such
as type of insurance, year of the visit,
alphabetize labels indicating the patient
name for faster filing.
Step 4 Data Entry
A patient account is created in the computer using the following
the information collected from the patient registration form
and insurance card.
Step 5 Generate a patient encounter form
A patient encounter Fee slip
form is generated Superbill
and placed on the
front of the patient’s Charge slip
chart. This document Billing form
becomes the source Charge capture form
of information for
billing. This docu-
ment has many
names, some of
which you can see
in the column to
the right.
The patient is seen by the physician and is discharged from that
office visit.
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01Andress (F)-01 4/17/07 3:00 PM Page 7
7
Established Patient, Office
An established patient is one who has been seen by the physi-

cian within the last 3 years. These visits are reported using codes
99211–99215. Detailed information regarding these codes can be
found in Tab Two.
The steps involved in an office visit for an established patient are
as follows:
Step 1 Scheduling of appointment

The patient either schedules a follow-up appointment while at
the office, or calls the office for an appointment.
Step 2 Preauthorization of services or procedures
If the physician is a specialist, the staff must check the
preauthorization to be sure it has not expired. If the referral
has expired, it will be necessary to obtain a new form from the
primary care physician. Most physician offices submit referrals
electronically as opposed to paper.
Step 3 Review and update patient registration form
Be sure that all information listed on the patient registration
form is accurate and complete. These forms should be
completely updated yearly, however, at each patient visit, the
staff should inquire as to any changes that may have occurred
in the patient’s insurance, address, employment, etc.
Step 4 Collect co-pays and deductibles
All co-pays should be collected at the time of patient check-in.
On Medicare patients, deductibles are not collected at the time
of the service. Medicare is billed and any deductible still due
is deducted from the physician payment. This is stated on the
Explanation of Medicare Benefits. The patient is then billed for
the deductible amount.

GENERAL
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GENERAL
Generate a patient
Step 5 encounter form
A patient encounter form is generated Fee slip
and placed on the front of the Superbill
patient’s chart. This document
becomes the source of information Charge slip
for billing. This document has many Billing form
names, some of which you can see Charge capture form
in the column to the right.
The purpose of the patient encounter form is to communicate
charges (services and procedures the patient received) and
diagnoses to the billing department. This form is also used to
inform the staff of any diagnostic studies that are to be ordered
and to indicate any follow-up appointments that may be
necessary.
The patient is seen by the physician and is discharged from that
office visit.
Patient Discharge
Step 1 Charges
Physician practices will have The patient charges are totaled
check-out staff procedures. on the patient encounter form.
Step 2 Posting
The patient charges are posted to the patient’s
account in the computer system.
Step 3 Payment
Patient’s If no insurance, the patient is expected to pay
financials at the time of the service.
If the patient has a co-pay that has not been
collected during check-in, they will be expected
to pay at discharge.
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01Andress (F)-01 4/17/07 3:00 PM Page 9
9
Step 3 Payment
If the patient has insurance, but it does not cover
office visits, the patient is expected to pay at the
time of service.
Any payment made is then posted to the patient’s
account.
The purpose of the CMS 1500 claim form is to create a standard for
collecting Medicare information. The most common claim denials
based on the claim form is incomplete or inaccurate diagnosis
codes (Box 21) and incorrect place of service codes (Box 24b). The
CMS 1500 form information has been completed, is accurate, and
ready for submission when all items in the following table have
been completed.
Step 4 Generate insurance form (CMS 1500 Form)
Step 5 Attachments
For filing paper Copy and staple any attachments that are neces-
claims only sary to the CMS 1500 form. If no attachments
are necessary, claim can be sent electronically.
Attachments are needed if there is a concurrent
care situation, if an unusual service or proce-
dure was performed.
Step 6 Signature, patient
Signatures are The patient must sign the CMS claim form if a
an important form is being sent by paper claim.
part of the On claims where the patient has signed an
claim form. authorization form, the phrase “SOF” or
“signature on file” can print in box 12 on the
CMS 1500 paper claim.
If claim is being submitted electronically, “SOF”
or “signature on file” can print in box 12.
When an illiterate or physically handicapped
patient signs by a mark (X), a witness must
enter his or her name and address next to
the mark on the claim form.
GENERAL
01Andress (F)-01 4/17/07 3:00 PM Page 10

GENERAL
Step 6 Signature, patient

A representative may sign the claim on the
patient’s behalf if the patient is physically or
mentally unable to sign. When this occurs,
the signature line must indicate the patient’s
name followed by the word “by,” the
representative’s name, address, relationship
to the patient, and the reason the patient
cannot sign.
If there is no signature, the claim will not be
transferred automatically to Medigap.
Step 6 Signature, provider
Signatures The claim must be signed by the provider or an
are an authorized representative if the claim is being
important generated on paper.
part of the No signature is necessary if the claim is being
claim form. sent electronically.
A signature stamp may be used if the
provider’s name is typed below.
Step 7 Insurance tracking
Submitted If the claim is manually produced (paper), an
claims insurance log must be kept with information
should be such as the patient name, amount of claim,
tracked. insurance carrier, and date submitted.
If the claim is submitted electronically, the
computer will provide the practice with a
report.
Step 8 Submit claim
Either mail or submit the claim electronically.
Claims should be submitted daily for better
cash flow.
10
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11
Step 8 Submit claim
When submitting a claim electronically, run a
presubmission report to identify any errors,
which may cause denials and correct them
before submission.
Step 9 Check is mailed
A check along Information is taken from EOB and posted
with an to the patient’s account.
explanation Any claim denials must be thoroughly
of benefits reviewed, corrected, and resubmitted if
(EOB) is possible.
mailed to
Automatic rebilling of claims to the carrier
the provider
without investigation and analysis of the
if the pro-
claim can result in duplicate claims and
vider is
duplicate payments. This can be construed
participating.
as fraudulent billing.
Preauthorization/Precertification
Preauthorization:
Some insurance carriers require permission to perform a service
or procedure before it is done. This preauthorization identifies
whether the insurance program will allow the service or
procedure to be performed based on the medical necessity
information provided by provider.
Precertification:
Identifies whether the service or procedure is covered under
the patient’s insurance plan. It is not based on the medical
necessity of the procedure, but on whether or not the patient
has coverage.
Although proper steps have been taken to obtain preauthoriza-
tion/precertification, there is no guarantee that services will be
covered.
GENERAL
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GENERAL
Documentation
Documentation is the story of patient visit, a legal document, and
serves as the groundwork for reimbursement of health-care
services and procedures. It explains to the carrier what you did,
why, and how.
In Tab 2, the Evaluation and Management codes are discussed
in detail to illustrate the various components necessary for
choosing the appropriate level of service.
Proper documentation will:
■ Allow your billing staff to identify the services and procedures
that you performed.
■ Allow for appropriate reimbursement.
General Instructions for Good Documentation

■ Make sure that you have the correct chart.
■ Be sure to write the patient’s name on each page when
documenting (this can be done by office staff).
■ Make sure all entries in the medical record are legible and
preferably written in black ink.
■ Be sure to date, sign (hard copy, or authenticate an electronic
signature) each entry.
■ For inpatient records, document the time using military time and
the service you are on, i.e., medicine, surgery, cardiology, etc.
■ Use standard abbreviations (it is a good idea to obtain a listing
from the hospital; most use Stedman’s).
■ Avoid “canned verbiage.” No two patients are the same.
■ Avoid vague language such as, “routine visit,” “follow-up,”
“doing well,” “check up,” “ exam unchanged,” etc.
■ Make sure there is a record of all prescriptions refilled and all
telephone calls with patients.
■ Be sure to either dictate or hand write the documentation as
soon as possible after the patient encounter (memories fade).
■ Document specifics of any unusual procedure or service that
requires more time than usual (document such things as the
time it took, what you did that took the extra time, or any
difficulties that you may have had either with the procedure
12
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13
itself or the patient). These procedures would be reported
using the – 22 modifier (see Tab 7).
■ Document the difference between an acute and a chronic
condition.
■ Be sure to include your reasoning to support the medical
necessity for the visit.
■ Document nonresponses to treatments or medications and any
newly developed symptoms.
■ Do not dictate the phrase “Dictated, not read” on your dictations.
You are responsible for verifying that the dictation is true and
correct.
Completion of a CMS 1500 Form

The CMS 1500 was revised to accommodate many changes
including addition of the NPI number for providers. The revisions
began in June of 2004 and the new form was released in January
of 2007.
CMS Areas Completion Instructions

Box 1: Type of Indicate the type of health insurance coverage:
insurance Medicare, Medicaid, Champus/Tricare,
Champva, group health plan, FECA/black
lung, other
Box 1a: Insured’s Contains the patient’s health insurance number
ID number
Box 2: Patient Enter patient’s name exactly as it is on the
name insurance card
Address, phone number
Do not leave a space between a prefix and a
name
For hyphenated names, capitalize both names
and separate by a hyphen
Leave a space between the last name and a suffix
GENERAL
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GENERAL

Box 3: Patient’s Enter the date of birth using two digits for the
date of birth month, two for the day, and four for the
and sex year.
Check the box that indicates the sex of the
patient; the sex of the patient must be valid
for the diagnosis of the patient
Box 4: Insured’s For Medicare: Enter the name of the insured
name person only if that person’s insurance is
primary to Medicare; if Medicare is primary,
leave it blank
Box 5: Patient’s Enter the complete mailing address and
address telephone number
If the patient lives in a nursing home, list the
nursing home address as the patient’s
Do not place punctuation in a city name that
contains an abbreviation
Box 6: Patient This relationship is the primary insured;
relationship choices are self, spouse, child, and other
to the insured Only complete this box if Box 4 is completed;
otherwise leave it blank
Box 7: Insured’s Only complete this box if Box 4 is completed,
address otherwise leave it blank.
Box 8: Patient’s Place the patient’s marital status and
status employment or student status
The choices for marital status are single,
married, and other
The choices for employment are employed,
full-time student, and part-time student
Box 9: Other Enter the name of the insured person who is
insured’s enrolled in a Medigap policy if the name is
name different from the name shown in Box 2;
enter the word “same” if it is the same
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15
Box 9a: Other Enter the policy or group number of the other
Insured’s Policy insured (Box 9)
or Group
Number
Box 9b: Other Enter the 8-digit date of birth, two digits for the
insured’s date month, two digits for the day, and four digits
of birth, sex for the year
Box 9c: Employer’s Enter the name of the other insured’s
Name or School employer or school.
Name
Box 9d: Insurance Enter the other insured’s insurance plan or
plan name or program name
program name
Box 10: Is patient’s If the patient’s condition is related to
condition related employment, an automobile accident, or
to: some other accident
This information is used for coordination of
benefits
If the patient’s condition is not related to any of
these, place an X in the “no” box for each
item
Box 10a: Employ- Yes or No
ment
Box 10b: Auto Yes or No
accident
Box 10c: Other Yes or No
accident
Box 10d: Reserved Enter information when asked by local carrier
for local use
Box 11: Insured’s Enter the insured’s policy, group, or FECA
policy, group, or number. If Box 4 is completed, then this field
FECA number needs to be completed
GENERAL
01Andress (F)-01 4/17/07 3:00 PM Page 16

GENERAL

Box 11a: Insured’s Date of birth and sex of the individual who
date of birth, carries the insurance
sex
Box 11b: Insured’s Name of the employer of the individual who
employer’s name carriers the insurance
Box 11c: Insurance Name of insurance plan of the individual who
plan name or carriers the insurance
program name
Box 11d: Is there Answer as to whether or not there is a
another health secondary insurance
benefit plan?
Box 12: Patient’s Enter the signature of the patient or the
or authorized patient’s representative and the date
person’s
This signature allows for the release of infor-
signature
mation necessary to process the claim
Box 13: Insured’s The insured’s signature must be entered in
or authorized this block; if the insured’s signature is on
person’s file, enter SOF
signature
Box 14: Date of Enter the date if the current illness (first
current illness, symptom), injury (accident), or pregnancy
injury or (last menstrual period)
pregnancy If an accident date is entered, complete Box
10b or 10c
For chiropractic services, enter the date of the
initiation of the course of treatment and the
x-ray date in Box 19
Box 15: If patient Do not complete this area for Medicare
has had same patients
or similar For all other insurer’s, the date should match
illness the same date or be later than the date
entered in Box 24a
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01Andress (F)-01 4/17/07 3:00 PM Page 17
17
Box 16: Dates This block provides the dates that the patient
patient unable to was employed but unable to work
work in current This field MUST be completed for all Workers’
occupation Compensation claims.
Box 17: Name of Enter the name and credentials of the
referring provider professional who requested the service
or other source
Box 17a: ID number The qualifying number should be listed just
of referring or left of the other ID number of the referring
ordering provider or ordering provider. The qualifying
numbers are:
OB State license number
1B BS provider number
1C Medicare provider number
1D Medicaid provider number
1G Provider UPIN number
1H CHAMPUS ID number
E1 Employer’s ID number
G2 Provider commercial number
LU Location number
N5 Provider plan network ID number
SY SSI number
X5 State industrial accident provider
number
ZZ Provider taxonomy
Box 17b: NPI Enter the NPI number of the referring or
number ordering provider
Box 18: Enter the admission and discharge dates
Hospitalization If the services were rendered in a facility other
dates related to than the patient’s home or a physician’s
current services office, provide the name and address of
that facility in Box 32
Box 19: Reserved Enter information when asked by local carrier.
for Local Use
GENERAL
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GENERAL

Box 20: Outside Place a “Yes” in the box when a provider,
diagnostic other than the provider billing for the
services/ service, performed the diagnostic test;
charges when “Yes” is checked, Box 32 must be
completed
Enter the purchase price of the tests in the
charges column; show the dollars and
cents, omitting the dollar sign
Box 21: Diagno- Enter the ICD-9-CM code for the diagnoses,
sis or nature conditions, problems, or other reasons
of illness or for the visit
injury Report at least one diagnosis per claim
Only four diagnosis codes can be submitted
Box 22: Medicaid Enter the codes and original Medicaid
resubmission reference number of a Medicaid claim
This area must be completed when
resubmitting a claim to Medicaid
Box 23: Prior Enter the number assigned by the peer review
authorization organization
number For laboratory services performed by a
physician office lab (POL), enter the 10-digit
CLIA certification number
Box 24a: Date(s) Enter the beginning and ending date of
of service service for the entire period reflected by the
procedure code.
Box 24b: Place Enter the appropriate 2-digit place of service
of service code
Box 24c: EMG Yes or No
Box 24d: Proce- Enter the appropriate CPT or HCPCS code for
dures, service, the service, procedure, or supply
or supplies
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19
Box 24e: Enter the appropriate diagnosis code reference
Diagnosis number (pointer) that is linked to the service,
pointer procedure, or supply
Box 24f: Enter the amount charged by the provider for
Charges each of the services or procedures listed on
the claim
Do not bill a flat fee for multiple dates of service
Box 24g: Days or Enter the number of days or units of proce-
units dures, services, or supplies listed in Box 24d
Box 24h: EPSDT Stands for early periodic screening, diagnosis,
and treatment services
Enter Yes or No
These services apply only to children who are
12 or younger and receive medical benefits
through Medicaid
Box 24i: ID Enter the qualifier identifying if the number is
qualifier a non-NPI.
The qualifying numbers are:
1B BS Provider number
LU Location number
SY SSI number
X5 State industrial accident provider number
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Box 24j: Rendering Enter the number of the rendering physician
provider number
Box 24: Supple-
mental informa- Supplemental information such as anesthesia
tion (gray area) duration in hours and/or minutes with start
and end times, narrative descriptions of
unspecified codes, NDC for drugs, vendor
product numbers, product numbers for
Health Care Uniform Code Council, can be
entered in the shaded areas of this box
Box 25: Federal Enter the tax ID number or social security
tax ID number number of the physician or supplier
Box 26: Patient’s Enter the patient’s account number in this
account area; this will then be referenced on the
number explanation of benefits for easier posting
of monies to the patient account
Box 27: Accept Check “Yes” when the physician accepts
assignment? assignment for the claim
Box 28: Total Enter the total amount charged for all
charge services, procedures, and supplies in Boxes
24f, lines 1 through 6
Enter the dollars and cents without the dollar
sign
Box 29: Amount Enter the dollar amount paid toward the total
paid cost of the service
Box 30: Balance Enter the dollar amount due after subtracting
due the amount paid
If the claim is Medicare, leave this area blank
Box 31: Signature The provider or his or her representative must
of physician or sign the provider’s name
supplier, includ- A stamp may be used, but the provider’s full
ing degrees or name must be typed below the stamp
credentials
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21
Box 32: Service If services were provided in a hospital, clinic,
facility location laboratory, or any facility other than the
information physician’s office or the patient’s home, this
area must be completed
Box 32a: NPI Enter NPI number of the service facility
number location
Box 32b: Other ID Enter the two digit qualifier identifying the
number non-NPI number followed by the ID number
LU Location number
SY SSI number
X5 State industrial accident provider number
Box 33: Physician’s Enter the billing name, address, and
supplier’s billing telephone number of the physician or
names, address, supplier who furnished the service
zip code, phone
number
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Box 33a: NPI number Enter NPI number of the service facility
location
Box 33b: Other Enter the two-digit qualifier identifying the
ID number non-NPI number followed by the ID
number.
LU Location number
SY SSI number
X5 State industrial accident provider
number
Place of Service Codes
When submitting a claim for reimbursement, a place of service

code must be placed in Item 24b on a CMS 1500 form. Not all of
the codes listed below are approved by all carriers. When
performing the billing function, the carrier should be contacted
to verify that the place of service code is valid.
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23
Code Type Description
03 School Service is provided at a school
04 Homeless shelter Service is provided at a shelter
that serves as temporary
housing for the patient
05 Indian Health Service is provided at a facility
Service/Free that is operated by the Indian
Standing Health Service where patients
Facility are not admitted
06 Indian Health Service is provided at a facility
Service/Free- that is operated by the Indian
standing facility Health Service where patients
are admitted as outpatients or
inpatients
07 Tribal 638 Free- Service is provided at a facility
standing facility that is operated by the Indian
Health Service under a 638
agreement, which provides
diagnostic, therapeutic, and
rehabilitation services to those
who are not admitted
08 Tribal 638 Free- Service is provided at a facility
standing facility that is operated by the Indian
Health Service under a 638
agreement, which provides
rehabilitation services to those
who are admitted as outpa-
tients or inpatients
11 Office Service is provided in an office
setting
12 Home Service is provided in the
patient’s or caregiver’s home
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13 Assisted-living Service is provided in a
facility residential facility with self-
contained living units that
provides support 24 hours a
day; this facility has the
capacity to arrange for other
services if needed
14 Group home Service is provided at a shared
living residence, where patients
receive supervision and other
services such as social,
behavioral, and custodial
15 Mobile unit Service is provided at a facility
that moves from place to place
to provide preventive services,
screening, diagnostic, and
treatment services
20 Urgent care Service is provided at a facility,
facility separate from a hospital
emergency room (ER), where
patients can be diagnosed and
treated for illness or injury;
these patients require
immediate medical attention
21 Inpatient hospital Service is provided at a hospital
22 Outpatient Service is provided at a portion of
hospital the hospital that provides
rehabilitation services to
patients who do not require
admission to the hospital
23 Emergency Service is provided at a hospital
Room-Hospital emergency department
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25
24 Ambulatory Service is provided at a
surgical center freestanding facility where
surgical and diagnostic services
are provided on an ambulatory
basis; cannot be provided in a
physician’s office
25 Birthing center Service is provided at a facility,
separate from a hospital or
physician’s office, where
maternity facilities are available
26 Military treat- Service is provided at a facility
ment facility operated by the Uniformed
Services
31 Skilled nursing Service is provided at a facility
facility that provides inpatient skilled
nursing care
32 Nursing facility Service is provided at a facility
that provides patients with
skilled nursing care and related
services
33 Custodial care Service is provided at a facility
that provides room and board
and other assistance to patients
on a long-term basis without a
medical component
34 Hospice Service is provided at a facility
other than the patient’s home,
where palliative and supportive
care for the terminally ill is
provided
41 Ambulance: land A land vehicle equipped to
provide transportation and life-
saving care to patients
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42 Ambulance: An air or water vehicle equipped
air/water to provide transportation and
life-saving care to patients
49 Independent Service is provided at a clinic,

clinic which is not part of a hospital
that is organized and operated
to provide preventive,
diagnostic, therapeutic,
rehabilitative, or palliative
services to patients
50 Federally Service is provided at a facility

qualified located in a medically
health center underserved area that provides
Medicare patients with
preventive care under the
direction of a physician
51 Inpatient Service is provided at a facility

psychiatric that provides inpatient psychi-
facility atric care for the diagnosis and
treatment of mental illness on a
24-hour basis
52 Psychiatric Service is provided at a facility for

facility: partial the diagnosis and treatment of
hospitalization mental illness that provides a
planned therapeutic program
for patients who do not require
full-time hospitalization, but
who need broader programs
that are not offered as
outpatients
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27
53 Community mental Service is provided at a facility that
health center provides the following services:
outpatient services for children,
elderly, individuals who are
chronically ill, and residents of
the center who were discharged
from inpatient treatment; day
treatment, partial hospitalization,
screening for patients being
considered for admission to
state mental health facilities to
determine the appropriateness
of such admission and consul-
tation and education services
54 Intermediate care Service is provided at a facility
facility/mentally that provides health-related care
retarded and services above the level of
custodial care to mentally
retarded patients
55 Residential sub- Service is provided at a facility
stance abuse that provides treatment for
treatment facility substance abuse to live-in
residents who do not require
acute medical care
56 Psychiatric residen- Service is provided at a facility for
tial treatment psychiatric care that provides a
center total 24-hour therapeutically and
professionally staffed group
living and learning environment
57 Nonresidential sub- Service is provided at a facility
stance abuse that provides treatment for
treatment facility substance abuse on an
ambulatory basis
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60 Mass immuniza- Service is provided at a facility where
tion center providers administer pneumo-
coccal pneumonia and influenza
vaccines and submit these services
for billing; can be a public health
center, pharmacy, or mall
61 Comprehensive Service is provided at a facility that
inpatient provides comprehensive rehabili-
rehabilitation tation services under the supervi-
facility sion of a physician to inpatients
with physical disabilities; services
include physical therapy (PT),
occupational therapy (OT), speech
pathology, psychological services,
and orthotics and prosthetics
62 Comprehensive Service is provided at a facility that
outpatient provides comprehensive rehabili-
rehabilitation tation services under the super-
facility vision of a physician to outpatients
with physical disabilities; services
include PT, OT, speech pathology,
psychological services, and
orthotics and prosthetics
65 End-stage renal Service is provided at a facility other
disease treat- than a hospital, which provides
ment facility dialysis treatment, maintenance,
and/or training
71 State or local Service is provided at a facility
public health maintained by the state or local
clinic health departments that provides
ambulatory primary care under
the direction of a physician
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29
72 Rural health clinic Service is provided at a facility,
which is certified as a rural
underserved area, that provides
ambulatory primary care under
the direction of a physician
81 Independent Service is provided at an
laboratory independent laboratory that is
certified to perform diagnostic
and/or clinical tests
99 Other place of Other place of service not
service identified
Claims Submission Issues

There are some common problems identified with claims
submissions:
■ Incorrect insurance number
■ Incorrect physician NPI number
■ Submission to an incorrect carrier
■ Incorrect diagnosis code (missing, incomplete)
■ Patient’s name, address, etc. as listed does not match
insurance carrier records
■ Gender of patient is incorrect
■ Incorrect date of service
■ Incorrect place of service code
■ Incorrect or missing modifier(s)
■ Incorrect units billed
■ Missing provider ID number
■ Illegible claim form
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Explanation of Benefits (EOB)
An EOB or remittance advice identifies which services,

procedures, and/or supplies were paid and which were denied.
All denials will contain a reason code that fully explains the
reason for denial. An EOB contains the following information:
Components of an Explanation of Benefits

Patient Name
Patient ID number or HIC number
Claim processing ID number
Provider name
Date of service
Procedure code
Diagnosis code
Allowable charge
Submitted charge
What portion is deductible and/or co-pay
What is paid and to whom
Patient responsibility amount
If no payment, the reason code for the nonpayment
EOBs will not be sent to providers who do not accept assign-
ment on claims. This is prohibited by the Federal Privacy Act
of 1974. In this case, the EOB will be sent to the patient. If an
appeal is required on a non-assigned claim, the patient must
provide the EOB along with a letter stating the provider is
permitted to assist in the appeal. The EOBs should be reviewed
periodically to ensure that the provider is receiving accurate
reimbursement.
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31
Denial of Claims
There are some common denials identified with claims submis-
sions. Below you will find a listing with a recommendation to
follow.
Rejected claims Recommendation

Claims are many times Review all claim information for
rejected due to incorrect or accuracy and completeness
invalid information (date of before submission. Correct all
birth, transposed numbers, rejected claims and resubmit.
provider numbers, dates of
service, incorrect gender,
etc.) submitted to the carrier.
Delays in payment Recommendation
Claims that are delayed can Correct claims quickly and
result due to claim being resubmit so that cash flow is
“in process,” where the not interrupted. Claims that
carrier is awaiting addi- have been suspended awaiting
tional information information from the patient
requested from the are more difficult to handle.
provider or beneficiary. Once the practice verifies that
the delay lies with the patient,
the practice should call the
patient to suggest perhaps
that they could help to provide
this information.
Service was not
covered by insurance Recommendation
Some services are not Send the patient a letter explain-
considered to be a covered ing that the claim was denied
service, i.e., hearing test, due to lacking coverage.
eyeglasses, preventive This charge now becomes the
medicine services, etc. patient’s responsibility.
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Service provided was for

a pre-existing condition Recommendation
Some services cannot be When the patient presents to the
reimbursed as the patient office as a new patient, ask
has a pre-existing about any pre-existing
condition (a condition for conditions. When performing
which they have already a service or procedure that
obtained care). may fall under that condition,
always check with the carrier
to see if a pre-existing clause
exists. If so, discuss the
charge with the patient to
identify whether or not the
patient wants to proceed with
the understanding that they
will have to pay.
Deductible is not met Recommendation

The patient is responsible for Ask the patient when they arrive
a certain dollar amount of for their appointment whether
deductible each year. or not they have seen any
Payment cannot be made other physicians since January
until that deductible is met. 1 of that calendar year. This
may provide some insight into
what may have already been
applied to the deductible. The
best practice is to submit the
bill to the insurance carrier
and to review the EOB/
remittance advice to identify
what dollar amount has been
applied to the deductible.
Once that figure is obtained,
bill the patient for the
deductible amount.
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33
Check Verification
A personal check is the most common form of payment in a
medical office. Important facts regarding checks:
■ Always check the name and address on a personal check
against the patient’s driver’s license.
■ On any suspicious or out-of-town check, call the bank to verify
that the funds are available. It is a good practice not to accept
out-of-town checks; however, some practices are located in
resort areas where out-of-town checks are common. In this
case, attempt to have the patient pay by credit/debit card.
■ Do not accept third-party checks.
■ Do not cash checks over the amount due to give the patient
cash back.
■ Do not accept a check in which the patient has inscribed
“PAYMENT IN FULL” on the check. Once this check is cashed,
it could be argued that no additional payment is needed.
■ Be sure the check is signed. If the unsigned check is from an
established patient and merely an oversight, the practice
should try to reach the patient and request that they stop by
to sign the check. If it is difficult for the patient to return to
sign the check, it can be handled in the following manner:
■ Write the word “over” on the signature line of the check.
■ On the back of the check in the endorsement area, write “Lack
of signature guaranteed,” the practice’s name, and one’s own
name and title. This tells the bank that the practice will accept
the loss in such a case where the patient would not honor the
check.
Returned Checks
The most common reason for a check to be returned, is for
nonsufficient funds (NSF). When this occurs, the following steps
should be followed:
■ Redeposit the check or call the patient to see if the check can
be redeposited. Most banks will allow a redeposit one time.
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■ If the check cannot be redeposited, ask the patient how they

would like to cover this outstanding balance. Credit card, debit,
cash, etc.
■ If the check is returned after the second deposit, call the patient
and ask how they intend to resolve this matter. If this phone call
becomes difficult send a letter demanding payment. This letter
should include the following information:
■ Check date
■ Check number
■ The bank on which it was drawn
■ The name of the person who wrote the check
■ The name of the person who the check was payable to
■ The amount of the check
■ The number of days the patient has to correct the matter
Some offices charge an additional administrative fee for returned
checks. This amount would also have to be included in the letter.
Financial Hardship
When patients have “true” financial problems and inability to pay,
a reasonable attempt must be made to collect the fee. A reasonable
attempt to collect would be demonstrated by the following:
■ Any collection process used to collect an amount from a non-
Medicare patient
■ Patient statements are sent to either the patient or guarantor
■ Collection letters or telephone calls in an effort to collect
payment; all telephone calls should be documented to create a
paper trail
Once it has been determined that the patient is a true hardship
case, the provider must determine the patient’s ability to pay
through a review of additional information requested from the
patient.
■ Request a copy of the patient’s tax form from the previous year
or a copy of their W-2 or statement of earnings from the Social
Security Administration
■ Some practices have developed financial determination forms
for the patient to complete
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35
Unpaid Claims
An Aged Trial Balance report should be obtained from the
practice computer. This report should be used to follow up
on all unpaid claims. This report can be run by the insurance
carrier or as one general report.
Step 1 Run computer-generated Aged Trial Balance report.
Report can be generated with the following
parameters:
■ By insurance carrier
■ By provider
■ By codes
■ By dollar amount
■ By practice (includes all providers, all codes, all
carriers)
Step 2 Begin follow-up by starting with the largest dollar
amount listed and continue through the smallest
amount.
Step 3a If no EOB was received, call carrier to obtain status
of claim.
Step 3b If EOB was received, review the EOB to ascertain the
reason for the denial.
Step 4a If claim requires additional information from the
provider, this should be completed and then
resubmitted.
Step 4b Follow up on denial reason code. Correct error and
resubmit.
Step 5 Never resubmit a claim without proper
investigation into why it has not been paid.
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Insurance Commissioner
There is an insurance commissioner in each state where

insurance problems can be reported for further action. Examples
of some of these problems are:
■ Delays in payment by third-party carriers
■ Incorrect denial of claims
■ Incorrect termination of a policy
Have information available when contacting the commissioner.
Such information would be:
■ Patient name, address, phone number
■ Insured’s name address, phone number
■ Name of insurance company
■ Policy number
■ Problem
Collections
Statute of Limitations
Each state has a statute of limitations, which sets a time limit*

on the maximum time one has to collect a debt. Consult the
table below to check this law.
Oral Written Promissory Open
State Agreements Contracts Notes Accounts
AK 6 6 6 6
AL 6 6 6 3
AR 3 5 6 3
AZ 3 6 5 3
CA 2 4 4 4
CO 6 6 6 6
CT 3 6 6 6
DC 3 3 3 3
DE 3 3 6 3
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37
FL 4 5 5 4
GA 4 6 6 4
HI 6 6 6 6
IA 5 10 5 5
ID 4 5 10 4
IL 5 10 6 5
IN 6 10 10 6
KS 3 5 5 3
KY 5 15 15 5
LA 10 10 10 3
MA 6 6 6 6
MD 3 3 6 3
ME 6 6 6 6
MI 6 6 6 6
MN 6 6 6 6
MO 5 10 10 5
MS 3 3 3 3
MT 5 8 8 5
NE 4 5 6 4
NH 3 3 6 3
NJ 6 6 6 6
NM 4 6 6 4
NV 4 6 3 4
NC 3 3 5 3
ND 6 6 6 6
NY 6 6 6 6
OH 6 15 15 ⫺
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OK 3 5 5 3
OR 6 6 6 6
PA 4 6 4 6
RI 15 15 10 10
SC 10 10 3 3
SD 6 6 6 6
TN 6 6 6 6
TX 4 4 4 4
UT 4 6 6 4
VA 3 5 6 3
VT 6 6 5 6
WA 3 6 6 3
WI 6 6 10 6
WV 5 10 6 5
WY 8 10 10 8
*
Reported in years.
Collection Abbreviations
Abbreviation Description
Atty Place with Attorney
B Bankrupt
Bal Balance
BTTR Best time to reach
C Collections
CB Call back
CLM Claim
DFB Demand for balance
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DC Disconnected
EOM End of month
EOW End of week
FN Final Notice
HSB Husband
HHC Have husband call
HU Hung up
INS Insurance
IP Insurance pending
L1, L2, L3 Letter 1, letter 2, letter 3
LB Line busy
LM Left message
LMVM Left message, voice mail
MR Mail return
NA No answer
NFA No forwarding address
NP No phone
NSF Nonsufficient funds
PA Payment arrangement
PH Phones
PF Payment in full
PM Payment in mail
PMT Payment
PN Private number
POE Place of employment
POW Payment on the way
PP Partial payment
PT Patient
S Spouse
SEP Separated
SK Skipped town
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TW Talked with
UE Unemployed
UTC Unable to contact
VE Verified employment
VI Verified insurance
Bankruptcy
Some patients file for bankruptcy in order to obtain relief of their

debts. The types of bankruptcy are:
Type Description
Chapter 7 All nonexempt assets of the patient are sold with
the proceeds distributed to the creditors.
Secured creditors are first to be paid. Unsecured
(like medical bills) are last to be paid. This is
considered an absolute bankruptcy in which
many or all debts are wiped out.
Chapter 9 Not relevant for medical bills. Used for reorganiza-
tion of a town.
Chapter 11 Not relevant for medical bills. Used for reorganiza-
tion of a business, when they want to continue
doing business.
Chapter 12 Used for reorganization for a farmer who cannot
meet financial obligations.
Chapter 13 Referred to as a wage earner’s bankruptcy. Pro-
tects the wage earner from creditors while the
wage earner makes arrangements to repay all or
some of the debts over 3–5 year. At the end of
3–5 years, the balance of what is owed on most
debts is erased. Portion the bills (about 75%)
over a fixed period.
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Overpayments
An overpayment can result when:

■ Payment results from two different sources for the same service
or procedure
■ Payment should have been sent to the patient
■ Payment resulted in more dollars than the allowed amount
■ Payment is the result of a computer or data entry error
All overpayments must be returned to the carrier within a
reasonable amount of time (2–4 weeks). If check is for multiple
patients, make a copy of the check and then deposit it. If check is
for that one patient only, copy check and return it to the carrier.
Attach a copy of the EOB/remittance advice so that the carrier can
identify the patient. Keep a copy of all correspondence regarding
this overpayment in a file.
Billing for Relatives
Medicare does not permit providers to bill for relatives or members

of their households.
Household members would include anyone living in the house as
part of the family, such as nanny, maid, butler, chauffeur, medical
caregiver, or assistant. Individuals considered to be boarders
(college students renting a room) would not be included. Relatives
that would be considered immediate are:
■ Spouse
■ Parent, child, brother, sister
■ Grandparents/grandchild and spouse
■ Stepparent, stepchild, stepbrother, stepsister
CPT (HCPCS Level I)

The CPT book is released in the later part of August or early
September of each year. The codes found in this book become
effective on January 1 the following year. It is imperative that a
new book be purchased each year due to revisions, new codes,
and deleted codes.
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Sections of the CPT Book
Code Range Section Heading

99201–99499 Evaluation and Management
00100–01999 Anesthesiology
99100–99140
10021–69990 Surgery
70010–79999 Radiology
80048–89356 Laboratory/Pathology
90281–99199 Medicine
99500–99602
Each section contains guidelines for the codes in that specific

section. These guidelines should be reviewed before using the
codes listed in that section.
In the event that a specific CPT code does not exist for the
procedure performed, each section contains unlisted codes for
this purpose. For example, unlisted procedure, pharynx,
adenoids, or tonsils, 42999.
CPT Symbols
Symbol Description
• New code
▲ Revised code
▼ ▼
New or revised description

●
Codes include conscious sedation
Codes exempt from use of modifier ⫺51
Codes that can be added onto a procedure
or service
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43
Clean Claim
A clean claim is one that has been submitted within the proper time
period and contains all the necessary information. This allows for the
claim to be paid promptly, as additional information does not have to
be requested.
A clean claim means:
■ It has no deficiencies and passes all the edits.
■ The third-party carrier does not have to obtain additional
information before processing the claim.
■ The claim may be investigated in a “postpayment” state, rather
than holding payment until any investigation that may take place
is completed.
Other claim-related terms:
■ Incomplete: A claim that is missing required information. The
provider is notified so that information can be sent.
■ Rejected: A claim that requires investigation and needs further
clarification. This claim would need to be resubmitted with the
necessary information.
■ Invalid: A claim that contains complete, necessary information, but
is incorrect. This claim would need to be resubmitted with the
proper corrections.
■ Dirty: A claim submitted with errors, a claim that requires manual
processing, or a claim that has been rejected for payment.
■ Dingy: A claim that cannot be processed for the service or
procedure, or bill type.
■ Paper: A claim that is submitted on paper, whether typed or
computer generated.
■ Electronic: A claim that is submitted to the carrier through a central
processing unit or by telephone line or direct wire.
Locum Tenens Providers

Locum tenens providers cover a physician during periods of illness,
pregnancy, or vacation. The locum tenens will cover the physician’s
practice and treat patients as if the practice was their own.
Established patients are still billed as established patients, as all
billing is reported under the regular physician. See the following
listing of conditions that must be met to bill for locum tenens:
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■ The patient’s regular physician is not available.

■ The regular physician pays the locum tenens a per diem fee.
■ The locum tenens cannot provide services to Medicare
patients for more than 60 days.
■ These services by the locum tenens are billed using modifier
–Q6 in Box 24d of the CMS 1500 form.
Managed Care
Summary of Managed Care Plans
Summary of most common types of managed care plans.
■ HMO—health maintenance organization
■ PPO—preferred provider organization
■ IPA—independent practice association
■ EPO—exclusive provider organization
■ POS—point of service
Managed Co-pay Authorization
Care Plan Deductible Payment Required
HMO Co-pay is fixed Capitated Yes
Fee for service
carve-outs
PPO Co-pay is fixed Fee for service Yes
Deductible
IPA Co-pay is fixed Capitated Yes
Fee for service
carve-outs
EPO Co-pay is fixed Capitated Yes
Fee for service
carve-outs
POS Co-pay is fixed Capitated Yes
Deductible Fee for service
carve-outs
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45
Do’s and Dont’s of Working with Managed Care
Do
■ Label each patient’s chart with the name of the patient’s
managed care organization. Bill each organization the same
day of the service.
■ Monitor the number of days it takes to be paid under a fee-
for-service method. Document any late capitation checks.
Promptly call your provider representative with the results.
■ Appeal inconsistent fee-for-service payments for the same
CPT code or unreasonable payments inconsistent with the
contracted fee schedule.
■ Appeal problem payment decisions directly to the medical
director of each organization.
■ Request financial reports each year and have the doctors
review them before contacting time. Network with other
practices involved with the managed care organization if
dissatisfied.
■ Read the regulations and requirements of the managed care
carrier and incorporate them into the policy and procedure
manual of the practice.
Don’t
■ Bill a patient who is a member of a managed care organiza-
tion unless it is for a deductible, co-payment, or excluded
benefit.
■ Let your doctors accept the decision of a nurse reviewer if
you feel the patient’s care would be compromised. Have your
doctor always speak to a medical director when services have
been denied.
■ Let the doctors discharge a patient or cancel a test they feel is
medically necessary when benefits have been denied. Discuss
the managed care carrier negatively with your patients.
■ Discriminate against managed care organization patients by
not giving them timely appointments.
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Quick Guide To Managed Care
Entity Advantages Disadvantages

Patient Cost reduction Less attention
Better benefits Restricted use of
providers
General confusion
Managed Fixed rates Contract demands
Care Cost reduction Adverse member
Plan Easy claim payment reactions
Small number of providers Multiple contract rates
Hospital Possible volume increase Reduced fees
Prompt payment Contract demands
Complex billing
Physician Possible volume increase Reduced fees
Prompt payment Contract demands
Maintaining current patients Complex billing
Upsets patient relations
Upsets referral patterns
Medicare
Nonparticipating Providers
Providers that do not participate in Medicare are subject to a certain

dollar amount that they can charge. This charge is referred to as a
“limiting charge.” The Medicare Fee Schedule contains a column
listing the limiting charge. A federal law prohibits a nonparticipating
provider from charging more than this limiting charge.
Deductibles and Co-pays
Medicare deductibles and co-pays cannot be waived on a routine

basis. If this should occur routinely, the practice could be in
violation of the Anti-Kickback Statute or False Claims Act.
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47
The following listing contains examples of inappropriate waiving
of Medicare deductibles and co-pays.
■ Routine reason of “financial hardship” given to patient
without proper investigation of finances.
■ Routine waiving of a specific group of individuals in order to
obtain additional patients (for example, all Medicare patients
living in the XYZ senior home).
Medicare Secondary Payor (MSP)
There are cases where another health insurance pays before the
patient’s Medicare benefits. In these cases, the other health insur-
ance is primary with Medicare being the secondary insurance.
This situation will arise under the following conditions:
MSP Billing Guide
Primary Insurer: Primary Insurance:

Medicare Other Insurance
The patient is 65 or older The patient is 65 or older and is
and is retired or disabled. still employed and covered
under an employer’s insurance
contract.
The patient works for the The patient has Veterans
military and carries Tricare Administration benefits that
insurance coverage. cover all services and
Medicare is primary and procedures.
Tricare is secondary.
The patient has Medicaid. The patient has Railroad
Medicaid becomes the se- Retirement benefits.
condary payor and covers
the patient’s deductible.
The patient is 65 or older The patient is 65 or older and
and retired. The patient’s retired. The patient’s spouse
spouse works, but has no works and both the spouse and
health insurance coverage patient have coverage through
through the employer. the spouse’s employer.
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MSP Billing Guide
Primary Insurer: Primary Insurance:

Medicare Other Insurance
The patient has coverage ■ The patient is a member of the
under a self-employed United Mine Workers of
plan, such as real estate America.
agents. ■ The patient’s injury or condition
is a result of a motor vehicle
accident.
■ The patient’s injury or condition
is a result of employment.
Physician Assistant Billing
Medicare pays the PAs’ employers in all settings at 85 percent of

the physician’s fee schedule. This includes:
■ Hospitals (inpatient, outpatient, and emergency departments)
■ Nursing facilities
■ Home
■ Offices and clinics
■ First assisting at surgery
Important billing facts:
■ Assignment is mandatory, state law determines supervision
and scope of practice.
■ Medicare pays the PAs’ employers for medical services
provided
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Supervision Reimbursement

Setting Requirement Rate Services
Office/clinic when State law 85% of physician’s fee All services PA is legally
physician is not on schedule authorized to provide that
3:00 PM
site would have been covered

if provided personally by
a physician
Office/clinic when Physician must 100% of physician’s fee Same as above
physician is on site be in the suite schedule
of the office
4/17/07
Home visit State law 85% of physician’s fee Same as above

House call schedule
49
Skilled nursing facility State law 85% of physician’s fee Same as above
& nursing facility schedule
Hospital State law 85% of physician’s fee Same as above
schedule
01Andress (F)-01
First assisting at sur- State law 85% of physician’s first Same as above
gery in all settings assist fee schedule
Federally certified State law Cost-based Same as above
rural health clinics reimbursement
HMO State law Reimbursement is on All services contracted for as
capitation basis part of an HMO contract
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Nurse Practitioner (NP) Billing
Important facts:
■ NPs must submit their own billing number for all professional
services “furnished in facility or other provider settings.”
■ A UPIN billing number must be obtained and submitted on all
claims. In situations when NPs are members of a group
practice, the group practice PIN number will be entered on
one line of the claim form and the NP UPIN in another.
■ Modifiers are now only applicable when submitting “assistant
at surgery” claims.
■ Payments to NPs now equal “80 percent of the lesser of either
the actual charge or 85 percent of the physician fee schedule
amount.
■ For assistant at surgery services, payments equal 80 percent
of the lesser of either the actual charge or 85 percent of the
physician fee schedule amount paid to a physician serving as
an assistant at surgery.”
■ Nurse practitioners will be unable, however, to receive
separate Medicare payments in rural health clinic (RHC) and
federally qualified health center (FQHC) settings.
Medicare Fee Schedule
There are three reimbursement columns in a Medicare fee

schedule:
PAR Participating provider fee
Non-PAR Nonparticipating provider fee
LC Limiting charge fee
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Medical Supplies and Equipment
Medicare can be billed for any supply and equipment that will be
used in a patient’s home. Medicare’s definition of a home
includes the following locations:
■ The patient’s home
■ A relative’s home where the patient is living
■ A home for senior citizens
■ A homeless shelter
Nursing homes cannot be considered a patient’s home and
therefore medical supplies and equipment cannot be billed.
Medicare Covered/Noncovered Services
Some of the most common covered and noncovered services

are listed in the following table. The Medicare manual for each
state will provide a comprehensive listing of these services.
Medicare Part B Medicare Part B
Covered Services Noncovered Services
Provider services (office visits, Cosmetic surgery
hospital visits, consultations,
nursing home visits, etc.)
X-rays, laboratory testing, PT, Dental services
OT, and other outpatient
diagnostic testing
Ambulatory surgical center Custodial care
(ASC) services
Surgical dressings, casts, Services resulting from
splints, etc. workers’ compensation or
motor vehicle accident
Certain braces Services deemed not
medically necessary
Durable medical equipment Routine physical examinations
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Medicare Billing Summary
CMS-1500 Deductibles: Allowable fees A Surgical Finan-

form is $100 for will vary ac- cial Disclosure
used to physician cording to the Form is
submit services plan; most required for all
claims and out- use Usual, nonassigned
patient Customary, claims of $500
and Reason- or more
able basis
Deadline for A minimum Coal miner Durable medical
processing of 45 days claims sent equipment
claims is must pass to: Federal (DME) claims
Dec. 31 of before a Black Lung must be sent
the year claim can Program to the appro-
following be sub- Box 828 priate DME
the DOS mitted Lanham- regional carrier
Seabrook, MD
20703–0828
Medicare Review Process
The following steps illustrate the Medicare review process. The

Medicare manual in each state will provide the details necessary
to begin this process.
Steps Action Key Points
1 Review ■ Claim must be requested within
6 months of the date on the
Explanation of Benefits.
2 Fair hearing ■ Claim must be requested in
writing within 6 months of the
result of the review.
■ Claim must exceed $100 in
amount.
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53
Steps Action Key Points
■ Hearings take place over the
phone, face-to-face, or on-the-
record (where the decision is
automatically based on the facts
submitted).
3 Administrative ■ Claim must be requested in writing
law judge within 60 days of the result of the
hearing fair hearing.
■ Claim must exceed $500 in
amount.
4 Appeals council ■ Claim must be requested in writing
review through the Social Security
Administration (SSA) Office of
Hearings and Appeals within 60
days of the result of the
administrative law judge hearing.
■ Claim must exceed $500 in amount.
5 Federal district ■ Civil action must be filed in federal
court hearing district court within 60 days of the
result of the Appeals Council
decision.
■ The claimant must be represented
by an attorney.
Advance Beneficiary Notice (ABN)
When a service is provided to a Medicare patient that Medicare

considers not medically necessary, the physician should notify
the patient by using an Advance Beneficiary Notice (ABN). This
notice must be completed, signed, and dated. The modifier –GA
must be used when submitting the claim for a service or proce-
dure where an ABN is on file in the physician’s office. The follow-
ing table contains a list of reasons that the physician practice
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believes the service or procedure may not be covered. This

reason must be stated clearly on the ABN that the patient signs.
1 Medicare does not usually pay for this many services
2 Medicare does not usually pay for this service
3 Medicare does not pay for this because it is a treatment
that has not been proven effective
4 Medicare does not pay for such extensive treatment(s)
5 Medicare does not pay for this equipment for the
diagnosis stated
6 Medicare does not pay for this many services within the
time frame reported
These ABN notices should be completed by all Medicare

patients, only when there is a possibility of noncoverage of the
service or procedure. Having patients sign ABNs blanketly is not
a good practice.
Medicaid
Medicaid Services Available
■ Inpatient and outpatient services

■ Physician visits
■ Dental visits (surgical)
■ Nursing facility services for those over age 21
■ Home health for those eligible for a skilled nursing facility
■ Family planning and supplies
■ Rural health clinics
■ Laboratory tests and x-rays
■ NP services
■ Federally qualified health center
■ Nurse midwife services
■ Early and periodic screen, diagnosis, and treatment services
(EPSDT) for individuals under age 21
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Confirming Medicaid Eligibility
Steps Procedure
Step 1 The patient must present a valid ID card.
Step 2 Eligibility can change monthly since it is based
on monthly income, so always verify using the
dedicated phone line.
Step 3 Confirmation of eligibility should be obtained
and maintained in the patient’s chart in case
of future denial of claim.
Step 4 Confirmation can also be obtained through a
“swipe” box. A print-out will indicate coverage.
Step 5 Retroactive eligibility is sometimes granted to
patients whose income has fallen below the
“state-set” eligibility level and who had high
medical expenses prior to filing for Medicaid.
Step 6 The office must verify any patient notification
of retroactive eligibility. If the patient made
payments for services during that time frame,
the payments must be returned to the patient,
and Medicaid should be billed.
Preauthorization
Some states have placed their Medicaid plans into an HMO.

These HMOs require preauthorization services which include:
■ Elective admissions
■ Reason for inpatient treatment
■ Admission diagnosis and outline of treatment plan
■ Emergency admissions
■ Medical justification for inpatient treatment
■ Date of admission
■ Admission diagnosis and outline of treatment plan
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■ Preoperation days greater than 1

■ Reason why surgery cannot be performed within 24 hours
of time need was established
■ Number of additional days requested
■ Outpatient procedure performed as an inpatient
■ Code and description of surgical procedure
■ Medical justification for performing the surgery as an
inpatient
■ Exceeding hospital stay limit (set by state) due to
complications
■ Beginning and ending dates originally authorized
■ Statement describing the complications
■ Date complications presented
■ Diagnosis for first illness
■ Diagnosis stated on original preauthorization request
■ Diagnosis for secondary disorder
Extension of Inpatient Days
■ Medical necessity for the extension
■ Number of additional days requested
■ Basis for approval of more than one preoperation day
■ Performance of multiple procedures that, when combined,
necessitate a length of stay in excess of that required for any
one individual procedure
■ Development of postoperative complications or a medical
history that dictates longer than usual postoperative
observation by medical staff
Physician Assistant (PA) Billing
Important facts:
■ 50 states cover medical services provided by PAs under their
Medicaid programs.
■ The rate of reimbursement, which is paid to the employing
practice and not directly to the PA, is either the same as or
slightly lower than that paid to physicians.
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Nurse Practitioner (NP) Billing
Important facts:
■ Federal law mandates direct reimbursement to pediatric (PNP)
and family (FNP) nurse practitioners providing services to
children.
■ Physician collaboration is not required within the federal
mandate.
■ Each state will determine the reimbursement rate for nurse
practitioners.
Medicaid Billing Summary
CMS-1500 Deadlines for All nonemergency Allowable

form is used processing hospitalizations fees will
to submit claims is must be preau- vary
claims determined thorized according
by each to each
individual state
state
A minimum Deductibles: Co-payments are There is no
of 45 days There is a required by Medicaid
must pass deductible most states, premium
before a for patients generally
claim can be who are ranging from
resubmitted. medically $2–$10 per
indigent encounter
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Tricare
TRICARE is a health-care program for:
■ Active duty members of the military and their qualified family
members
■ CHAMPUS-eligible retirees and their qualified family
members
■ Eligible survivors of members of the uniformed ser-
vices
It consists of three plans with varying benefits:
1. TRICARE Prime
2. TRICARE Extra
3. TRICARE Standard
TRICARE differs from other insurance carriers as the fiscal
year for collecting deductibles runs from October 1 through
September 30.
Physician Assistant (PA) Billing
Important facts:
■ TRICARE covers all medically necessary services provided
by a physician assistant.
■ The PA must be supervised in accordance with state law.
■ The supervising physician must be an authorized TRICARE
provider.
■ The employer bills for the services provided by the PA.
■ The allowable charge for all medical services provided by
PAs under TRICARE Standard, the fee-for-service program,
except assisting at surgery, is 85% of the allowable fee for
comparable services rendered by a physician in a similar
location.
■ Reimbursement for assisting at surgery is 65% of the
physician’s allowable fee for comparable services.
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■ PAs are eligible providers of care under TRICARE’s two
managed care programs, TRICARE Prime and Extra.
■ TRICARE Prime is similar to an HMO.
■ TRICARE Extra is run like a preferred provider organization
in which practitioners agree to accept a predetermined dis-
counted fee for their services.
Workers’ Compensation
Eligibility consists of an on-the-job injury or a condition that is the

direct result of their job.
The law states that a waiting period must elapse before income
benefits are payable. This period is determined by each individ-
ual state.
Classifications of workers’ compensation consist of:
■ Medical claims with no disability
■ Temporary disability
■ Permanent disability
■ Vocational rehabilitation
■ Death of a worker
The provider must accept workers’ compensation as payment in
full and cannot bill any additional fees.
Fees are reimbursed either by the Medicare fee schedule or a
private fee schedule and are determined by each individual state.
Miscellaneous Terms/Facts
■ Guarantor: the individual who is responsible for payment
of the medical bill. For children to be guarantors, they must
be either 18 or 21 years of age (depending on the state
regulations)
■ Major Medical: an insurance policy that covers medi-
cal expenses resulting from catastrophic or prolonged
illness/injuries, or coverage for such things as office
visits that are not included in the plan’s coverage
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Miscellaneous Facts
■ Claims denied as “not medically necessary” cannot be billed

to the patient, unless an ABN has been completed acknowl-
edging a patient’s understanding of the service and why it
may or may not be covered. The burden of medical necessity
is placed on the provider and is the primary reason for
Medicare denials across the country.
■ Use an Evaluation and Management (E&M) code when
pronouncing death of a patient.
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Evaluation and Management Services
Evaluation and Management (E&M) codes are CPT codes used
for the reporting of certain services such as office visits, con-
sultations, inpatient services, emergency room services, nursing
facility services, domiciliary care services, and home services.
Each category of E&M service contains two to seven levels for
billing. Each level requires a specific amount of documentation
to be billable.
These services are listed in the following Table of Evaluation
and Management Services.
CPT Codes Description
99201–99205 New patient office visit codes
99211–99215 Established patient office visit codes
99221–99223 Initial hospital service
99231–99233 Subsequent hospital service
99241–99245 Consultation, outpatient
99251–99255 Consultation, inpatient
99234–99236 Hospital Observation or inpatient care services
99217–99220 Hospital Observation services
99281–99285 Emergency room services
99304–99306 Initial nursing facility service
99318 Annual nursing facility assessment
99307–99310 Subsequent nursing facility service
99293–99294 Initial inpatient pediatric critical care
99295–99296 Inpatient neonatal critical care
99298–99300 Continuing intensive care services
99341–99345 Home services, new patient

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99347–99350 Home services, established patient
99324–99328 Domiciliary care, new patient
99334–99337 Domiciliary care, established patient
99381–99387 Preventive med codes, new patient
99391–99397 Preventive med codes, established patient
99354–99355 Prolonged care, outpatient
99356–99357 Prolonged care, inpatient
99358–99359 Prolonged care, without direct patient contact
The Principles of Documentation were released in 1995 as
collaboration between the American Medical Association (AMA)
and the Centers for Medicare and Medicaid Services (CMS,
known then as Health Care Finance Administration). These
guidelines were revised in 1997 and 2000 and are still
undergoing revisions. Until the final guidelines are released,
CMS instructs providers to use either the 1995 or 1997 guide-
lines; the decision becomes the provider’s.
Principles of Documentation
The medical record:
1. is a tool of clinical care and communication.
2. should be complete and legible.
3. should include as documentation:
a. the reason for the visit; appropriate history, physical
examination, review of diagnostic test results and any
other ancillary services.
b. the provider’s assessment of the patient’s condition, clinical
impressions, or diagnoses.
c. a plan of care/treatment plan.
d. the date and legible identity of the person who provided
the service.
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63
4. should contain the rationale for ordering diagnostic services.
5. should contain accessibility to past and present diagnoses.
6. should contain appropriate health risk factors.
7. should contain the patient’s progress, responses to treatment,
complications, and changes in treatment or diagnoses.
8. should support the CPT and ICD-9 codes billed.
9. should be confidential.
Seven components are involved in E&M services.
Components of E&M Services
1. History
2. Examination
3. Medical Decision-Making
4. Counseling
5. Coordination of Care
6. Nature of Presenting Problem
7. Time
The first three items above (history, examination, and medical
decision-making) are the key components in choosing a level
of service.
Time
Time, which is No. 7 on the list, is only a consideration if

counseling is 50% or more of the visit.
Some CPT codes are time-based codes. Time-based codes are
chosen by the time associated with the service provided. These
codes are used to report episodes of Critical Care and
Psychology service areas. The only time-based codes listed in
the Table of Evaluation and Management Services are the
prolonged care codes. When choosing an E&M code based
on time, the documentation requirements are very specific.
The documentation in the medical record must illustrate that
counseling is 50% or more of the visit. For example, a note
should look like this:
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“I spent 45 minutes with Barbara Smith and her husband today.

Of that 45 minutes, 30 minutes was spent discussing the results
of her abnormal echocardiogram.”
The note should then provide a summary of the key components
of the discussion. This documentation illustrates that counseling
was more than 50% of the visit.
The following note does not meet this criterion:
“I spent 30 minutes with Barbara discussing the results of her
abnormal echocardiogram.”
This note does not illustrate that the time spent counseling
Barbara Smith was 50% or greater than the total time of the
office visit.
History
There are four levels of history:
Level Description
1 Problem focused
2 Expanded problem focused
3 Detailed
4 Comprehensive
Within these four levels, there are four types of history:
Types Description
1 Chief compliant
2 History of present illness
3 Review of systems
4 Past, family, and social history
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Chief complaint (written as cc)
The chief complaint is the reason for the visit, or why the
patient sought care. This is generally in the patient’s own
words and is a short phrase or two. It is important to be
specific when documenting this element and to not use
vague language as this may disqualify the patient encoun-
ter for reimbursement. For example, the following table
illustrates language that is vague; it does not state why
the patient sought care.
Incorrect Correct
cc - check-up cc - check-up on high blood pressure
Follow-up visit Follow-up visit for back pain
✓ up ✓ up on diabetes
Routine visit Routine visit for reflux
To elicit the chief complaint, ask broad questions such as:

■ What brings you in today?
■ Tell me what’s been going on?
History of Present Illness (written as HPI)
The history of present illness is a description of the present

illness from the beginning of symptoms to the time of the
patient encounter.
This is an expansion of the chief complaint and should contain
all the information necessary for a differential diagnosis.
Begin with open-ended questions such as:
■ Tell me more about the pain.
■ What else is going on?
■ What was that like for you?
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Use facilitating expressions to encourage the patient to continue,

such as:
■ Mmm Hmm
■ Yes?
■ Uh Huh?
■ And what else?
Now use more directed questions to complete this history,
such as:
■ What is wrong?
■ When did it start going wrong?
■ How did it go wrong?
■ Why do you think it is wrong?
Use multiple-choice questions such as:
■ Do you have nausea, vomiting, constipation, or diarrhea?
■ Is the headache sharp, dull, shooting?
Use Yes or No questions, such as:
■ Do you have a headache every day?
■ Do you have any allergies?
Use quantitative questions, such as:
■ How many loose stools do you have a day?
■ How many dizzy spells do you have in a day?
Avoid leading questions, such as:
■ You don’t smoke do you?
■ You haven’t had any dizziness, have you?
Avoid compound questions, such as:
■ Do you have trouble urinating? When does it bother
you?
There are eight elements of the history of present illness.
They are:
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67
HPI Elements
1 Location: Where is the injury or condition?
2 Quality: Is the pain sharp, dull, crushing, gnawing?
3 Severity: On a scale of 1 to 10, how bad is it, or use
descriptive words such as mild, severe, etc.
4 Duration: How long have you had the injury or illness?
5 Timing: When did you first experience the symptom or
problem?
6 Context: What were you doing when this occurred?
7 Modifying factors: What have you done to improve your
symptoms? Laid down, took analgesics?
8 Associated signs & symptoms: What else bothers you
when this occurs?
There are two levels of HPI:

1. Brief: documentation of one to three elements from the
previous list.
2. Extended: documentation of four or more elements from the
previous list OR the status of three chronic conditions.
A brief history focuses on the patient’s problem, while an
extended history will go beyond that to obtain information that
may support multiple diagnoses. An example of a brief HPI is as
follows:
cc - complaining of knee pain
HPI - pain has been present in left knee (location) for 2 weeks
(timing)
In the previous example, left knee is the location and 2 weeks is
the timing. Two elements of HPI are met, location and timing.
Continuing to build on this note will provide more information
about the patient’s complaint and justify an extended HPI. See
the following example:
cc - complaining of knee pain
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HPI - pain has been present in left knee for 2 weeks. Patient
states that pain has gotten so severe (severity), that Advil used
to help but now it doesn’t (modifying factors). Patient reports
pain started when she played softball (context) with her son and
fell running to a base.
In the last note, left knee is the location and 2 weeks is the
timing, pain is so severe, analgesics do not relieve it anymore,
pain started when playing softball. In this note, five elements of
HPI are met, location, timing, severity, modifying factors, and
context.
Review of Systems (written as ROS)
An ROS is an accounting of signs and symptoms of various

organ systems obtained through a series of questions. There are
14 systems contained in an ROS. These systems are:
Organ Systems
1 Constitutional
2 Eyes
3 Ears, nose, mouth, throat
4 Cardiovascular
5 Respiratory
6 Gastrointestinal
7 Genitourinary
8 Musculoskeletal
9 Integumentary
10 Neurological
11 Psychiatric
12 Endocrine
13 Hematological/lymphatic
14 Allergic/immunological
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69
There are three levels of ROS:
Level Description
1 Problem pertinent Review and documentation
of one system
2 Extended Review and documentation
of two to nine systems
3 Complete Review and documentation
of at least 10 systems
A problem pertinent ROS involves a review of system(s) that can

be affected by, play a role in, or are likely to be involved in the
patient’s problem.
An extended review includes a more in-depth review of system(s).
A complete review includes 10 of the 14 systems listed above. This
type of review is considered comprehensive in nature.
Past, Family, Social History (written as PFSH)
A past history contains information about the patient’s past

experiences with illnesses, injuries, and treatments. This may
include information about the following:
■ Hospitalizations
■ Illnesses and/or injuries
■ Surgeries
■ Current medications
■ Allergies to drugs or the environment
■ Age-appropriate immunization status
■ Age-appropriate dietary or feeding status
A family history contains information about the patient’s family.
This may include information as:
■ Diseases of either the mother, father, siblings, children
■ Health status or cause of death of any of the above
■ Diseases of family members that may be hereditary or cause
the patient to be at risk
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A social history contains information about past or current

activities and/or conditions. This may include such informa-
tion as:
■ Marital status
■ Employment
■ Use of controlled substances
■ Use of alcohol
■ Living arrangements
■ Current employment
■ Occupational history
■ Level of education
■ Sexual history
The two levels of PFSH
Level Description
1 Pertinent Documentation of one history
area
2 Complete Documentation of two
to three history areas,
depending on the cate-
gory of E&M service
A complete history must contain the documentation of

either two or three history areas, depending on the cate-
gory of E&M service. The following tables identify which
types of service require the documentation of two his-
tory areas (2 out of 3 rule) and which type of service
requires the documentation of three history areas
(3 out of 3 rule).
3 Out of 3 Rule
When the service type is one of an “initial” contact, all three
history areas must be documented.
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71
Visit Types
1. New office service
2. Consultation, outpatient
3. Consultation, inpatient
4. Initial hospital service
5. Initial nursing facility service
6. Home services, new patient
7. Observation services
8. Observation services or inpatient hospital
2 Out of 3 Rule
When the service type is one of an established service, only two
of the three history areas must be documented.
Visit Types
1. Established office service
2. Consultation, follow-up inpatient
3. Subsequent hospital service
4. Subsequent nursing facility service
5. Home services, established patient
6. Emergency services
History Summary
Type of History CC HPI ROS PFSH

Problem Present Brief N/A N/A
focused
Expanded prob- Present Brief Problem N/A
lem focused Pertinent
Detailed Present Extended Extended Pertinent
Comprehensive Present Extended Complete Compre-
hensive
EVAL
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MGMT
Examination
The examination portion of the visit contains documentation of
the objective findings of the provider of the service. There are
currently two sets of examination guidelines; 1995 and 1997. The
1995 guidelines are somewhat subjective, whereas the 1997
guidelines are very specific. The provider of the service may
choose which guideline set he/she wants to use.
1995 Examination Guidelines
Level Description
Problem focused A limited examination of the affected body
area or organ system
Expanded prob- A limited examination of the affected body
lem focused area or organ system and other
symptomatic or related organ systems
Detailed An extended examination of the affected
body area(s) and other symptomatic or
related organ system(s)
Comprehensive A general multisystem examination or a com-
plete examination of a single organ system
Body Areas
Chest (including breasts and axillae)
Abdomen
Back (including spine)
Neck
Genitalia, groin, buttocks
Head (including the face)
Extremities, each one would be an area
72
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73
Organ Systems
Constitutional
Eyes
Ears/Nose/Mouth/Throat
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Musculoskeletal
Neurological
Integumentary
Psychiatric
Hematological/lymphatic/immunological
1997 Examination Guidelines
The 1997 examination guidelines contain a multisystem

examination, plus 10 single specialty examinations. These
examinations are as follows:
General Multisystem
1. Cardiovascular
2. Ears, Nose, Mouth, Throat
3. Eye
4. Genitourinary
5. Hematological/Lymphatic/Immunological
6. Musculoskeletal
7. Neurological
8. Psychiatric
9. Respiratory
10. Integumentary
EVAL
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MGMT
Under the general multisystem examination, the following

requirements must be met:
Level Description
Problem focused Perform and document 1 to 5 elements
identified by a bullet.
Expanded prob- Perform and document at least 6 elements
lem focused identified by a bullet.
Detailed Perform and document at least 2 elements
identified by a bullet from each of 6 areas/
systems or at least 12 elements identified
by a bullet in 2 or more areas/systems.
Comprehensive Perform all elements identified by a bullet in
at least 9-organ system or body areas and
document at least 2 elements identified by
a bullet from each of 9 areas/systems.
A detailed listing of these requirements by body areas and organ
systems can be found in the Federal Register.
Under the specialty guidelines, the following requirements must
be met:
Level Description
Problem focused Perform and document 1 to 5 elements
Expanded prob- Perform and document at least
lem focused 6 elements identified by a bullet.
Detailed Perform and document at least 12 elements
Comprehensive Perform all elements identified by a bullet
and document every italicized element in
a shaded area and at least 1 nonitalicized
element in each of the nonshaded areas.
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75
Medical Decision-Making
The medical decision-making portion of the visit entails the
complexity of establishing the diagnosis and/or management
option(s). Medical decision-making is measured by the following
three components:
Components of Medical Decision-Making

The number of diagnoses and/or management options
The amount and/or complexity of medical records, diagnostic
tests, and other information to be reviewed and analyzed
The risk of significant complications, morbidity and/or mortality
The Four Levels of Medical Decision-Making
Number of Risk of Com-

Diagnoses/ Amount and/or plication and/
Management Complexity of or Morbidity
Level Options Data Reviewed orMortality
Straight- Minimal Minimal/None Minimal
forward
Low com- Limited Limited/Low Low
plexity
Moderate Multiple Moderate Moderate
complexity
High Extensive Extensive High
complexity
Two of the three above indicators will establish the level of
medical decision-making.
If a patient presents with multiple diagnoses and multiple
management options must be considered, the complexity of the
medical decision-making is increased. The amount and/or com-
EVAL
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MGMT
plexity of data that must be obtained, reviewed, and analyzed

during the patient encounter must be clear and concise.
For test results, document thought processes, analysis, and
evaluation of both positive and negative findings. Their impact
on treatment should be documented. Review of the patient
medical record, past and present, should be documented with
comments. Note the extent of records and data that is reviewed
with an analysis.
The potential risk to the patient is an important element in
assessing the complexity of this key component of medical
decision making. The following table can be used to identify risk:
Table of Risk
Type of Problem Description

Minimal May not require presence of physician, but
service provided under the physician’s
supervision
Self-limited/ Runs definite and prescribed course; tran-
minor sient in nature and not likely to perma-
nently alter health status; or has a good
prognosis with management/compliance
Low severity Risk of morbidity without treatment low; little
to no risk of mortality without treatment;
full recovery without functional impairment
expected
Moderate Risk of morbidity without treatment
severity moderate; moderate risk of mortality
without treatment; uncertain prognosis
or increased probability of prolonged
functional impairment
High severity Risk of morbidity high to extreme; moderate
to high risk of mortality without treatment
or high probability of severe, prolonged
functional impairment
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77
Examples of various types of risk are illustrated in the following
table:
Diagnostic
Level of Presenting Procedures Management
Risk Problems Ordered Options Selected
Minimal Insect bite, ECG, chest Rest, gargle,
cold, Tinea x-ray, KOH, bandages
corporis UA
Low Cystitis, sprains, Pulmonary OTC drugs, PT,
controlled DM, functions, BE, OT, IV fluids,
controlled BP skin biopsies minor surgery/
no risk
Moderate Lump in breast, Arteriogram, Rx mgmt, IV
colitis, lumbar fluids w/meds,
pneumonia puncture, closed treat-
endoscopies/ ment of frac-
no risk ture, elective
major surgery
High Acute MI, psych CV imaging Emergency
illness studies major surger-
w/threat, TIA, w/contrast, ies, DNRs,
trauma endoscopies monitoring
w/risk toxic drugs
Medical Necessity
Although the service may `contain a properly documented history,
examination, and medical decision-making, if there is no medical
necessity for the level of service chosen for billing, the service may
be downcoded by the carrier. The government definition of medical
necessity is that it is a service that is reasonable and necessary for
the diagnosis or treatment of illness or injury, or to improve the
functioning of a malformed body member.
EVAL
MGMT
Page 78

The Decision Matrix for New Office Patients
Medical Nature of Counseling/

Decision- Presenting Coordination
Code History Examination Making Problem of Care Time
2:59 PM
99201 Problem Problem Straight- Self-limited/ Yes 10

focused focused forward minor
99202 Expanded Expanded Straight- Low to Yes 20
problem problem forward moderate
focused focused
4/17/07
99203 Detailed Detailed Low Moderate Yes 30
78
99204 Compre- Compre- Moderate Moderate Yes 45
hensive hensive to high
99205 Compre- Compre- High High Yes 60
02Andress (F)-02
hensive hensive
Requires all three key components to be documented.
*Current Procedural Terminology © 2006 American Medical Association, All Rights Reserved.
MGMT
EVAL
Page 79

The Decision Matrix for Established Office Patients

2:59 PM
99211 Generally Minimal No 5

does not
require a
physician
4/17/07
99212 Problem Problem Straightfor- Self-limited/ Yes 10

focused focused ward minor
79
99213 Expanded Expanded Low Low to Yes 15

problem problem moderate
focused focused
02Andress (F)-02
99214 Detailed Detailed Moderate Moderate Yes 25

to high
99215 Compre- Compre- High Moderate Yes 40
MGMT
hensive hensive to high
EVAL
Requires all two of the three key components to be documented.
Page 80

The Decision Matrix for Initial Hospital Patients

2:59 PM
99221 Detailed/ Detailed/ Straight- Low Yes 30

Compre- Compre- forward
hensive hensive or low
4/17/07
99222 Compre- Compre- Moderate Moderate Yes 50

hensive hensive
80
99223 Compre- Compre- High High Yes 70
hensive hensive
02Andress (F)-02

MGMT
EVAL
Page 81

The Decision Matrix for Subsequent Hospital Patients

2:59 PM
99231 Problem Problem Straightfor- Patient is Yes 15

focused focused ward/Low stable, recov-
ering, or
improving
4/17/07
99232 Expanded Expanded Moderate Responding Yes 25

problem problem inadequately
81
focused focused or minor

complication
99233 Detailed Detailed High Unstable or Yes 35

developed
02Andress (F)-02
significant
complication
of problem
MGMT
EVAL
Page 82

Discharge Services
Code Hospital Discharge Day
99238 Includes final exam, discussion of hospital stay, instructions for care 30 minutes or less
2:59 PM
Preparation of discharge records

99239 Includes final exam, discussion of hospital stay, instructions for care Over 30 minutes
Preparation of discharge records
The Decision Matrix for Consultation, Outpatient

4/17/07
82
02Andress (F)-02
99242 Expanded prob- Expanded prob- Straight- Low Yes 30

lem focused lem focused forward
MGMT
99244 Comprehensive Comprehensive Moderate Moderate to high Yes 60

EVAL
99245 Comprehensive Comprehensive High Moderate to High Yes 80

Page 83

The Decision Matrix for Consultation, Inpatient

2:59 PM

99252 Expanded Expanded Straight- Low Yes 40

problem problem forward
4/17/07
focused focused
83
99254 Comprehensive Comprehensive Moderate Moderate to Yes 80

02Andress (F)-02
high
99255 Comprehensive Comprehensive High Moderate to Yes 110

High
MGMT
EVAL
Page 84

The Decision Matrix for Hospital Observation or Inpatient Care

2:59 PM
99234 Detailed/Com- Detailed/Com- Straight- Low Consistent N/A

prehensive prehensive forward with nature
or low of problems
99235 Comprehensive Comprehensive Moderate Moderate Consistent N/A

4/17/07
with nature
of problems
84
99236 Comprehensive Comprehensive High High Consistent N/A
with nature
02Andress (F)-02
of problems

MGMT
EVAL
Page 85

The Decision Matrix for Hospital Observation Services

2:59 PM
99218 Detailed/Com- Detailed/Com- Straight- Low Consistent N/A

prehensive prehensive forward with nature
or low of problems
99219 Comprehensive Comprehensive Moderate Moderate Consistent N/A

4/17/07
with nature
of problems
85

with nature
02Andress (F)-02
of problems
99217 Discharge Day—Can only be used if discharge is on other than the initial date
MGMT
of N/A observation status.
EVAL
Page 86

The Decision Matrix for Emergency Room Services

2:59 PM
99281 Problem Problem Straight- Self- Consistent N/A

focused focused forward limited/ with nature
minor of problems
99282 Expanded Expanded Low Low to Consistent N/A
problem problem moderate with nature
4/17/07
focused focused of problems
86
99283 Expanded Expanded Moderate Moderate Consistent N/A
problem problem with nature
focused focused of problems
99284 Detailed Detailed Moderate High Consistent N/A
02Andress (F)-02
with nature
of problems
with nature
MGMT
EVAL
of problems

Page 87

After Hours Codes For Emergencies
99052 Services requested between 10 pm and 8 am, report in addition to the basic
service code
2:59 PM
99054 Services requested on Sundays and holidays in addition to the basic service code
The Decision Matrix for Initial Nursing Facility
Comperhensive Medical Nature of Counseling/

New or Decision- Presenting Coordination
4/17/07
established History Examination Making Problem of Care Time

99304 Detailed Comprehensive Straight- Low Yes 30
87
forward
or low
99305 Compre- Comprehensive Moderate Moderate Yes 40
hensive
02Andress (F)-02
Compre- Comprehensive Moderate High Yes 50

99306
hensive to High
MGMT
EVAL
Page 88

The Decision Matrix for Subsequent Nursing Facility
Subsequent Medical Nature of Counseling/

New or Decision- Presenting Coordination
Established History Examination Making Problem of Care Time
2:59 PM
99307 Problem Problem Straight- Patient is stable, recov- Yes 15

focused focused forward ering, or improving
99308 Expanded Expanded Low Responding Yes 25
problem problem inadequately or
focused focused developed minor
4/17/07
complication
99309 Detailed Detailed Moderate Patient has devel- Yes 35
88
oped a significant
complication or a
significant new
problem
02Andress (F)-02
99310 Compre- Compre- High Unstable or developed

hensive hensive significant compli-
cation or new
significant problem
MGMT
EVAL
Requires two of the three key components to be documented.

Page 89

The Decision Matrix For Annual Nursing Facility Assessment
Code History Examination Medical Decision-Making Nature of Presenting Problem

2:59 PM
99318 Detailed Comprehensive Low to moderate Patient is stable,

recovering, or
improving

4/17/07
The Decision Matrix for Discharge Services

89
Code Nursing Facility Discharge Day Management
99238 Includes final exam, discussion of hospital stay, 30 minutes or less

instructions for care, prescriptions, preparation
02Andress (F)-02
of discharge records
99239 Includes final exam, discussion of hospital stay, Over 30 minutes

instructions for care, prescriptions, preparation
MGMT
EVAL
of discharge records
Page 90

The Decision Matrix for Home Services, New Patient

2:59 PM
99341 Problem Problem Straight- Low Yes 20

focused focused forward
99342 Expanded Expanded Straight- Low Yes 30

problem problem forward
4/17/07
focused focused
90
99343 Detailed Detailed Moderate High Yes 45
99344 Compre- Comprehen- Moderate High Yes 60

hensive sive
02Andress (F)-02
99345 Compre- Comprehen- High Unstable problem, Yes 75

hensive sive requires
immediate
MGMT
attention
EVAL

Page 91

The Decision Matrix for Home Services, Established Patient

2:59 PM
99347 Problem Problem Straight- Self-limited or Yes 15

focused, focused forward minor
interval
99348 Expanded Expanded Low Low to moderate Yes 25

4/17/07
problem problem
focused, focused
91
interval
99349 Detailed, Detailed Moderate Moderate to high Yes 40

interval
02Andress (F)-02
99350 Compre- Compre- Moderate Moderate to high Yes 60

hensive, hensive
interval
MGMT
EVAL
Page 92

The Decision Matrix for Domiciliary Care, New Patient

2:59 PM
99324 Problem Problem Straight- Low severity Consistent 20

focused focused forward with
problem
99325 Expanded Expanded Low Moderate severity Consistent 30
problem problem with
4/17/07
focused focused problem

99326 Detailed Detailed Moderate Moderate to high Consistent 45
92
severity with
problem
99327 Compre- Compre- Moderate High severity Consistent 60
hensive hensive with
02Andress (F)-02
problem
99328 Compre- Compre- High Patient may be unsta- Consistent 75
hensive hensive ble or may have with
MGMT
developed a signi- problem

EVAL
ficant new problem

requiring immediate
physician attention
Page 93

The Decision Matrix for Domiciliary Care, Established Patient

2:59 PM
99334 Problem Problem Straight- Self-limited or Consistent 15

focused focused forward minor with
problem
99335 Expanded Expanded Low Low to moderate Consistent 25
problem problem severity with
4/17/07
focused focused problem

93
99336 Detailed Detailed Moderate Moderate to high Consistent 40

with
problem
99337 Compre- Compre- Moderate Patient may be Consistent 60
02Andress (F)-02
hensive hensive to high unstable or may with

have developed a problem
significant new
problem requir-ing
MGMT
EVAL
immediate physi-
cian attention
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MGMT
The Decision Matrix for Inpatient Pediatric Critical Care

Code Description
99293 Initial inpatient pediatric critical care, per day, for the
evaluation and management of a critically ill infant or
young child, 29 days through 24 months of age
99294 Subsequent inpatient pediatric critical care, per day, for
the evaluation and management of a critically ill infant
or young child, 29 days through 24 months of age
The Decision Matrix for Inpatient Neonatal Critical Care

Code Description
99295 Initial inpatient neonatal critical care, per day, for the
evaluation and management of a critically ill neonate,
28 days of age or less
99296 Subsequent inpatient neonatal critical care, per day, for
the evaluation and management of a critically ill
neonate, 28 days of age or less
The Decision Matrix for Continuing Intensive Care

Code Description
99298 Subsequent intensive care, per day, for the evaluation
and management of the recovering very low birth
weight infant (present body weight less than 1500
grams)
and management of the recovering low birth weight
infant (present body weight less than 1500–2500
grams)
and management of the recovering infant (present
body weight less than 2501–5000 grams)
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95
The Decision Matrix for Preventive Medicine
Services, New Patient
Initial preventive medicine service including a comprehensive

history and examination, counseling; anticipatory guidance/risk
factor reduction interventions, and the ordering of appropriate
laboratory/diagnostic procedures.
Code Description
99381 Infant, under 1 year of age
99382 Early childhood, age 1–4 years
99383 Late childhood, age 5–11 years
99384 Adolescent, age 12–17 years
99385 Age 18–39 years
99386 Age 40–64 years
99387 Age 65 years and over
The Decision Matrix for Preventive Medicine

Services, Established Patient
Periodic preventive medicine re-evaluation including a com-

prehensive history and examination, counseling; anticipatory
guidance/risk factor reduction interventions, and the ordering
of appropriate laboratory/diagnostic procedures.
Code Description
99391 Infant, under 1 year of age
99392 Early childhood, age 1–4 years
99393 Late childhood, age 5–11 years
99394 Adolescent, age 12–17 years
99395 Age 18–39 years
99396 Age 40–64 years
99397 Age 65 years and over
EVAL
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The Decision Matrix for Prolonged Care Services, Outpatient
Code Description Time

99354 Prolonged physician service in the First hour
office or outpatient setting requiring
direct (face-to-face) patient contact
beyond the usual service
99355 Each additional 30 minutes 30
The Decision Matrix for Prolonged Care Services, Inpatient

The Decision Matrix for Prolonged Care Services,

Without Direct Patient Contact

Critical Care
Critical care services are not site specific. They can be performed
in any location of the hospital. They are provided for episodes of
conditions that are generally life-threatening. They are not used for
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97
inpatient days when a patient is in the Intensive Care Unit or Cardio
Care Unit of a hospital. In these cases, the appropriate inpatient
codes should be utilized. There is no limit to the number of critical
care services that can be provided and billed each day. These
services may be provided to patients under the following conditions:
■ Central nervous system or circulatory system failure
■ Hepatic, renal, or respiratory failure
■ Severe infection
■ Postoperative complications
The time spent providing critical care services may be time spent
providing the following services:
■ Direct care to the patient
■ Review of studies and test results
■ Discussion of patient with other team members
■ Documentation of critical care in the medical record
■ Time spent with family members or patient decision makers
Critical care codes are time-based and are billed as follows:
■ 99291 Critical care, first 30-74 minutes
■ 99292 Critical care, each additional 30 minutes (list separately in
addition to code 99291)
Examples of Billing for Critical Care Codes
Total Time Documented

for Critical Care
Services Provided Billing for Critical Care
Less than 30 minutes Use appropriate inpatient code
30–74 minutes 99291
75–104 minutes 99291 and 99292
105–134 minutes 99291 and 99292 ⫻ 2
135–164 minutes 99291 and 99292 ⫻ 3
165–194 minutes 99291 and 99292 ⫻ 4
194 minutes or more 99291 and 99292 for the length
of time spent
EVAL
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MGMT
Note: Only one physician can bill for a given hour of critical care,
even though more than one physician may be involved.
Codes that are bundled into Critical Care are as follows:
36000 Introduction of needle or intracatheter, vein
36410 Venipuncture, child over age 3 or adult, requiring
physician
36415 Collection of venous blood by venipuncture
36540 Collection of blood specimen from a completely
implantable venous access device
36600 Arterial puncture, blood for diagnosis
43752 Naso- or orogastric tube placement with fluoroscopic
guidance
71010 Chest x-ray, single view, frontal
71015 Chest x-ray, stereo, frontal
71020 Chest x-ray, two views, frontal and lateral
91105 Gastric intubation, aspiration/lavage for treatment
92953 Temporary transcutaneous pacing
93561 Indicator dilution studies, arterial/venous catheter
with cardiac output measure
93562 Subsequent measurement of cardiac output
94656 Ventilation management, first day
94657 Subsequent days
94660 Continuous positive airway pressure (CPAP),
initiation/management
93662 Continuous negative pressure ventilation (CNP),
initiation/management
94760 Noninvasive oximetry for oxygen saturation, single
determination
94762 By continuous overnight monitoring
99090 Analysis of information/data in computers
G0001 Routine venipuncture for collection of specimen
These cannot be billed separately when billing for critical care.

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99
Inpatient Neonatal and Pediatric Critical Care Services
99293 Initial inpatient pediatric critical care, per day, for the
evaluation and management of a critically ill infant or
young child, 29 days through 24 months of age
99294 Subsequent inpatient pediatric critical care, per day, for
the evaluation and management of a critically ill infant
or young child, 29 days through 24 months of age
99295 Initial inpatient neonatal critical care, per day, for the
evaluation and management of a critically ill neonate,
28 days of age or less
99296 Subsequent inpatient neonatal critical care, per day, for
the evaluation and management of a critically ill
neonate, 28 days or less
and management of the recovering very low birth
weight infant (present weight less than 1500 grams)
and management of the recovering low birth weight
infant (present body weight of 1500–2500 grams)
and management of the recovering infant (present
body weight of 2501–5000 grams)
Care rendered to patients with CPT codes 99293–99292 include:

■ Management
■ Monitoring and treatment
■ Respiratory
■ Pharmacologic control of the circulatory system
■ Enteral and parenteral nutrition
■ Metabolic and hematologic maintenance
■ Parent/family counseling
■ Case management services
■ Personal direct supervision of the health-care team

EVAL
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Documentation Formats
The most commonly used format, of the three currently used
documentation formats, is SOAP.
Description
S ubjective Includes patient complaints, history of illness or
injury, answers to questions about organ sys-
tems, and past, family and/or social history
O bjective Includes findings on examination of the patient
A ssessment Includes the prognosis and/or differential
diagnosis of the patient and diagnostic
studies
P lan Includes patient instructions, testing to be
performed, next appointment, prescriptions,
referrals
The next most commonly used is SNOCAMP:

Description
S ubjective Includes patient complaints, history of
illness/injury, answers to questions
about organ systems, and PFSH.
N ature of present- Includes a disease, illness, injury, symp-
ing problem tom, or finding that relates to the chief
complaint
O bjective Findings on patient exam
C ounseling/coor- Patient visits where counseling con-
dination of stitutes more than 50% of the visit
care
A ssessment Includes prognosis and/or differential
diagnosis of the patient and diagnostic
studies
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101
Description
M edical Complexity of the visit and physician’s thought
decision- process; this component is subjective and is
making based on three components:
1) number of diagnoses/management
options
2) amount and/or complexity of data
3) risk of mortality/morbidity
P lan Includes patient instructions, tests to be
performed, next appointment, Rx, referrals
Concurrent Care
Concurrent care is the provision of similar services to the same
patient by more than one provider on the same day. When both
providers bill the same diagnosis code, a claim denial may
occur. If there is no documentation to support the medical
necessity for the second provider, the provider who sends the
claim in first gets paid, the second claim gets denied.
To eliminate this claim denial, document the need for the second
provider to be involved in the patient’s care. Generate a paper
claim (CMS 1500 form) and attach the documentation to the
form. The claim form should be completed with the appropriate
CPT and ICD-9-CM codes.
Consultations
Consultations are requested when an opinion is asked of a
colleague regarding a patient. There are two types of
consultations:
■ Inpatient (99241–99245)
■ Outpatient (99251–99255)

EVAL
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When documenting a consultation, the following information

must be present:
■ The reason for the consult
■ Who requested the consult
■ The appropriate level of history, examination, and medical
decision-making
■ A diagnosis or impression and treatment plan
■ Disposition of patient, “Will follow” or “Patient will return
to your office in follow-up”
The Three Rs of a Consultation
1. Request
2. Render an opinion
3. Report
If all of the above are not met, consultation codes cannot be
billed. Consultation codes can be used by primary care physi-
cians when they examine their patients and submit a report
for medical clearance prior to surgery.
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103
Surgery Coding/Anesthesia Coding/Anesthesia
Facts:
■ Anesthesia is billed using time units that equal 10 to 15
minutes per unit (based on state regs).
■ Time begins when the physician or certified registered nurse
anesthetist (CRNA) prepares the patient for induction and
ends when the patient is released from anesthesia care in
the recovery room.
■ Time is rounded to one decimal place, when necessary.
■ Time is not used when administering local medications
intravenously.
Physical Status Modifiers are used to report that the anesthesia
administered was complicated by the physical status of the
patient.
Important facts:
■ Some payers will reimburse a higher amount when these
modifiers are used.
■ In other cases, such as Medicare, payers do not recognize
these modifiers.
■ Each case is carrier-specific and the reporting rules for
the carrier must be obtained prior to submission of the
claim.
Physical Status Modifiers
Modifier Description
P1 A normal healthy This modifier indicates that the
patient patient was healthy.
P2 A patient with a This modifier indicates that the
mild systemic patient had some type of
disease mild disease process, such
as hypertension.
SURG
ANES
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SURG Copyright © 2007 by F. A. Davis.

ANES
Physical Status Modifiers
severed systemic patient had a severe systemic
disease disease that could affect the
care of the patient. This
modifier may be used with
a patient who is a brittle
diabetic with complications of
congestive heart failure and
uncontrolled hypertension.
severe systemic patient has a severe disease
disease that is a that is a threat to life, such as
threat to life a patient who has had a heart
attack and now requires an
angioplasty.
P5 A moribund patient This modifier is used for
who is not expected critically injured patients who
to survive without require emergency surgery.
the procedure
P6 A declared brain-dead This modifier is used for a
patient whose patient who is brain-dead
organs are being being maintained on life
removed for support waiting for organ
transplant harvesting.
Monitored Anesthesia Care

Monitored anesthesia consists of the following:
■ Preanesthesia evaluation
■ Perianesthesia evaluation
■ Postanesthesia evaluation
■ Patient evaluation on admission and discharge from anesthesia
care
■ Time-based records of vital signs and level of consciousness
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Medically Directed Anesthesia Services
Medically directed services occur when a physician is responsible

for the direction of 2, 3, or 4 concurrent cases involving CRNAs.
These medically directed services are reported using the
modifier –QX.
Moderate (Conscious) Sedation
Moderate (conscious) sedation occurs when sedation is achieved

with or without the administration of an analgesic. This sedation
places the patient into a lower level of consciousness, allowing
for certain procedures to be carried out.
Medicare does not permit these codes (99143 and 99145) to be
billed separately and considers them bundled into the procedure.
HCPCS Modifiers for Anesthesia Services
AA Anesthesia services performed personally by an
anesthesiologist
AD Medical supervision by a physician; more than four
concurrent anesthesia procedures at one time
G8 Monitored anesthesia care (MAC) for deep, complex,
complicated, or markedly invasive surgical procedure
G9 Monitored anesthesia care for patient who has history
of severe cardiopulmonary condition
QK Medical direction of 2, 3, or 4 concurrent anesthesia
procedures involving qualified individuals
QS Monitored anesthesia care service
QX CRNA service with medical direction by a physician
QY Anesthesiologist medically directs one CRNA
QZ CRNA service without medical direction by a physician

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Surgery
The operative record is a major part of the medical record, as it
is the direct source for reporting procedures performed.
Accurate operative records will translate into accurate billing and
proper reimbursement.
Important Definitions
■ Assistant surgeon: Assists the primary surgeon in charge

of the case with a specific surgical procedure.
■ Cosurgeon: Two surgeons of different specialties are
required for a specific surgical procedure.
■ Team surgery: A single procedure requires more than two
different surgeons of two different specialties.
Global Surgeries
Components of a global surgery package are:

■ Preoperative visits
■ Intraoperative services
■ Complications following surgery
■ Postoperative visits and pain management
■ Supplies
■ Miscellaneous services such as staple and suture removal,
casts, splints, removal of catheters, etc.
■ These items cannot be billed separately since they are
considered part of the surgical package.
Services that can be billed separately are as follows:
■ Separately identifiable service from the surgery (use separate
diagnosis code when reporting)
■ Diagnostic testing and procedures
■ Second procedures that are distinct from the original
procedure
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■ Initial consultation that prompted the decision for surgery
■ History and physical that is performed more than 1 day before
the surgery
■ Reoperations due to complications
■ Dialysis
■ Immunosuppressive drug therapy for organ transplants
■ Critical care
Modifiers Used with Global Surgery Billing
■ Modifier –24
■ Modifier –25
■ Modifier –57
■ Modifier –58
■ Modifier –76
■ Modifier –77
■ Modifier –78
■ Modifier –79
See Tab 7 for details of these modifiers.
Bilateral Surgeries
Important facts:
■ If code indicates the procedure is performed on both sides of
the body, then the second side cannot be billed separately
■ If additional procedures are billed by the same physician
on the same day, use modifier –51 (See Tab 7)
Minor Surgeries
Important facts:
■ They are not usually global
■ If there is a 10-day postoperative period, all surgery and
postsurgery visits would be included in the global fee
■ Underlying conditions can be billed separately
■ The day of the procedure is not counted in the global fee
period

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Multiple Surgeries
Important facts:
■ When two physicians of different specialties perform separate
procedures during the same session, each surgeon will bill for
the specific procedure performed; there is no modifier required.
■ When billing a procedure code that takes one or more sessions,
third-party carriers will pay one time during the global fee
period.
■ When more than one procedure is performed at the same
operative session, list the major procedure first, followed by the
lesser procedures.
Critical Care
Critical care can be billed separately for preoperative and
postoperative care when the following conditions exist:
■ Constant attention is required by the physician
■ Care is unrelated to the surgical procedure performed
Postoperative Pain
■ Bill code 62319 for the first day of pain management by
continuous epidural
■ Bill code 01996 for daily management of the epidural drug after
the catheter was inserted.
■ Physician services related to PCA (patient-controlled analgesia) is
included in the global fee.
Surgical Tray
Medicare can be billed for a surgical tray when performing certain
surgical procedures. Billing surgical trays with other third-party
carriers is carrier specific and requires the provider to check with
each carrier individually. The code for billing surgical tray is A4550.

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Documenting the Operative Report
The documentation of a procedure requires documentation of
the complete story. It explains what procedure was performed,
how they were performed, what tissues, organs, or bones were
involved, and why it was necessary to perform the procedure.
All information must be complete, consistent, and in a form that
is ready to be coded.
Components Involved in Coding

from Operative Reports
An operative report is comprised of four main elements:
Four Elements of an Operative Report
1. Heading
2. History or indication for surgery
3. Body (operation(s)/procedure(s) in detail)
4. Findings
The heading consists of five major components:
Components of the Heading
1. Hospital-specific information
2. Patient-specific information
3. Date of operation or surgery
4. Specific information regarding operation
5. Operation(s) or procedure(s) performed
Depending on the type of operation and the course
of surgery, other information may be found in the
heading.
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from Operative Reports (Continued)
Components of the Heading
1. Hardware
2. Components
3. Grafts
4. Complications
5. Drains
6. Tourniquet time
7. Other material left in place
Heading
Hospital-Specific Information
1. Name of hospital
2. Address of hospital
3. Patient’s medical record or other number used to track
the patient
4. Admission date
Heading
Patient-Specific Information
1. Name
2. Date of birth and/or age
3. Sex
Heading
Date of Operation or Surgery
Example: 11/10/05
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from Operative Reports (Continued)
Heading
Specific Information Regarding Operation
1. Attending surgeon: all surgeons involved should be
listed, i.e., primary surgeon, cosurgeons, and
assistant surgeons
2. Cosurgeon
3. Surgery resident, if applicable
4. Surgery assistants, if applicable
5. Anesthetic (general, local)
6. Complications
7. Estimated blood loss
Diagnoses
1. Preoperative diagnoses
2. Postoperative diagnoses
Heading
Operation or Procedure Performed
Specific case information is inserted in this section
History or Indication for Surgery
Contains a brief history of why the surgery is indicated.
Body (operation(s)/procedure(s) in detail)

Contains a detailed accounting of the operation(s)
from start to finish.
Findings
Contains a synopsis of the findings during the
operation.
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There are other sources of documentation that could influence

the coding of the operation or procedure. These documents are
as follows:
■ Progress notes
■ Physician orders
■ Pathology reports
■ Discharge summary
■ History and physicals
■ Emergency department reports
■ Ventilator management forms
■ Anesthesiology forms
■ Recovery room course and information
■ Complications
■ Ambulance services
■ Consultant’s reports
Surgical and Postoperative Codes
ICD-9-CM Codes
ICD-9-CM categories 996–999 contain the majority of the codes
used when reporting surgical and postoperative complications.
When coding an inpatient service, the condition leading to the
admission to the hospital is the primary code used for billing.
For outpatient services, the diagnosis code that reflects the most
current reason for this episode of care would be primary.
The principal diagnosis is defined as the reason the patient was
admitted to the hospital.
Surgical Modifiers
Surgical modifiers used other than those listed in the Global
Surgery section of this tab are:
■ Modifier –22
■ Modifier –51
■ Modifier –52
■ Modifier –54
■ Modifier –56
■ Modifier –99
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Elective Surgery Notice
When nonparticipating providers submit a Medicare claim
for an elective surgery, the patient must be presented with an
elective surgery notice, which identifies the charges and their
liability. This notice must be presented to the patient whenever
the procedure charge is $500 or more.
Requirements for procedure to be considered elective:
■ If the surgery is postponed, there will be no damage to the
patient’s health.
■ There is no urgency for this surgery.
■ This surgery can be scheduled in advance.
Physicians who do not participate in Medicare must provide their
elective surgery patients with a fee disclosure form. This form
must contain the following:
■ The estimated charge (can’t be higher than the limiting charge)
■ The estimated Medicare allowable charge
■ The difference between the two charges
■ The patient’s coinsurance amount
The Patient’s Out-of-Pocket Expenses
The charge to the patient must not exceed 115% of the Medicare
allowable amount. An example of this estimation calculation can
be seen in the following table:
Description Fee
Charge for the procedure $1,000.00
Medicare allowable amount $550.00
Medicare approved charge $550.00
(Whichever of the above fees
is the lowest, 1,000 or 550)
Difference between Medicare approved $450.00
charge and actual charge
(1,000 – 550 ⫽ 450)
Coinsurance (20%) $110.00
(20% of the Medicare approved
charge, 550 ⫻ .20 ⫽ 110)
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Description Fee
Patient’s portion of the bill if $560.00
Medicare deductible was met
(450 ⫹ 110 ⫽ 560)
If the patient’s Medicare $660.00
deductible has not been met
(560 ⫹ 100 ⫽ 660)
Integumentary System Coding

Considerations when billing for procedures involving the skin:
■ Location
■ Where is it?
■ Method
■ Was it incised, excised, shaved?
■ Structures
■ Did it involve only skin or did it also involve muscle?
■ Depth
■ Was it deeper than the subcutaneous tissue?
■ Type
■ Was it complete, partial?
■ Size
■ Report using centimeters
■ Number
■ How many lesions?
Incision and Drainage
Considerations when billing for incision and drainage of an

abscess or cyst:
■ Site
■ Arm, face, etc.
■ Depth
■ Skin, soft tissue
■ Method
■ Incision, puncture
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Removal of Foreign Bodies
Considerations when billing for removal of foreign bodies:

■ Site
■ Face, leg, hand, eye
■ Depth
■ Muscle, subcutaneous tissue
■ Complexity
■ Superficial, complicated
Repairs
Repair codes are used to suture lacerations from injury or

procedures. If suturing is required as a result of a procedure,
the reimbursement is included in that procedure code and
CANNOT be billed for separately.
Types of Repairs
Simple Closure of a partial or full thickness wound to the
skin and subcutaneous tissues. No involvement
of deep structures.
Interme- Closure of wounds/lacerations involving repair of
diate one or more deeper layers of subcutaneous tissue
and nonmuscle fascia along with the skin.
Complex Closure of layered wound that requires additional
work, such as scar revision, débridement,
retention sutures, etc.
Considerations for repairs:

■ Location
■ Foot, hand, face
■ Size
■ Reported in centimeters
■ Structure
■ Skin, subcutaneous tissue, muscle
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Steps for Coding Wound Repairs

1. The repaired wound should be measured and recorded
in centimeters, whether curved, angular, or stellate.
2. When multiple wounds are repaired, add together the lengths
of those in the same classification and report as a single item.
When more than one classification of wounds is repaired, list
the more complicated as the primary procedure and the less
complicated as the secondary procedure, using modifier –51.
3. Decontamination and/or débridement is considered a sepa-
rate procedure only when gross contamination requires
prolonged cleansing, when appreciable amounts of tissue
are removed, or when débridement is carried out separately
without immediate primary closure.
4. If the wound repair involves nerves, blood vessels and/or
tendons, choose codes from appropriate subsection of the
Surgery section (nervous, cardiovascular, etc.) for repair of
these structures.
Burns
Considerations for local treatment of burns:

■ Anesthesia
■ With or without
■ Depth
■ Depth of burn
■ Location
■ Hand, face
■ Percent
■ Percent of body surface
■ Size
■ Small, medium
Rule of Nines
An approximation of the area of skin burnt. It divides the body
into units of surface area that are divisible by nine—with the
exception of the perineum. In an adult, the following are the
respective percentages of the total body surface area:
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Adults:
■ Head and neck total for front and back: 9%
■ Each upper limb total for front and back: 9%
■ Thorax and abdomen front: 18%
■ Thorax and abdomen back: 18%
■ Perineum: 1%
■ Each lower limb total for front and back: 18%
The Rule of Nines is relatively accurate for adults but not for
children due to the relative disproportion of body part surface
area.
Children:
■ Head and neck total for front and back: 18%
■ Each upper limb total for front and back: 9%
■ Thorax and abdomen front: 18%
■ Thorax and abdomen back: 18%
■ Perineum: 1%
■ Each lower limb total for front and back: 13.5%
Fracture Coding
Fracture codes include evaluation and management (E&M)
services:
■ E&M service the day of the fracture treatment
■ Treatment of the fracture, i.e., pinning, open, closed
■ Placement and removal of initial cast or splint
■ Follow-up care provided
Subsequent casts can be billed for separately.
Dislocations are reported by two factors:
1. The method in which they were stabilized
2. The type of manipulation used
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Endoscopy Coding
There are two types of endoscopy:
1. Diagnostic
2. Therapeutic
Diagnostic Minor Therapeutic Major Therapeutic
Procedures Procedures Procedures
Diagnostic Biopsy of different Removal of tumor,
endoscopy lesion in a polyp, or lesion
different area using hot biopsy,
or snare
Biopsy of the same Removal of foreign Ablation of tumor,
lesion in the same body polyp, or lesion
area by other
technique
Brushing or washing Dilation
to collect a Removal of stent
specimen
Miscellaneous Facts
■ Use two codes when reporting the replacement of a
pacemaker battery:
■ Code for the removal of the pulse generator
■ Code the insertion of the new pulse generator
■ Replacement of the pacemaker within the first 2 weeks is
included in the original code and cannot be billed for
separately
■ Surgical endoscopy includes diagnostic endoscopy
■ When a C-section has been performed, the physician who
performed the procedure is responsible for the postpartum
care
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■ All sleep studies include tracing, interpretation, and report
■ Surgical arthroscopy includes diagnostic arthroscopy;
therefore, this can never be billed for separately
■ An E&M service can be billed the same day as PT if the
service is separately identifiable. The modifier –25 must
be attached to the E&M service
■ There are three approaches to hysterectomies:
■ Abdominal
■ Vaginal
■ Laparoscopic, vaginal
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RAD PATH Copyright © 2007 by F. A. Davis.
Radiology
Radiology billing and coding is divided into four sections:
1. Diagnostic radiology, to include computerized tomography
(CT scans), magnetic resonance imaging (MRI), and
interventional radiology
2. Diagnostic ultrasound
3. Radiation oncology
4. Diagnostic and therapeutic nuclear medicine
All procedures in the CPT book are listed by anatomical site and
body system. These procedures are presented by type of service
and body site. Radiation oncology is presented according to the
following outline:
■ Treatment planning
■ Medical radiation physics
■ Treatment delivery
■ Treatment management
Radiology procedures are many times denied due to lacking
medical necessity. Accurate diagnosis coding is instrumental in
the reimbursement process for radiology codes. It is the order-
ing physician or physician extender’s responsibility to provide
the diagnosis when ordering a radiology procedure. A physician
extender is an individual whose professional level is between a
nurse and a physician. Examples of physician extenders are
nurse practitioners and physician assistants.
Unless the radiology service is being performed in a free-
standing facility where the equipment is also owned, most
radiology coding includes only the professional component. In a
hospital setting, the equipment is owned by the hospital, but the
interpretation is performed by the radiologist and is billed using
a modifier –26, or –PC for professional component.

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Component Description Modifier
Technical Includes equipment, supplies, personnel ⫺TC
(technician), costs to perform the
procedure
Professional Physician’s interpretation, report; also ⫺26
includes costs of physician education
and malpractice insurance
Global One physician provides both technical None
and professional components of the
procedure
A written report is considered part of the interpretation; therefore,
it cannot be billed separately.
With Contrast
This phrase is used when a study is requested with the use of a
contrast material for enhancement of the image. This phrase can
be found with the following codes:
■ Computerized tomography (CT scan)
■ Computerized tomography angiography (CTA)
■ Magnetic resonance imaging (MRI)
■ Magnetic resonance angiography (MRA)
Contrast material is administered via an intravenous line (within a
vein), intra-articular (within a joint), or intrathecally (within a
sheath: through the theca of the spinal cord.)
CT and MRI scans are listed in the CPT book either with or with-
out contrast. The following table shows some of these codes.
CPT Code Description
70450 Computed tomography (CT scan) head, or
brain; without contrast material
70460 With contrast material
74150 Computed tomography (CT scan) abdomen;
without contrast material
74160 With contrast material
The placement of the IV line for the administration of contrast is
considered part of the procedure and cannot be billed for separately.
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Positron Emission Tomography (PET scan)

A PET scan is a diagnostic tool that is most often used to detect
cancer and to examine the effects of cancer therapy by biochem-
ical changes.
PET scans can be used in the following areas:
■ Brain
■ Heart
■ Cancerous tumors
Emergency Department X-rays
■ Medicare will only pay for one interpretation of an x-ray
procedure. This interpretation fee is generally reimbursed to
the radiologist for a formal written report and not the emer-
gency department physician for their review of the film. Most
other carriers follow the Medicare guidelines and will not
reimburse for an emergency department review.
Consultations
X-ray consultations performed on x-rays made elsewhere must
contain a written report. To bill for this consultation, CPT code
76140 should be used.
Key Elements to Help in Radiology Coding and Billing
The following lists include components that are found within the
specific procedures that need consideration when considering a
code. For example, a chest x-ray is a diagnostic procedure. A chest
x-ray may be a single view, frontal, code 71010, a two view, frontal
and lateral, code 71020, or a complete, four or more views, code
71030. It is important to read the codes carefully before assigning a
code to a service or procedure. Does this diagnostic procedure
have more than one view? Is it a complete or limited study? Is it
with contrast, or without? All of these questions must be answered
to properly code a diagnostic procedure.
Diagnostic Procedures
1. Number of views
2. Complete or limited study
3. With or without contrast
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Ultrasound Procedures
1. Complete or limited
2. Unilateral or bilateral
3. With or without duplex scan
Nuclear Medicine Procedures
1. Type of radionuclide
2. Amount of radionuclide
3. Limited, multiple, or whole body area
4. Single or multiple determinations
5. With or without flow
6. Qualitative or quantitative
Computerized Tomography (CT)
1. With or without contrast media (type and amount)
2. Multiplanar scanning and/or reconstruction
Magnetic Resonance Imaging (MRI)
1. With or without contrast media (type and amount)
2. Number of sequences
Modifiers
Modifiers used in radiology coding are ⫺22, ⫺26, ⫺32, ⫺51, ⫺52,
⫺53, ⫺58, ⫺59, ⫺62, ⫺66, ⫺76, ⫺77, ⫺78, ⫺79, ⫺80, ⫺90, ⫺99.
Modifier Description Billing Notes
⫺22 Unusual proce- ■ Used rarely in radiology, and
dural service when used, requires additional
documentation to support use
■ Not recognized by most
carriers
■ Used with CT scans when
additional views or slices are
needed
■ DO NOT OVER USE
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⫺26 Professional com- ■ Used when the physician
ponent provides an interpretation
of the study; this interpre-
tation requires a separate
written and signed report;
simple verbiage, such as WNL
within normal limits (WNL) or
fx radius-normal, does not
meet the requirements
⫺32 Mandated service ■ Used when the service is
mandated
■ Used rarely in radiology;
sometimes used by Workers’
Compensation
⫺51 Multiple proce- ■ Use this modifier when more
dures than one procedure is
performed by the same
physician on the same date,
on the same patient
⫺52 Reduced service ■ Use this modifier when
a procedure is partially
reduced or eliminated at
the physician’s direction
■ Used when a postreduction
film of fracture care is taken;
use the comprehensive x-ray
code to identify the fracture;
once the fracture has been
reduced, use the compre-
hensive x-ray code again with
modifier –52 to indicate that a
reduced level of service was
provided
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⫺53 Discontinued ■ Used when the physician
service chooses to terminate the
procedure
■ Would be used when the x-ray
procedure is discontinued
because the patient is at risk
■ Use a diagnosis code that is
appropriate, such as, procedure
not carried out because of
contraindication (V64.1),
procedure not carried out
because of patient’s election
(V64.2), procedure not carried
out for another reason (V64.3)
⫺58 Staged or related ■ Applying this code to the
procedure or second related procedure dur-
service by the ing a postoperative period will
same physician result in a denial of the claim
during the ■ Cannot be used in conjunction
postoperative with codes whose descriptions
period state that the code represents
one or more services
⫺59 Distinct proce- ■ This modifier indicates that the
dural service procedure was distinct or
separate from the other
procedure performed on the
same day
⫺62 Two surgeons ■ Used when the skills of two
different physicians from two
different specialties are needed
to perform a procedure on a
patient during the same
operation
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■ Cannot be used by two physi-
cians of the same specialty
⫺66 Surgical team ■ Used when a complex procedure
requires the services of
physicians from different
specialties and other highly
skilled individuals
■ May be used in instances of mul-
tiple traumas, heart transplants,
separation of conjoined twins
⫺76 Repeat proce- ■ Some carriers will not allow
dure by same radiology to use this modi-
physician fier; each modifier is carrier-
specific, so it is best to always
check with the individual carriers
before using modifiers
■ It is used to identify that the
procedure had to be performed
again and that this was not a
duplicate billing; without this
modifier in this circumstance, the
claim will be denied as duplicate
⫺77 Repeat proce- ■ Use of this modifier is rare as a
dure by second interpretation and report
another phy- are unusual in radiology
sician ■ Add this modifier to the second
service
■ Sometimes used when a phy-
sician wants a better look using
a darker density, so patient must
return for second procedure with
darker density
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⫺78 Return to operating for ■ Used when a subsequent
related procedure procedure is related to the
during the post- first and requires the use
operative period of an operating room
⫺79 Unrelated procedure ■ Used when an unrelated
or service by the procedure is performed by
same physician the same physician during
during the postop- the postoperative period
erative period of the original procedure
⫺99 Multiple modifiers ■ Used to report that mul-
tiple modifiers are being
reported in this claim
Diagnostic Radiology
Minimum
In the radiology section of the CPT book, the word “minimum”
becomes a key factor in billing. This word indicates that there is
no ceiling beyond what is mentioned for that particular code.
See the following table for an example of this wording.

73630 Radiologic examination, foot, complete, minimum
three views
If an x-ray of a left foot contained 4 views, the same code

73630 would be used.
If an x-ray of a left foot contained 2 views, the code 73620,
two views, would be used.
Details make the difference:
An x-ray of a hip, unilateral, one view is code 73500.
An x-ray of a hip, complete, minimum of two views is code
73510.
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An x-ray of a hip, bilateral, minimum of two views of each hip,

including anteroposterior view of pelvis is code 73520.
An x-ray of a hip during an operative procedure is code 73530.
An x-ray of pelvis and hips, infant or child, minimum of two
views is code 73540.
Transcatheter Services
Transcatheter supervision and interpretation codes include the
following services:
■ Contrast, angiography/venography, roadmapping, fluoro-
scopic guidance for the intervention
■ Measurement of the vessel
■ Angiography/venography completion, except for procedures
through existing catheters for follow-up studies
■ Diagnostic angiography/venography performed during a
transcatheter therapeutic radiological and interpretive service
is separately reportable, unless otherwise specified
Diagnostic Ultrasound
Terminology
Term Definition
A-mode Signifies a one-dimensional ultrasonic
measurement procedure
M-mode Signifies a one-dimensional ultrasonic record
amplitude and velocity of moving echo-producing
structures
B scan Signifies a two-dimensional ultrasonic scanning
procedure with a two-dimensional display
Real-time Signifies a two-dimensional ultrasonic scan-
scan ning procedure with display of both two-
dimensional structure and motion with time
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Doppler evaluation of vascular structures is separately report-
able, unless color flow is used only for anatomic structure
identification.
A complete ultrasound examination of the abdomen consists
of B-mode scans of:
■ Liver
■ Gallbladder
■ Common bile duct
■ Pancreas
■ Spleen
■ Kidneys
■ Upper abdominal aorta
■ Inferior vena cava
■ Any abnormality found in the abdomen
A complete ultrasound examination of the retroperitoneum
consists of B-mode scans of the:
■ Kidneys
■ Abdominal aorta
■ Common iliac artery origins
■ Inferior vena cava
■ Any abnormality found in the retroperitoneum
Radiation Oncology
Items Included in Radiation Oncology
1. Initial consultation
2. Clinical treatment planning
3. Simulation
4. Medical radiation physics
5. Dosimetry
6. Treatment devices
7. Special services
8. Clinical treatment management procedures
9. Normal follow-up care for 3 months following
completion of radiation
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Clinical Treatment Planning

Treatment planning for radiation oncology is a highly specialized
service, which includes the following:
1. Interpretation of special testing
2. Tumor localization
3. Treatment volume determination
4. Treatment time/dosage determination
5. Choice of treatment modality
6. Determination of number and size of treatment ports
7. Selection of appropriate treatment devices
Treatment Planning Definitions
1. Simple Planning requires a single treatment area of
interest encompassed in a single port or
simple parallel opposed ports with simple
or no blocking
2. Intermediate Planning requires three or more converging
ports, two separate treatment areas,
multiple blocks, or special time dose
constraints
3. Complex Planning requires highly complex blocking,
custom shielding blocks, tangential ports,
special wedges or compensators, three or
more separate treatment areas, rotating
or special beam considerations, com-
bination of therapeutic modalities
Therapeutic Radiology Simulation Definitions
1. Simple Simulation of a single treatment area with
either a single port or parallel opposed
ports; blocking is simple or may not exist
2. Intermediate Simulation of three or more converging
ports, two separate treatment areas,
multiple blocks
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Therapeutic Radiology Simulation Definitions
3. Complex Simulation of tangential portals, three or
more treatment areas, rotation or arc
therapy, complex blocking, custom
shielding blocks, brachytherapy source
verification, hyperthermia probe veri-
fication, or any use of contrast materials
4. Three- Three-dimensional reconstruction of
dimensional tumor volume and surrounding
reconstruction of tumor volume and
surrounding critical normal tissue
structures from direct CT and or MRI
scans in preparation for noncoplanar or
coplanar therapy; the simulation uses
documented three-dimensional beam’s
eye view volume dose displays of
multiple or moving beams
Proton Beam Definitions

1. Simple Proton treatment delivery to a single treat-
ment area using a single nontangential
or oblique port, custom block with com-
pensation and without compensation
2. Intermediate Proton treatment delivery to one or more
treatment areas using two or more ports
or one or more tangential or oblique
ports, with custom blocks and compen-
sators.
3. Complex Proton treatment delivery to one or more
treatment areas using two or more ports
per treatment area with matching or
patching fields and/or multiple isocen-
ters, with custom blocks and compen-
sators.
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Hyperthermia
Types of Hyperthermia CPT Codes
1. External (superficial, deep) 77600, 77605
2. Interstitial 77610, 77615
3. Intracavity 77620
Physics planning and interstitial insertion of temperature sensors, and

the use of external or interstitial heat-generating sources are included in
the above codes. Consultations may be billed separately with the above
procedures.
Clinical Brachytherapy
Brachytherapy Applications
1. Simple Application of 1–4 sources
2. Intermediate Application of 5–10 sources
3. Complex Application of more than 10 sources
Interventional Radiology Procedures
Interventional procedures are most often performed by the same

physician, but may be performed by two physicians. For
example, a liver biopsy may be performed by a surgeon and a
radiologist. The surgeon’s responsibility would be the placement
of the needle and the tissue sampling. The radiologist would be
responsible for performing the x-rays, dye injections, and film
interpretations.
Nuclear Medicine
Diagnostic
Nuclear medicine codes do not include radium or other radioele-
ments and should be reported separately. Nuclear medicine
procedures may be performed independently or during the
course of care.
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Therapeutic
The administration codes for oral and intravenous administra-
tion are inclusive of the mode of administration. When reporting
intra-arterial, intracavitary, and intra-articular administration,
also use the following codes when appropriate:
■ Appropriate injection and or procedure codes
■ Imaging guidance
■ Radiological supervision and interpretation codes
Basic Radiology Definitions
Term Definition
Anteroposterior (AP) Front to back
Anteroposterior and Two projections are included in this
lateral examination: front to back and side
Contrast material Usually a radiopaque material that is
placed into the body to enable a system
or body structure to be visualized;
common terms include nonionic and
low osmolar contrast medial (LOCM),
ionic and high osmolar contrast media
(HOCM), barium, and gadolinium
Decubitus (DEC) Patient lying on their side
Frontal Face forward
Lateral (LAT) Side view
Modality A form of imaging, including x-ray,
fluoroscopy, ultrasound, nuclear
medicine, duplex Doppler, CT, and MRI
Oblique (OBL) Oblique view of the object is being x-
rayed
Posteroanterior (PA) Back to front
Real-time Immediate imaging, usually in movement
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Basic Radiology Definitions (continued)
Term Definition
Stent Tube to provide support in a body cavity or
lumen
Subtraction The removal of an overlying structure to better
visualize the structure in question; this is
done in a series by imposing one x-ray on
top of another
Tomogram A specialized type of x-ray imaging that
provides slices through a body structure to
obliterate overlying structures; commonly
performed for studies on the kidneys or the
temporomandibular joint (TMJ)
Laboratory
Laboratory and pathology studies cover the following
areas:
■ Organ panels
■ Urinalysis
■ Chemistry
■ Hematology
■ Blood banking
■ Drug testing
■ Cytopathology
■ Surgical pathology
Organ panels consist of various components that are generally
ordered together. An example can be seen in the following basic
metabolic panel:
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Test CPT Code
Calcium 82310
Carbon dioxide 82374
Chloride 82435
Creatinine 82565
Glucose 82947
Potassium 84132
Sodium 84295
Urea nitrogen 84520
The above tests, as with other panels, are components of the

basic metabolic panel and would be billed using CPT code
80048. Billing all of the above codes individually would be
unbundling (complete description of this term can be found in
Tab 5) and, therefore, would be considered a matter of fraud and
abuse. If only two of the above tests are ordered, only the two
individual codes would be billed.
Other organ panels are:
Panel CPT Code
General health panel 80050
Electrolyte panel 80051
Comprehensive metabolic panel 80053
Obstetric panel 80055
Lipid panel 80061
Renal function panel 80069
Acute hepatitis panel 80074
Hepatic function panel 80076
In addition to the widely ordered panels above, other common
tests are:

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Test CPT Code

Urinalysis, by dip stick, non-automated, with 81000
microscopy
Urinalysis, by dip stick, automated, with 81001
microscopy
Urinalysis, by dip stick, non-automated, without 81002
microscopy
Urinalysis, by dip stick, automated, without 81003
microscopy
Cholesterol, total 82465
Triglycerides 84478
Glucose, quantitative, except reagent strip 82947
Glucose, blood, reagent strip 82948
Glucose tolerance test, 3 specimens 82951
Beyond 3 specimens 82952
Glucose, monitoring device for home use 82962
Prostate specific antigen (PSA) 84152
Thyroid stimulating hormone (TSH) 84443
Gonadotropin, chorionic, quantitative (HCG) 84702
Blood count, automated diff with WBC 85004
Complete blood count (CBC), automated, with 85025
automated diff. Includes Hgb, Hct, RBC, WBC,
and platelet count
Complete blood count (CBC) without diff. 85027
Prothrombin time 85610
Partial thromboplastin (PTT) 85730
Urine culture, bacterial, quantitative colony count 87086
Sensitivity studies, antibiotic disk method, per 87184
plate (12 fewer discs)
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Surgical Pathology
Surgical pathology codes include accession, examination, and

report. There are six levels of surgical pathology codes.
Level Definition and Examples of Level CPT Code
I Surgical pathology, gross exam 88300
II Surgical pathology, gross and 88302
microscopic exam
■ Appendix
■ Skin, plastic repair
■ Vas deferens, sterilization
III Surgical pathology, gross and 88304
microscopic exam
■ Carpal tunnel tissue
■ Gallbladder
■ Tonsils
IV Surgical pathology, gross and 88305
microscopic exam
■ Colon biopsy
■ Joint resection
■ Stomach biopsy
V Surgical pathology, gross and 88307
microscopic exam
■ Breast, mastectomy – partial/simple
■ Cervix, conization
■ Liver biopsy – needle/wedge
VI Surgical pathology, gross and 88309
microscopic exam
■ Colon, total resection
■ Prostate, radical resection
■ Soft tissue tumor, extensive resection

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Collection of Specimen
Description CPT Code
1. Venipuncture, routine collection of venous 36415
blood
2. Venipuncture, routine collection of venous G0001
blood, Medicare patient
3. Collection of capillary blood specimen 36416
(heel, finger, ear)
Modifiers
Modifiers used in pathology coding are ⫺22, ⫺26, ⫺32, ⫺52,

⫺53, ⫺59, ⫺90, ⫺91.
⫺22 Unusual proce- ■ Used rarely in radiology, and
dural service when used, requires additional
documentation to support their
use
■ Not recognized by most carriers
■ Used with CT scans when
additional views or slices are
needed
■ DO NOT OVER USE
⫺26 Professional ■ Used when the physician
component provides an interpretation of the
study; this interpretation requires
a separate written and signed
report; simple verbiage, such as
within normal limits (WNL) or fx
radius-normal, does not meet the
requirements
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139
⫺32 Mandated service ■ Used when the service is
mandated
■ Used rarely in radiology;
sometimes used by Workers’
Compensation
⫺52 Reduced service ■ Use this modifier when a
procedure is partially reduced
or eliminated at the
physician’s direction
■ Used when a postreduction
film of fracture care is taken;
use the comprehensive x-ray
code to identify the fracture;
once the fracture has been
reduced, use the
comprehensive x-ray code
again with modifier –52 to
indicate that a reduced level
of service was provided
⫺53 Discontinued ■ Used when the physician
service chooses to terminate the
procedure
■ Would be used when an x-ray
procedure is discontinued
because the patient is at risk
■ Use a diagnosis code that is
appropriate, such as,
procedure not carried out
because of contraindication
(V64.1), procedure not carried
out because of patient’s
election (V64.2), procedure
not carried out for another
reason (V64.3)
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⫺59 Distinct ■ This modifier indicates that
procedural the procedure was distinct or
service separate from the other
procedure performed on the
same day
⫺90 Reference ■ Used when laboratory
(outside) procedures are performed by
laboratory someone other than the
reporting physician
⫺91 Repeat clinical ■ Used when it is necessary to
diagnostic report the same test on the
laboratory same day to obtain multiple
test test results
■ Cannot be used for confir-
mation of results
■ Cannot be used when there is
a problem with the specimen
or equipment
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Unbundling
The process of coding integral services separately from a procedure
is called unbundling. If the component is considered part of the
bundled service, it cannot be coded separately. For example, CPT
code 93000 is a code for Electrocardiogram, routine ECG, with at least
12 leads, with interpretation and report. If codes 93005 (ECG tracing
only, without interpretation and report) and 93010 (ECG with
interpretation and report only) were billed together, it would be
considered unbundling, as both elements are found in the all-
inclusive CPT code of 93000.
Add-On Codes
There are codes that are performed in addition to the main CPT code.
Add-On Code Facts:
■ These codes are called Add-on codes.
■ They are not reported with the modifier –51 for multiple
procedures as other CPT codes would be.
■ They cannot be billed by themselves.
■ Add-on codes are identified by wording that designates it is an
Add-on code.
Examples:
Primary Add-On
Code Description Code Description
96409 Chemotherapy adminis- 96415 Infusion technique,
tration, intravenous; 1 to 8 hours, each
push technique additional hour (list
separately in addi-
tion to code for pri-
mary procedure)
92607 Evaluation for prescription 92608 Each additional 30
for speech-generating minutes (list separa-
augmentative and alter- tely in addition to
native communication code for primary
device, face-to-face with procedure)
the patient; first hour
MED
Page 142

There are instances where more than one add-on code is used. See the following table.
Add-On Second Add-
Primary Code Code Description On Code Description
Any outpatient 99354 Prolonged physician service 99355 Each additional 30
3:01 PM
evaluation and in the office or other minutes (list sepa-

management outpatient setting requir- rately in addition
code (e.g., ing direct (face-to-face) to code for primary
99201–99205, patient contact beyond procedure)
99211–99215, the usual service (e.g.,
99241–99245) prolonged care and treat-
MED
4/17/07
ment of an acute asth-

matic patient in an
142
outpatient setting); first
hour (list separately in
addition to code for office
or other outpatient
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Evaluation and Manage-

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Multiple Procedure/Services
Certain procedures can be reported separately without the risk
of unbundling. For example, a patient hospitalized for a mental
condition can receive interactive psychotherapy in conjunction
with an Evaluation and Management code. Both the psychother-
apy code and the Evaluation and Management codes would be
billed for that date of service.
Separate Procedures
Any code that is designated as a “separate procedure” cannot be
billed in addition to the code for the comprehensive procedure
as it is considered to be a part of the comprehensive procedure.
If a code listed as “separate procedure” is coded independent of
any other procedure, it can then be billed.
Injections
Injections of immune globulins require the CPT code for the
actual immune globulin serum and a CPT code for the adminis-
tration of the injection. Immune globulin codes range from
90281–90399 for the serum. They should be reported with the
appropriate delivery code. These codes range from 90780 to
90784. A description of codes 90780 and 90781 can be found in
the following section. Vaccines and toxoids are reported using
codes 90476–90748. Descriptions of codes 90782–90784 follow.

90772 Therapeutic, prophylactic, or diagnostic injection
(specify material injected); subcutaneous or
intramuscular
90773 ■ Intra-arterial
90774 ■ Intravenous
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Immunization administration codes for vaccines are reported

using the following administration codes.

90465 Immunization administration under 8 years old
(includes percutaneous, intradermal, subcuta-
neous, or intramuscular), when the physician
counsels the patients; first injection (single or
combination vaccine/toxoid), per day
90466 ■ Each additional injection (single or combination
vaccine/toxoid) per day; list separately in
addition to code for primary procedure
90467 Immunization administration under 8 years old
(includes intranasal or oral routes of adminis-
tration) when the physician counsels the patient;
first administration (single or combination
vaccine/toxoid), per day
90468 ■ Each additional administration (single or
combination vaccine/toxoid) per day; list
separately in addition to code for primary
procedure
90471 Immunization administration (includes percuta-
neous, intradermal, subcutaneous, or intramus-
cular), one vaccine (single or combination
vaccine/toxoid)
90472 ■ Each additional vaccine (single or combination
vaccine/toxoid); list separately in addition to
code for primary procedure.
90473 Immunization administration by intranasal or oral
route; one vaccine (single or combination
vaccine/toxoid)
90474 ■ Each additional vaccine (single or combination
vaccine/toxoid); list separately in addition to
code for primary procedure
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Common Vaccines and Toxoids
90632 Hepatitis A vaccine, adult dosage, for intramus-
cular use
90645 Hemophilus influenza b vaccine (Hib), HbOC
conjugate (4-dose schedule), for intramuscular
use
90648 Hemophilus influenza b vaccine (Hib), PRP-T
conjugate (4-dose schedule), for intramus-
cular use
90656 Influenza virus vaccine, split virus, preservative
free, for children 6–35 months of age, for
intramuscular use
90660 Influenza virus vaccine, live, for intranasal use
90665 Lyme disease vaccine, adult dosage, for
intramuscular use
90700 Diphtheria, tetanus toxoids, and acellular
pertussis vaccine (DtaP), for use in individuals
younger than 7 years, for intramuscular use
90702 Diphtheria, tetanus toxoids (DT) absorbed for use
in individuals younger than 7 years, for
intramuscular use
90703 Tetanus toxoids adsorbed, for intramuscular use
90704 Mumps virus vaccine, live for subcutaneous use
90705 Measles virus vaccine, live for subcutaneous use
90707 Measles, mumps, and rubella virus vaccine, live
for subcutaneous use
90712 Poliovirus vaccine, (any type) (OPV), live, for oral
use
90713 Poliovirus vaccine, inactivated, (IPV), for
subcutaneous or intramuscular use
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Therapeutic, Diagnostic Infusions

(Excludes Chemotherapy)
CPT codes 90780 and 90781 are used to report prolonged intra-
venous injections. They are not used for billing of the following
services:
■ Intradermal
■ Subcutaneous
■ Intramuscular
■ Routine intravenous (IV)
Choose the appropriate code based on time.
CPT Code Description Time

90760 Intravenous infusion, hydration; initial Up to
1 hour
90761 Each additional hour up to 8 hours (list 2–8 hours
separately in addition to the code for
the primary procedure).
Psychiatry
Billing codes for psychiatry services include:
90801–90802 Psychiatric diagnostic interview examinations
Office or Outpatient
90804–90809 Insight oriented, behavior modifying and/or
supportive psychotherapy
90810–90815 Interactive psychotherapy
Inpatient Hospital, Partial Hospital, or Residential Care Facility
90816–90822 Insight oriented, behavior modifying and/or
supportive psychotherapy
90823–90829 Interactive psychotherapy
90845–90857 Other psychotherapy
90862–90899 Other psychiatric services or procedures

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147
Guide to coding psychiatric services:
■ Psychiatric diagnostic interviews must include history, mental
status, and a disposition
■ Interactive psychiatric diagnostic interviews are generally
provided to children; they use physical aids and nonverbal
communication to overcome barriers between the patient and
the clinician due to language skills that have either been lost,
or have not yet developed
■ Psychiatric therapeutic services are found in two categories:
■ Interactive psychotherapy
■ Insight oriented, behavior modifying and/or supportive
psychotherapy
■ Some patients receive psychotherapy only, while others
receive Evaluation and Management services (see Tab 2)
in addition
■ Psychotherapy codes are chosen based on the type
of psychotherapy, the place of service, face-to-face
time spent with the patient, and whether or not an
Evaluation and Management code is performed on
the same day.
■ Medicare will not accept psychiatric therapy codes
90804–90829 billed on the same day as an Evaluation
and Management code.
Physical Medicine and Rehabilitation

Important facts:
■ Medicare patients and many other carriers require a written
plan of care before the patient begins physical therapy.
■ Some codes are time-based codes and therefore require the
documentation of time to be billable.

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Some examples of commonly used physical therapy codes are:

97001 Physical therapy evaluation
97002 Physical therapy re-evaluation
97003 Occupational therapy evaluation
97004 Occupational therapy re-evaluation
97010 Application of a modality to one or more areas;
hot or cold packs
97012 ■ Traction, mechanical
97014 ■ Electrical stimulation (unattended)
97022 ■ Whirlpool
97026 ■ Infrared
97028 ■ Ultraviolet
97032 Application of a modality to one or more areas;
electrical stimulation (manual), each 15 minutes
97033 ■ Iontophoresis, each 15 minutes
97035 ■ Ultrasound, each 15 minutes
97110 Therapeutic procedure, one or more areas, each
15 minutes; therapeutic exercises to develop
strength and endurance, range of motion and
flexibility
97116 ■ Gait training (includes stair climbing)
97124 ■ Massage, including effleurage, pétrissage, and/
tapotement (stroking, compression, percussion
97140 Manual therapy techniques (e.g., mobilization/
manipulation, manual lymphatic drainage, manual
traction), one or more regions, each 15 minutes
97150 Therapeutic procedure(s), group (2 or more
individuals)
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149
Gastroenterology
Gastroenterology is the study of the stomach and intestine and
diseases associated with them. Following is a select list of the
most commonly used codes for these services. A complete
listing can be found in the Medicine section of the CPT book
under subsection Gastroenterology.

91000 Esophageal intubation and collection of washings
for cytology, including preparation of specimens
(separate procedure)
91010 Esophageal motility
91105 Gastric intubation, and aspiration or lavage for
treatment (for ingested poisons)
Gastroenterology Surgical Codes
There are many other gastroenterology codes listed in the

surgery section of the CPT book. Some of the most commonly
used codes are:
Important definitions:
■ Sigmoidoscopy: the examination of the entire rectum,
sigmoid colon, and may include examination of a portion of
the descending colon.
■ Colonoscopy: the examination of the entire colon, from the
rectum to the cecum, and may include the examination of the
terminal ileum.
Note: There is sometimes confusion between the two procedures
and codes explained above. It is important to read the proce-
dural report carefully to establish the completeness of the
examination.

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43235 Upper gastrointestinal endoscopy including
esophagus, stomach, and either the duodenum
and/or jejunum as appropriate; diagnostic, with
or without collection of specimens by brushing
or washing (separate procedure)
43239 ■ With biopsy, single or multiple
43243 ■ With injection sclerosis of esophageal and/or
gastric varices
43246 ■ With directed placement of percutaneous
gastrostomy tube
43260 Endoscopic retrograde cholangiopancreatography
(ERCP)
43262 ■ With sphincterotomy/papillotomy
43264 ■ With endoscopic retrograde removal of calculus
from biliary and/or pancreatic ducts
45330 Sigmoidoscopy, flexible; diagnostic, with or without
collection of specimen(s) by brushing or washing
(separate procedure)
45333 ■ With removal of tumor(s), polyp(s), or other
lesion(s) by hot biopsy forceps or bipolar cautery
45338 ■ With removal of tumor(s) polyp(s), or other
lesion(s) by snare technique
45378 Colonoscopy
45382 ■ With control of bleeding (e.g., injection, bipolar
cautery, unipolar cautery, laser, heater probe,
stapler, plasma coagulator)
45383 ■ With ablation of tumor(s), polyp(s), or other
lesion(s) not amenable to removal by hot biopsy
forceps, bipolar cautery, or snare technique
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151
lesion(s) by hot biopsy forceps or bipolar cautery
lesion(s) by snare technique
Ophthalmology
Ophthalmology is the study of the eye, its anatomy, physiology,
and pathology. Following is a select list of the most commonly
used codes for these services. A complete listing can be found
in the Medicine section of the CPT book under subsection
Ophthalmology.
Three types of ophthalmology services:
Type Description
Interme- Evaluation of a new or existing condition complicat-
diate ed with a new diagnostic or management problem
not necessarily relating to the primary diagnosis,
including history, general medical observation,
external ocular and adnexal examination and other
diagnostic procedures as indicated; may include
the use of mydriasis for ophthalmoscopy
Compre- Evaluation of the complete visual system; consists of
hensive a single service entity but need not be performed
at one session; includes history, general medical
observation, external and ophthalmoscopic
examinations, gross visual fields, and basic
sensorimotor examination; it often includes, as
indicated, biomicroscopy, examination with
cycloplegia or mydriasis and tonometry; includes
initiation of diagnostic and treatment programs
Special Services in which a special evaluation of part of the
visual system is made, which goes beyond the
services included under the general ophthalmo-
logical services
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Special services that are separately billable are:

■ Fluorescein angioscopy
■ Quantitative visual field examination
■ Refraction or extended color vision examination (Nagel’s
anomaloscope)
92002 Ophthalmological service: medical examination
and evaluation with initiation of diagnostic and
treatment program; intermediate, new patient
92004 ■ Comprehensive, new patient, one or more visits
92012 Ophthalmological service: medical examination
and evaluation with initiation or continuation of
diagnostic and treatment program; intermediate,
established patient
92014 ■ Comprehensive, established patient, one or
more visits
Codes used for office visits can be either the Ophthalmology codes or
the Evaluation and Management codes. It is the physician’s choice.
Biofeedback
There are two codes used to report biofeedback services. These
codes may require pre-authorization by the carrier.
90901 Biofeedback training by any modality
90911 Biofeedback training, perineal muscles, anorectal
or urethral sphincter, including EMG and/or
manometry
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Dialysis
End-Stage Renal Disease (ESRD)
ESRD services are outpatient codes and are reported with the
following codes:
90918–90921 ESRD-related services per full month
90922–90925 ESRD-related services (less than a full month),
per day
Guide to Reporting ESRD
■ The various levels are age-specific.
■ These codes are not billable with hospitalization codes.
■ Codes 90918–90921 are used to report consecutive services.
■ Codes 90922–90925 are used to report services that are not
performed consecutively during the month.
■ Each month is considered to be 30 days.
■ Procedures for other medical problems and complications
unrelated to ESRD are not included in the monthly ESRD service
and are reported separately.
Hemodialysis
Hemodialysis codes are inpatient codes used to report hemodialysis

procedures in addition to Evaluation and Management codes for the
same day. These services are reported with the following codes:
90935 Hemodialysis procedure with single physician evaluation
90937 Hemodialysis procedure requiring repeated evaluations
with or without substantial revision of the dialysis
prescription
90940 Hemodialysis access flow study to determine blood
flow in grafts and arteriovenous fistulae by an
indicator method
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Miscellaneous Dialysis Procedures
There are dialysis procedures other than hemodialysis. These

codes are reported using CPT codes 90945 and 90947.
90945 Dialysis procedure other than hemodialysis
(e.g., peritoneal dialysis, hemofiltration, or other
continuous renal replacement therapies), with
single physician evaluation
90947 Dialysis procedure other than hemodialysis (e.g.,
peritoneal dialysis, hemofiltration, or other
continuous renal replacement therapies) requir-
ing repeated physician evaluations, with or with-
out substantial revision of dialysis prescription
90997 Hemoperfusion, e.g., with activated charcoal or
resin
Dialysis Training
Dialysis training is reported using CPT codes 90989–90993. Code

90989 is used to report the completion of the dialysis-training
course. Code 90993 is used to report training per session.
Otorhinolaryngologic Services
Otorhinolaryngology is the study of the ear, nose, and throat.
Following is a select list of the most commonly used codes
for these services. A complete listing can be found in the
Medicine section of the CPT book under subsection Special
Otorhinolaryngologic Services.
Diagnostic procedures are reported as part of the office visit code
and cannot be billed for separately. This includes such tests as
otoscopy, rhinoscopy, and tuning fork test, and whispered voice.

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155
92506 Evaluation of speech, language, voice,
communication, and or auditory processing
92507 Treatment of speech, language, voice, communication,
and/or auditory processing disorder; individual
Audiologic Function Tests

Commonly Used Codes
92551 Screening test, pure tone, air only
92552 Pure tone audiometry (threshold); air only
92553 ■ Air and bone
92567 Tympanometry (impedence testing)
92568 Acoustic reflex testing; threshold
92590 Hearing aid exam and selection; monaural
92591 ■ Binaural
92592 Hearing aid check
92593 ■ Binaural
92594 Electroacoustic eval for hearing aid, monaural
92595 ■ Binaural
Cardiovascular Services
Cardiology is the study of the heart and its functions. Follow-
ing is a select list of most commonly used cardiology codes.
A complete listing can be found in the Medicine section of the
CPT book under subsection Cardiovascular.
Important Definitions
■ Echocardiography: Echocardiography includes obtaining
ultrasonic signals from the heart and great arteries, with
two-dimensional image and/or Doppler ultrasonic signal
documentation, and interpretation and report.
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■ Cardiac catheterization: Cardiac catheterization is a diagnostic

medical procedure that includes introduction, positioning and
repositioning of catheter(s), when necessary, recording of
intracardiac and intravascular pressure, obtaining blood
samples for measurement of blood gases or dilution curves
and cardiac output measurements (Fick or other method,
with or without rest and exercise and/or studies) with or
without electrode catheter placement, final evaluation and
report of procedure.
92950 Cardiopulmonary resuscitation (CPR) (cardiac arrest)
92982 Percutaneous transluminal coronary balloon
angioplasty; single vessel
93000 Electrocardiogram, routine ECG, with at least
12 leads; with interpretation and report
93005 ■ Tracing only, without interpretation and report
93010 ■ Interpretation and report only
93015 Cardiovascular stress test using maximal or sub-
maximal treadmill or bicycle, continuous electro-
cardiographic monitoring, and/or pharmacological
stress; with physician supervision, with interpre-
tation and report
93040 Rhythm ECG, one to three leads; with interpretation
and report
93224 Electrocardiographic monitoring for 24 hours by
continuous original ECG waveform recording and
storage, with visual superimposition scanning;
includes recording, scanning analysis with report,
physician review and interpretation
93307 Echocardiography, transthoracic, real-time with
image documentation (2D) with or without
M-mode recording; complete
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93320 Doppler echocardiography, pulsed wave and/or
continuous wave with spectral display (list
separately in addition to codes for
echocardiographic imaging); complete
93325 Doppler echocardiography color flow velocity
mapping (list separately in addition to codes
for echocardiography)
93350 Echocardiography, transthoracic, real-time with
image documentation (2D) with or without M-
mode recording; during rest and cardiovascular
stress test using treadmill, bicycle exercise and/
or pharmacologically induced stress, with
interpretation and report
93501 Right heart catheterization
93510 Left heart catheterization
Electrocardiograms can be called either ECGs or EKGs.
Pulmonary
Pulmonary is the study of the lungs and/or the pulmonary artery.
Following is a select list of most commonly used pulmonary
codes. A complete listing can be found in the Medicine section
of the CPT book under subsection Pulmonary.

94010 Spirometry, including graphic record, total and timed
vital capacity, expiratory flow rate measurement(s),
with or without maximal voluntary ventilation
94060 Bronchospasm evaluation: Spirometry as in 94010,
before and after bronchodilator (aerosol or
parenteral)
94150 Vital capacity, total (separate procedure)
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94656 Ventilation assist and management, initiation of
pressure volume preset ventilators for assisted
or controlled breathing, first day
94657 ■ Subsequent days
94660 Continuous positive airway pressure ventilation
(CPAP), initiation, and management
94664 Demonstration and/or evaluation of patient
utilization of an aerosol generator, nebulizer,
metered dose inhaler, or IPPB device
Allergy and Clinical Immunology

Allergy sensitivity testing is the performance and evaluation of
selective cutaneous and mucous membrane tests in correlation
with the history, physical examination, and other observations
of the patient. Immunology is the parenteral administration of
allergenic extracts as antigens at periodic intervals, usually on
an increasing dosage scale to a dosage that is maintained as
maintenance therapy. A complete listing of codes can be found
in the Medicine section of the CPT book under subsection
Allergy and Clinical Immunology.
Important Billing and Coding Facts
■ Professional services (Evaluation and Management codes) are
included in CPT codes 95115–95199, which are the allergen
immunotherapy codes
■ Evaluation and Management codes can only be used if there
is a separate and identifiable service being performed on the
same date. Use modifier –25 with the Evaluation and
Management code should this occur
■ Codes 95115 and 95117 do not include the extract itself, only
administration of the allergy injection
■ Codes 95120 through 95134 include both the administration of
the injection and the extract. These are referred to as complete
service codes, as they also include the preparation, antigen,
supplies, and observation of the patient after injection
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■ Code number of allergens correctly; for example:
■ 95130: Single stinging insect venom
■ 95131: Two stinging insect venoms
■ 95132: Three stinging insect venoms
Neurology and Neuromuscular Procedures

Neurology is the study of the nervous system. Following is a select
list of most commonly used neurology codes. A complete listing
can be found in the Medicine section of the CPT book under
Neurology and Neuromuscular Procedures.
Important Billing and Coding Facts
■ Hyperventilation and/or phonic stimulation is included in codes
95812–95822 and cannot be billed separately
■ EEG codes are time-based codes and must be chosen correctly
based on time of monitoring
■ Electromyography and nerve conduction tests are based on the
number of extremities tested

95812 Electroencephalogram (EEG) extended monitoring;
41–60 minutes
95813 ■ Greater than 1 hour
95816 Electroencephalogram (EEG) including recording
awake and drowsy
95819 ■ Including awake and asleep
95860 Needle electromyography; one extremity with or
without related paraspinal areas
95861 ■ Two extremities with or without related paraspinal
areas
95863 ■ Three extremities with or without related paraspinal
areas
95864 ■ Four extremities with or without related paraspinal

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95900 Nerve conduction, amplitude and latency, velocity
study, each nerve; motor, without F-wave study
95903 ■ Motor, with F-wave study
95904 ■ Sensory
Chemotherapy
Chemotherapy is the treatment of various diseases by using
chemical agents. Following is a select list of the most commonly
used Chemotherapy codes. A complete listing can be found in
the Medicine section of the CPT book under Chemotherapy.
Important Facts
■ Evaluation and Management codes can be billed with
Chemotherapy procedures when warranted
■ Preparation of the chemotherapy is included in the
administration code
■ When chemotherapy is delivered by different techniques, each
code should be billed separately by method of delivery
96401 Chemotherapy administration, subcutaneous or
intramuscular, nonhormonal antineoplastic
96402 ■ Hormonal antineoplastic
96409 Chemotherapy administration, intravenous; push
technique, single or initial substance/drug
96413 ■ Intravenous infusion technique, up to 1 hour,
single or initial substance/drug
96415 ■ Intravenous infusion technique, 1 to 8 hours,
(list separately in addition to code for primary
procedure)
96420 Chemotherapy administration, intra-arterial push
technique
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96422 ■ Infusion technique, up to 1 hour
96423 ■ Infusion technique, each additional hour up
to 8 hours, each additional (list separately
in addition to code for primary procedure)
96521 Refilling and maintenance of portable pump
96522 Refilling and maintenance of implantable pump
or reservoir for drug delivery, systemic (e.g.,
intravenous, intra-arterial)
Moderate Sedation (Conscious)

Moderate (conscious) sedation is a drug-induced depression of
consciousness during which patients respond purposefully to
verbal commands, either alone or accompanied by light tactile
stimulation. No interventions are required to maintain a patent
airway, and spontaneous ventilation is adequate. Cardiovascular
function is usually maintained.
Important Facts
■ Pre- and postsedation evaluations are included in these codes
and cannot be billed for separately
■ Does not include maximum allowable concentration (MAC)
anesthesia or minimal or deep sedation
The following services cannot be billed for separately:
■ Assessment of the patient
■ Establishment of IV access and fluids to maintain patency,
when performed
■ Administration of agent(s)
■ Maintenance of sedation
■ Monitoring of oxygen saturation, heart rate, and blood
pressure
■ Recovery (not included in intra-service time)
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99143 Moderate sedation services (other than 00100–
01999), provided by the same physician
performing the diagnostic or therapeutic serv-
ice that the sedation support, requiring the
presence of an independent trained observer
to assist in the monitoring of the patient’s level
of consciousness and physiological status;
under 5 years of age, first 30 minutes intra-
service time.
99144 ■ Age 5 years or older, first 30 minutes intra-
service time
99145 ■ Each additional 15 minutes intra-service time
service)
99148 Moderate sedation services (other than 00100–
01999), provided by the physician other than the
health-care professional performing the
diagnostic or therapeutic service that the
sedation supports; under 5 years of age, first 30
minutes intra-service time
99149 ■ Age 5 years or older, first 30 minutes intra-
service time
99150 ■ Each additional 15 minutes intra-service time
service)

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(ICD-9-CM)
The International Classification of Diseases, 9th edition, Clinical
Modifications (ICD-9-CM) is the coding system used to report the
diagnosis or condition of the patient. This system takes a descrip-
tion of the patient’s condition, illness, or injury and translates it
into numerical and alphanumerical format. The ICD-9-CM manual
is published in the Spring and Fall of each year. To ensure that
the codes billed are accurate, it is necessary to purchase a new
manual each year. These codes provide the medical necessity for
the service or procedure that was performed.
Dx Codes ⴝ Medical Necessity ⴝ Reimbursement
Three Volumes of ICD-9-CM

Volume 1 This volume consists of the most specific informa-
tion about the conditions, diseases, and injuries
Volume 2 This volume contains an alphabetic listing of
Volume 1
Volume 3 This volume contains information that is reserved
for hospital use
Volume One
A listing of the chapters found in Volume of the ICD-9-CM

manual can be found in the following:
Chapter Title Diagnosis Codes
1 Infectious and Parasitic Diseases Codes 001–139
2 Neoplasms Codes 140–239
3 Endocrine, Nutritional and Metabolic Codes 240–279
Diseases, and Immunity Disorders
4 Diseases of the Blood and Blood- Codes 280–289
Forming Organs
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Chapter Title Diagnosis Codes

5 Mental Disorders Codes 290–319
6 Diseases of the Nervous System Codes 320–389
and Sense Organs
7 Disease of the Circulatory System Codes 390–459
8 Diseases of the Respiratory System Codes 460–519
9 Diseases of the Digestive System Codes 520–579
10 Diseases of the Genitourinary Codes 580–629
System
11 Complications of Pregnancy, Child- Codes 630–677
birth, and the Puerperium (the
period of confinement after labor)
12 Diseases of the Skin and Codes 680–709
Subcutaneous Tissue
13 Diseases of the Musculoskeletal Codes 710–739
System and Connective Tissue
14 Congenital Anomalies Codes 740–759
15 Certain Conditions Originating in Codes 760–779
the Perinatal Period (period
shortly before and after birth)
16 Symptoms, Signs, and Ill-Defined Codes 780–799
Conditions
17 Injury and Poisoning Codes 800–999
Supplemental Chapters Diagnosis Codes

V Codes: Supplemental Classification of Codes V01–V83
Factors of Influencing Health Status and
Contact with Health Services
E Codes: Supplemental Classification of Codes E800–E999
External Causes of Injury and Poisoning
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165
Appendices Title
A Morphology of Neoplasms (M Codes)
B Glossary of Mental Disorders
C Classification of Drugs by American Hospital
Formulary Service List Number and Their ICD-9-
CM Equivalents
D Classification of Industrial Accidents According to
Agency
E Three-Digit Categories
Volume Two
Three Sections
1 Index to Diseases and Injuries
2 Table of Drugs and Chemicals
3 Alphabetic Index to External Causes of Injuries and Poisonings
Easy Diagnosis Coding

Steps Rules
1 Determine the main term that best describes the condi-
tion or symptom of the patient
2 Use Volume 2 of the ICD-9-CM book to look up that main
term; this Volume is alphabetized
3 Read any cross-references such as “see also” and go to
that category
4 Read all subterms and explanations; refer to indented
terms under the main term to obtain further clarification
5 Check the code listed in Volume 2 against the tabular
listing in Volume 1
6 Review all instructions and notes in Volume 1 to be sure
the code selected is accurate
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Coding Conventions
Convention Definition/Example
Typeface Bold type indicates main terms and codes in
Volume 1.
EXAMPLE: CONVULSIONS
Brain 780.39
Febrile 780.31
Italicized type This type indicates categories that cannot be
reported as a primary diagnosis code. This
type is also used for identification of
exclusion notes.
Example: 250 Diabetes Mellitus
Excludes gestational diabetes (648.8)
[Bracketed] These are used to enclose synonyms, alterna-
tive terminology, or explanatory phrases.
Example: 482.2 Pneumonia due to Hemophilus
influenza [H. influenza]
(Parentheses) These are used to enclose supplementary
words that may be present in the
description.
Example: 198.4 Other parts of nervous system
Meninges (cerebral) (spinal)
Colons: These are used in the tabular listing after an
incomplete term that needs a modifier to
make it assignable.
Example: 021.1 Enteric tularemia
Tuleremia: cryptogenic intestinal
Braces These enclose a series of terms, each of which
is modified by the statement appearing to
the right of the brace.
Example: 560.2 Volvulus
Knotting
Strangulation
Torsion
Twist } of intestine,
bowel or colon
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ICD-10
The following list contains changes that exist between the 9th
revision of the ICD code book (ICD-9-CM) and the 10th revision.
Volume I is a tabular listing that contains alphanumeric codes.
Volume II is an instructional manual, which provides rules and
regulations for mortality and morbidity coding. Volume III is the
alphabetic index, which provides the index to all the codes listed
in Volume I. The ICD-10 contains more descriptions.
ICD-9-CM ICD-10
Old Title: International Classifi- New Title: International Statis-
cation of Diseases, 9th Revi- tical Classification of Diseases
sion, Clinical Modifications and Related Health Problems
Contains a chapter titled Splits out the chapter to the
Diseases of the Nervous following chapters:
System and Sense Organs ■ Diseases of the Nervous
System
■ Diseases of the Eye and
Adnexa
■ Diseases of the Ear and
Mastoid Process
Contains a chapter titled Renames this chapter Mental and
Mental Disorders Behavioral Disorders
Supplement: Classification of Becomes a chapter and is no
Factors Influencing Health longer considered a supple-
Status and Contact with ment to the code book
Health Services (V codes)
Supplement: Classification of Becomes a chapter and is no
External Causes of Injury longer considered a supple-
and Poisoning (E codes) ment to the code book
Contains codes that require Contains codes that require
4 and 5 digits more than 5 digits
Many other changes were made to the descriptions found throughout
the book. This book was published in 1994 and is currently used in Europe.
It is expected to be implemented in the United States in the year 2007.
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V Codes
V codes describe circumstances surrounding a patient’s health
status and identify reasons for medical treatment other than for
a disease process or injury.
Three Categories of V Codes
1 Problem-Oriented
2 Service-Oriented
3 Fact-Oriented
V codes can be used as primary codes in certain instances. For
examples, see the following table:
Scenario Code
Patient presents for removal of cast V54.8
Patient presents for preoperative clearance V72.8
Patient presents for chemotherapy V58.1
Problem-Oriented
A problem-oriented V code identifies a factor that may affect

the patient, but that is not an injury or an illness. Examples of
problem-oriented V codes are:
■ V76.11: Special screening mammogram for high-risk patients
■ V46.13: Encounter for weaning from a respirator
Service-Oriented
A service-oriented V code identifies that a service was an exami-

nation, therapy, ancillary service, or aftercare. It will identify a
patient that is not currently sick, but who is looking for medical
services for another reason. Examples of service-oriented V
codes are:
■ V67.2: Follow-up examination following cancer chemotherapy
■ V58.32: Removal of sutures
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Fact-Oriented
A fact oriented V code simply states a fact. Examples of fact-

oriented V codes are:
■ V27.2: Outcome of delivery; twins, both live born
■ V02.6: Viral hepatitis
E Codes
E codes are used to establish medical necessity, identify causes
of injury and poisoning, and identify medications.
1 Can never be primary codes
2 Do not affect the amount of reimbursement
3 Can speed up the reimbursement process by providing
additional information to the insurance payor
4 Child abuse takes precedent over all other E codes
5 Cataclysmic events take priority over all other E codes
except for abuse
6 Transportation accidents take priority over all other E
codes except cataclysmic events and abuse
Examples of E codes are:
■ E884.0: Fall from playground equipment
■ E917.0: Struck accidentally by object or persons in sports
■ E901.0: Excessive cold
Late Effect Codes

Two Types of Late Effects Codes
■ General
■ Injury-related
Late effect codes should be the primary diagnosis when it is
the primary reason for the visit. To use late effect codes, code
first the condition of the late effect and code the late effect
code second.
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For example:
■ 012.22: Isolated tracheal tuberculosis, bacterial examination
unknown
■ 137.0: Late effects of respiratory tuberculosis
General Late Effect Codes
These codes describe a residual condition produced after the

acute phase of an illness (usually 1 year or more). Examples of
these codes are:
■ 137.0: Late effects of tuberculosis
■ 438._: Late effects of cerebrovascular accident
Late Effects of Injuries, Poisonings, Toxic Effects,

and Other External Causes
These codes can be used to indicate a cause of “late effect” in

which the cause is classified elsewhere. These late effect codes
can be used at any time after the acute injury. Examples of these
codes are:
■ 906.3: Late effect of contusion
■ 908.0: Late effect of internal injury to chest
Examples of Late Effects With the Cause
Cause Late Effect
Fracture Malunion
Cardiovascular accident Hemiplegia
Third-degree burn Deep scarring
Polio Contractures
Laceration Keloids
Breast implants Ruptured implant
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Truncated Diagnosis Code
A truncated diagnosis code is one that has not reported with the
required 4th or 5th digit.
There are fewer than 100 codes that are three-digit codes, all
others require additional digits for billing. It is the responsibility
of the provider to assign the diagnosis codes.
Example: Abdominal Pain 789.0_ (requires a 5th digit)
0 Unspecified site
1 Right upper quadrant
2 Left upper quadrant
3 Right lower quadrant
4 Left lower quadrant
5 Periumbilical
6 Epigastric
7 Generalized
8 Other specified site
Multiple Diagnosis Codes

■ All diagnosis codes must be prioritized in order of significance
and linked to the appropriate procedure or service.
■ When coding both surgical and medical problems on the same
patient, list the surgical problem first. When the severity of the
medical problem supersedes the importance of the surgical
problem, the medical problem is then listed first.
■ A maximum of four diagnosis codes can be submitted per
claim.
Nonspecific/Unspecified Codes
Codes that are referred to as nonspecific or unspecified are
not the most specific codes possible for the reporting of the
diagnosis or condition of the patient. In Volume 1, these
codes are listed as
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NOS (not otherwise specified) and in Volume 2, they are listed as

NEC (not elsewhere classified).
An example of these codes would be:
■ 420.90: Acute pericarditis, unspecified NOS
■ 682.9: Cellulitis, NOS
■ 599.0: Infection, genitourinary tract NEC
Signs and Symptom Codes

When a definitive diagnosis code is not available, use a sign or
symptom code.
Example: Suspected pneumonia, but not sure until x-ray. Diag-
noses used for this visit would be the symptoms of the patient.
■ Wheeze
■ Shortness of breath
■ Cough
Example: Possible fracture of wrist, but not sure until x-ray. Diag-
noses used for this visit would be the symptoms of the patient.
■ Swelling
■ Pain in wrist
ICD-9-CM Guidelines for Coding and Reporting

■ Identify each service, procedure, or supply with a diagnosis
code
■ Chronic diseases should be reported if appropriate
■ Always use the code with the highest degree of specificity;
add 4th and 5th digits when appropriate
■ Properly link all diagnosis codes to the CPT code
■ Do not code using “rule-out,” “suspected,” “probable,”
“questionable,” etc.
■ Use signs and symptoms when a definitive diagnosis code is
not available
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173
■ Code the primary diagnosis code first, followed by the
secondary, tertiary, and so on
■ Do not code a diagnosis code that is no longer applicable
■ For surgical procedures, code the diagnosis applicable to the
procedure; if at the time the claim is filed the postoperative
diagnosis is different from the preoperative diagnosis, use the
postoperative diagnosis for billing
Principal Versus Primary Diagnosis Code

■ Principal diagnosis: reported on inpatient hospital claims
(facility, Part A Medicare); reported on UB-92 forms; the princi-
pal diagnosis is the condition determined after the study that
resulted in the patient’s admission to the hospital
■ Primary diagnosis: reported by the physician (professional,
Part B Medicare); reported on HCFA 1500 claim forms; the
primary diagnosis is the most significant condition for which
services and/or procedures were provided
Hypertension/Hypertensive Table
The hypertension table is a complete listing of hypertension
codes and conditions associated with hypertension. The table
consists of three columns:
1. Malignant
2. Benign
3. Unspecified
Malignant hypertension is a form with vascular damage and
a diastolic blood pressure reading of 130mm HG or greater.
Benign is a form of mild or controlled hypertension with no
damage to the patient’s vascular system or organs.
Unspecified hypertension is where there is no notation of
benign or malignant status found in the patient’s medical
record.
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Neoplasm Table
Neoplasms are new growths in which cell reproduction is out of
control. It is important to know whether the tumor is malignant
or benign. Malignant is when the growth is cancerous, invasive,
or capable of spreading to other parts of the body. Benign is
when the growth is noncancerous, nonmalignant, noninvasive.
The Neoplasm Table is arranged by anatomical site and contains
four classifications:
Type of Neoplasm Description
Malignant
■ Primary ■ Primary malignant growth is the original
tumor site. All malignant tumors are
considered primary unless otherwise
noted as metastatic or secondary.
■ Secondary ■ Secondary malignant growth is where
the tumor has metastasized (spread) to a
secondary site, either adjacent to the
primary site or to a remote region of the
body.
■ Ca in Situ ■ Ca in Situ is a malignant tumor that is
localized, circumscribed, encapsulated,
and noninvasive (has not spread to other
tissues or organs).
Benign ■ A benign growth is a noninvasive,
nonspreading, nonmalignant tumor.
Uncertain ■ Uncertain behavior is a type of growth
behavior in which it is not possible to predict
subsequent morphology or behavior from
the submitted specimen. In order to
assign a code from this column, the
pathology report must specifically indicate
the “uncertain behavior” of the neoplasm.
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Type of Neoplasm Description
Unspecified nature ■ Unspecified nature is a type of
growth in which a neoplasm is identi-
fied, but there is no further indication
of the histology or nature of the tumor
reflected in the documented diagnosis.
Assign a code from this column when
the neoplasm was destroyed or
removed and a tissue biopsy was
performed and results are pending.
Hint: If the statement does not classify the neoplasm, refer to the Index
to Diseases entry for the condition documented instead of the table. That
entry will contain a code that can be cross-checked in the table.
Primary Malignancies
Primary malignancies are coded if the note in the medical record

states:
■ Metastatic from a site
■ Spread from a site
■ Primary neoplasm of a site
■ A malignancy for which no specific classification is
documented
■ A recurrent tumor
Example: Carcinoma of the cervical lymph nodes, Metastatic
from the breast.
Primary: breast
Secondary: cervical lymph nodes
Secondary Malignancies
Secondary malignancies are Metastatic and indicate that a

primary cancer spread to another part of the body.
Example: Metastatic carcinoma from breast to lung
Assign two codes:
1. Primary malignant neoplasm of the breast: 174.9
2. Secondary neoplasm of the lung: 197.0
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The following table lists secondary sites for malignancies:
1 Bone
2 Brain
3 Diaphragm
4 Heart
5 Liver
6 Lymph Nodes
7 Mediastinum
8 Meninges
9 Peritoneum
10 Pleura
11 Retroperitoneum
12 Spinal Cord
Re-excision
A re-excision is when a pathologist recommends that the

surgeon perform a second excision to widen the margins of the
original tumor site. The pathology report may not specify a
malignancy at this time, but the patient is still under treatment
for the original neoplasm.
M Codes
M codes are morphology of neoplasm codes. They are used to
report the type of neoplasm. They are used by the hospital to
report neoplasms to the cancer registry.
An example of these codes would be:
■ M8041/3: Small cell carcinoma NOS
■ M8000/0: Neoplasm, benign
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Table of Drugs and Chemicals
The table of drugs and chemicals lists drugs and chemicals that
have caused a poisoning or adverse effect. It is divided into six
external cause codes:
External Cause Description Codes
1 Poisoning These codes are assigned 960–989
according to the classifica-
tion of the drug or chemical
involved in the poisoning
2 Accident These codes are used for acci- E850–E869
dental overdoing, wrong
substance given or taken,
drug inadvertently taken, or
accidents in the use of drugs
and chemical substances
during a medical or surgical
procedure
3 Therapeutic These codes are used for the E930–E952
use external effect caused by
correct substance properly
administered in therapeutic
or prophylactic dosages
4 Suicide These codes are used to report E950–E952
attempt self-inflicted poisonings
5 Assault These codes represent a E961–E962
poisoning inflicted by
another person who
intended to kill or injure the
patient
6 Undetermined These codes are used if the E980–E982
record does not state
whether the poisoning was
intentional or accidental
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Fracture Coding
When coding fractures, if the note does not state whether or not
the fracture is open or closed, assume that it is closed and code
it appropriately. When dealing with multiple injuries, list them in
descending order of severity.
Types of Fractures
Types of Closed
Fractures Description
Comminuted Has more than two fragments of bone that
are broken off; it is unstable and contains
many bone fragments and tissue damage
Linear The fracture runs along the length of the bone
Spiral The bone is broken as a result of a twisting
motion and is sometimes confused with an
oblique fracture
Depressed Skull fracture with the bone forced inward
Simple Fracture does not break the skin and
has little, if any tissue damage
Impact/ The vertebral column is compressed and then
Compression breaks under the pressure
Complex Fracture that severely damages the soft tissue
around the fracture site
Stress A fracture caused by repeated stress to the
bone
Double Multiple fractures of the same bone occurring
at the same time
Greenstick Bendlike fracture found mostly on children;
the bone is not broken through.
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Types of Fractures (Continued)
Types of Closed
Fractures Description
Impacted The bones are broken and the ends are
smashed together in a head-on fashion
Fragmented A fracture where the trauma leaves many
broken bones inside the patient
Oblique Fracture forms an oblique break in the bone;
very rare
Fissure Also known as a hairline fracture; minimal
trauma to the bone and tissues; it is an
incomplete fracture, as it is not all the way
through the bone
Closed There is a fracture with no broken skin
Infected A fracture where the area has become infected
Compound/Open A fracture that breaks the skin
Pathological Fracture is caused by some type of disease
process
Miscellaneous Commonly Used Codes

Codes Description
278.02 Overweight
305.1 Tobacco use disorder
333.94 Restless leg syndrome (RLS)
338.1 Acute pain
338.2 Chronic pain
519.11 Acute bronchospasm
528.3 Cellulitis and abscess
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Miscellaneous Commonly Used Codes (Cont’d)

Codes Description
649.5 Spotting complicating pregnancy
784.91 Postnasal drip
781.2 Abnormality of gait
783.2 Abnormal loss of weight and
underweight
795.81 Elevated CEA (carcinoembryonic antigen)
V58.32 Encounter for removal of sutures
V72.11 Encounter for hearing examination
following failed hearing screening
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Modifiers
Modifiers are two- to five-digit numeric or alphanumeric
characters that can be reported with CPT codes. They provide
additional information regarding the code to which they are
attached. These codes indicate that the CPT code has been
altered in some way, but the basic code is the same.
When to use a modifier:
1. When only part of a service or procedure is performed
2. When a service or procedure has been reduced
3. When a service or procedure has been increased
4. When unusual circumstances surround the service or
procedure
5. The service or procedure was performed multiple times
6. The procedure was bilateral
7. The procedure can be reported either as a technical or
professional service
8. When an adjunctive service was performed
9. When the service or procedure was performed by more than
one physician
10. When the service or procedure was performed in more than
one location
11. For anesthesia: when the physical status of the patient needs
to be reported for the administration of anesthesia
Some modifiers are informational only and do not affect
reimbursement of the claim.These informational modifiers can
affect whether or not the claim will be paid or denied. Others,
however, can affect reimbursement.
Types of Modifiers
Abbreviation Modifier Use With: Code Range

E Evaluation and Management Codes 99201–99499
A Anesthesia Codes 00100–01999
S Surgery Codes 10021–69990
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Abbreviation Modifier Use With: Code Range

R Radiology Codes 70010–79999
P Pathology & Laboratory Codes 80048–89356
M Medicine Codes 90281–99602
Evaluation and Management (E&M)

Code Modifiers
The modifiers used with E&M codes are ⫺21, ⫺24, ⫺25, ⫺32,
⫺52, ⫺57.
Effect on Accepted by
Modifier ⫺21 Description Payment Medicare
Prolonged E&M No effect Yes
Service
Explanation
This modifier is used to identify face-to-face time with a patient
that is prolonged or greater than normal. Can only be used on
the highest level of E&M service within each category. CPT
codes that can be used with the ⫺21 modifier are 99205, 99215,
99220, 99223, 99233, 99236, 99381–99387, and 99391–99397.
Unrelated E&M Failure to use Yes
service by same modifier
physician during may cause
the postop period claim denials
Explanation
It may be necessary to indicate that the E&M service performed
during a postoperative period was not related to the procedure
performed. CPT codes that can be used with the ⫺24 modifier
are 99201–99499 and 92002–92014.
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Significant sepa- Failure to use Yes
rately identifiable modifier
E&M service by may cause
the same physi- claim denials
cian on the same
day of procedure
Explanation
It may be necessary to perform a separate service, above and
beyond the procedure performed. Should also be used with
Preventive Medicine services when patient also presents with a
complaint that requires further treatment or testing. CPT codes
that can be used with the ⫺25 modifier are 92002–92014 and
99201–99499.
Mandated service No effect Yes
Explanation
It may be necessary to provide an E&M service at the request of
a third-party carrier, government, or peer review organization.
Use this modifier to identify mandated consultations. Commonly
used with Workers’ Compensation cases. CPT codes that can be
used with the ⫺32 modifier are 99201–99499, 00100–01999,
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Reduced service Yes Yes
Explanation
It may be necessary to report a reduced E&M service, when a
complete service is not performed. This is not commonly used
with E&M services, however, can be used with Preventive
Medicine services. CPT codes that can be used with the ⫺52
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modifier are 99201–99499, 00100–01999, 10040–69979, 70010–

79999, 80049–89399, and 90700–99199. Codes 99201–99499
cannot use this modifier on Medicare claims.
Decision for surgery Yes Yes
Explanation
It may be necessary to report an E&M service that resulted in a
decision to perform surgery. This service would be performed
the day prior to and/or day of the surgery. CPT codes that can be
used with the ⫺57 modifier are 92002–92014 and 99201–99499.
Anesthesia Modifiers
The modifiers used with anesthesia codes are ⫺22, ⫺23, ⫺32,
⫺47, ⫺51, ⫺53, ⫺59.
Unusual proce- Yes Yes
dural service
Explanation
It may be necessary to report a procedure that is greater than
that normally required. Overuse of this modifier may trigger an
audit. Appropriate documentation must accompany the claim to
establish the medical necessity for the unusual service. CPT
codes that can be used with the modifier ⫺22 are 00100–01999,
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Unusual anesthesia Yes Yes
*Current Procedural Terminology © 2006 American Medical Associa-
tion, All Rights Reserved.
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185
Explanation
It may be necessary to report a procedure that usually requires
no anesthesia or local anesthesia, or requires general anes-
thesia. This modifier is used only by anesthesia. CPT codes
that can be used with the modifier ⫺23 are 00100–01999.
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Anesthesia by surgeon No effect No
Explanation
Is used when regional or general anesthesia is provided by the
surgeon without an anesthesiologist or CRNA involvement. Does
not include local anesthesia.
Multiple procedures Yes Yes
Explanation
Is used when multiple procedures, other than E&M services,
are performed at the same session by the same provider. The
additional procedure is identified by the addition of the ⫺51
modifier. This modifier is not used for the billing of trigger point
injections. CPT codes that can be used with the ⫺51 modifier are
00100–01999, 10040–69979, 70010–79999, and 90700–99198.
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Discontinued Yes Yes
procedure
Explanation
Is used when procedures are terminated after they are started,
or after anesthesia is started due to extenuating circumstances
or a threat to the patient’s health. Cannot be used for elective
cancellation of a procedure. CPT codes that can be used with the
⫺53 modifier are 00100–01999, 10040–69979, 70010–79999,
80049–89399, and 90700–99199.
Distinct procedural Yes Yes
service
Explanation
Is used when procedures not usually performed together are
performed, are distinct, and medically necessary. CPT codes
that can be used with the ⫺59 modifier are 00100–01999,
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Surgery Modifiers
The modifiers used with surgery codes are ⫺22, ⫺26,⫺32, ⫺47,
⫺50, ⫺51, ⫺52, ⫺53, ⫺54, ⫺55, ⫺56, ⫺58, ⫺59, ⫺62, ⫺66, ⫺76,
⫺77, ⫺78, ⫺79, ⫺80, ⫺81, ⫺82, ⫺99.
Unusual procedural Yes Yes
service
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187
Explanation
audit. Appropriate documentation must accompany the claim
to establish the medical necessity for the unusual service. CPT
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Professional Yes Yes
component
Explanation
It may be necessary to report only a physician’s interpretation of
a test. CPT codes that can be used with the modifier ⫺26 are
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Explanation
It may be necessary to provide an E&M service at the request
of a third-party carrier, government, or peer review organization.
used with Workers’ Compensation cases. CPT codes that can
be used with the ⫺32 modifier are 99201–99499, 00100–01999,
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Anesthesia by surgeon No effect Yes
Explanation
Is used when regional or general anesthesia is provided by the
surgeon without an anesthesiologist or CRNA involvement. Does
not include local anesthesia.

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Bilateral procedure Yes Yes
Explanation
It is used to report bilateral procedures performed at the same
operative session. Add the ⫺50 modifier to the second proce-
dure. Do not use with codes that are performed bilaterally. CPT
codes that can be used with the ⫺50 modifier are 10040–69979,
70010–79999, and 90281–99199.
Explanation
00100–01999, 10040–69979, 70010–79999, and 90700–99198.
Explanation
It may be necessary to report a reduced E&M service when
a complete service is not performed. This is not commonly
used with E&M services, however, can be used with Preven-
tive Medicine services. CPT codes that can be used with the
⫺52 modifier are 99201–99499, 00100–01999, 10040–69979,
70010–79999, 80049–89399, and 90700–99199. Codes
99201–99499 cannot use this modifier on Medicare claims.

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189
procedure
Explanation
Is used when procedures are terminated after they are started, or
after anesthesia is started due to extenuating circumstances or a
threat to the patient’s health. Cannot be used for elective cancel-
lation of a procedure. CPT codes that can be used with the ⫺53
modifier are 00100–01999, 10040–69979, 70010–79999, 80049–
89399, and 90700–99199.
Surgical care only Yes Yes
Explanation
It is used to report a procedure when a surgeon performs the
procedure, but another physician performs the postoperative
care. CPT codes that can be used with the ⫺54 modifier are
10040–69990 and 90281–99199.
Postoperative Yes Yes
care only
Explanation
It is used to report a procedure when a physician performs the
postoperative care only and another surgeon performs the
procedure. CPT codes that can be used with the ⫺55 modifier
are 10040–69990 and 90281–99199.
Preoperaative Yes No
care only
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Explanation
It is used to report when one physician performs the preoper-
ative care and the other physician performs the procedure. CPT
codes that can be used with the ⫺56 modifier are 10040–69979.
Staged or related proce- Yes Yes
dure or service by
same physician during
the postoperative period
Explanation
It is used to report when the same physician performs a staged
or related procedure during the postoperative period. CPT codes
70010–79999, and 90281–99199.
service
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Two surgeons Yes Yes
Explanation
Is used when two surgeons work together as primary surgeons
if the procedure is so complex that it requires two surgeons to
manage. Each surgeon is of a different specialty. CPT codes that
can be used with the ⫺62 modifier are 10040–69979,
70010–79999, 90281–99199.
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191
Surg team Yes Yes
Explanation
Is used when procedures that are extremely complex are
performed under a surgical team concept. CPT codes that can be
used with the ⫺66 modifier are 10040–69979 and 70010–79999.
Repeat procedure Yes Yes
by same physician
Explanation
Is used when the same physician repeats the exact same service.
CPT codes that can be used with the ⫺76 modifier are 10040–
69979, 70010–79999, and 90281–99199.
Repeat procedure by Yes Yes
another physician
Explanation
Is used when a procedure is repeated by a different physician, at
a separate time on the same day. CPT codes that can be used
with the ⫺77 modifier are 10040–69979, 70010–79999 and
90281–99199.
Return to operating Yes Yes
room for related
procedure during
the postoperative
period
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Explanation
Is used when a patient needs to return to the operating room to
treat complications of the original surgery. CPT codes that can be
used with the ⫺78 modifier are 10040–69979, 70010–79999, and
90281–99199.
Unrelated procedure Yes Yes
or service by the
same physician
during the postop-
erative period
Explanation
Is used when an unrelated procedure is performed by the same
physician during the postoperative period of the original
are 10040–69979, 70010–79999, and 90281–99199.
Assistant surgeon Yes Yes
Explanation
Is used to identify the services of an assistant surgeon necessary
for a procedure. CPT codes that can be used with the ⫺80
modifier are 10040–69979, 70010–79999, and 90281–99199.
Minimum assistant Yes Yes
surgeon
Explanation
Is used when the services of additional surgeons (second or
third assistant) are required for a procedure. CPT codes that can
and 90281–99199.

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193
Assistant surgeon, Yes Yes
when a qualified
resident is
unavailable
Explanation
Is used when a surgical assist is necessary for a procedure, but
there is no resident available. CPT codes that can be used with
the ⫺82 modifier are 10040–69979, 70010–79999, and 90281–
99199.
Multiple modifiers No effect Yes
Explanation
Is used to report that there are multiple modifiers being used for
this claim. CPT codes that can be used with the ⫺99 modifier are
10040–69979, 70010–79999, and 90281–99199.
Radiology Modifiers
The modifiers used with radiology codes are ⫺22, ⫺26,⫺32, ⫺50,
⫺51, ⫺52, ⫺53, ⫺58, ⫺59, ⫺62, ⫺76, ⫺77, ⫺78, ⫺79, ⫺80, ⫺99.
service
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
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Professional component Yes Yes
Explanation
It may be necessary to report only a physician’s interpretation
of a test. CPT codes that can be used with the modifier ⫺26 are
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Explanation
operative session. Add the ⫺50 modifier to the second pro-
cedure. Do not use with codes that are performed bilaterally.
CPT codes that can be used with the ⫺50 modifier are
10040–69979, 70010–79999, and 90281–99199.
Explanation

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195
00100–01999, 10040–69979, 70010–79999, and 90700–99198.
Explanation
It may be necessary to report a reduced E&M service, when a
modifier are 99201–99499, 00100–01999, 10040–69979, 70010–
79999, 80049–89399, and 90700–99199. Codes 99201–99499
cannot use this modifier on Medicare claims.
procedure
Explanation
or after anesthesia is started due to extenuating circumstances
cancellation of a procedure. CPT codes that can be used with
the ⫺53 modifier are 00100–01999, 10040–69979, 70010–79999,
80049–89399, and 90700–99199.
Staged or related pro- Yes Yes
cedure or service
by same physician
during the posto-
perative period
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Explanation
70010–79999, and 90281–99199.
service
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Two surgeons Yes Yes
Explanation
Is used when two surgeons work together as primary surgeons
if the procedure is so complex that it requires two surgeons to
manage. Each surgeon is of a different specialty. CPT codes that
70010–79999, 90281–99199.
by same physician
Explanation
Is used when the same physician repeats the exact same
service. CPT codes that can be used with the ⫺76 modifier
are 10040–69979, 70010–79999, and 90281–99199.

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Repeat procedure by Yes Yes
another physician
Explanation
Is used when a procedure is repeated by a different physician,
at a separate time on the same day. CPT codes that can be
and 90281–99199.
room for a related
procedure during
the postoperative
period
Explanation
treat complications of the original surgery. CPT codes that can
and 90281–99199.
or service by same
physician during the
postoperative period
Explanation
physician during the postoperative period of the original pro-
cedure. CPT codes that can be used with the ⫺79 modifier are
10040–69979, 70010–79999, and 90281–99199.
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Assistant surgeon Yes Yes
Explanation
Is used to identify the services of an assistant surgeon necessary
for a procedure. CPT codes that can be used with the ⫺80
modifier are 10040–69979, 70010–79999, and 90281–99199.
Explanation
10040–69979, 70010–79999, and 90281–99199.
Pathology and Laboratory Modifiers

The modifiers used with pathology and laboratory codes are
⫺22, ⫺26,⫺32, ⫺52, ⫺53, ⫺59, ⫺90, ⫺91.
service
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.

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199
Professional Yes Yes
component
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Explanation
It may be necessary to report a reduced E&M service when
a complete service is not performed. This is not commonly
used with E&M services, however, can be used with Preventive
modifier are 99201–99499, 00100–01999, 10040–69979,
70010–79999, 80049–89399, and 90700–99199. Codes

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Discontinued procedure Yes Yes
Explanation
Is used when procedures are terminated after they are started, or
after anesthesia is started due to extenuating circumstances, or
a threat to the patient’s health. Cannot be used for elective
⫺53 modifier are 00100–01999, 10040–69979, 70010–79999,
80049–89399, and 90700–99199.
service
Explanation
performed, are distinct, and medically necessary. CPT codes that
can be used with the ⫺59 modifier are 00100–01999, 10040–
69979, 70010–79999, 80049–89399, and 90700–99199.
Reference (outside) No effect No
laboratory
Explanation
Is used when laboratory tests are performed by a laboratory
other than the reporting physician. Any laboratory or pathology
CPT code could be used with the ⫺90 modifier.
Repeat clinical Yes Yes
diagnostic
laboratory test
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201
Explanation
Is used when laboratory tests are performed on specimens from
the same patient source more than one time on the same day.
This code is not used when a test is rerun to confirm results.
This modifier may be used on a patient who has diabetes and
requires multiple glucose tests on the same day. Failure to use
this modifier may result in claim denial as they may be viewed
as duplicate claims. Any laboratory or pathology CPT code could
be used with the ⫺91 modifier.
Medicine Modifiers
The modifiers used with pathology and laboratory codes are
⫺22, ⫺26,⫺32, ⫺50, ⫺51, ⫺52, ⫺53, ⫺55, ⫺56, ⫺58, ⫺59, ⫺76,
⫺77, ⫺78, ⫺79, ⫺99.
Unusual proce- Yes Yes
dural service
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Professional component Yes Yes
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.

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Explanation
used with Workers’ Compensation cases. CPT codes that can
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
Explanation
operative session. Add the ⫺50 modifier to the second
procedure. Do not use with codes that are performed bilaterally.
10040–69979, 70010–79999, and 90281–99199.
Explanation
00100–01999, 10040–69979, 70010–79999, and 90700–99198.
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203
Explanation
It may be necessary to report a reduced E&M service when a
modifier are 99201–99499, 00100–01999, 10040–69979,
70010–79999, 80049–89399, and 90700–99199. Codes
procedure
Explanation
or after anesthesia is started due to extenuating circumstances,
⫺53 modifier are 00100–01999, 10040–69979, 70010–79999,
80049–89399, and 90700–99199.
Postoperative Yes Yes
care only
Explanation
It is used to report a procedure when a physician performs the
postoperative care only and another surgeon performs the
are 10040–69990 and 90281–99199.
Preoperative Yes No
care only
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Explanation
It is used to report when one physician performs the preopera-
tive care and the other physician performs the procedure. CPT
codes that can be used with the ⫺56 modifier are 10040–69979.
Staged or related Yes Yes
procedure or service
by same physician
during the post-
operative period.
Explanation
70010–79999, and 90281–99199.
service
Explanation
10040–69979, 70010–79999, 80049–89399, and 90700–99199.
by same physician
Explanation
10040–69979, 70010–79999, and 90281–99199.
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205
by another
physician
Explanation
Is used when a procedure is repeated by a different physician
at a separate time on the same day. CPT codes that can be
and 90281–99199.
room for related
procedure during
Explanation
and 90281–99199.
or service by same
physician during the
Explanation
are 10040–69979, 70010–79999, and 90281–99199.
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Explanation
10040–69979, 70010–79999, and 90281–99199.
Ambulatory Service Centers (ASC)/

Hospital Outpatient Modifiers
The modifiers used in ASC billing are ⫺25, ⫺27, ⫺50, ⫺52, ⫺58,
⫺59, ⫺73, ⫺74, ⫺76, ⫺77, ⫺78, ⫺79, ⫺91.
Significant separately Yes, failure Yes
identifiable E&M to use modi-
service by the same fier may
physician on the same cause claim
day of procedure denials
Explanation
It may be necessary to perform a separate service, above and
beyond the procedure performed. Should also be used with
Preventive Medicine services when patient also presents with a
complaint that requires further treatment or testing. CPT codes
that can be used with the ⫺25 modifier are 92002–92014 and
99201–99499.
Multiple outpatient Yes Yes
hospital E&M ser-
vices on same date
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207
Explanation
This modifier is to be used for facility billing only. It is used to
report the utilization of hospital resources related to separate
and distinct E&M services performed in multiple outpatient
hospital settings on the same date.
Explanation
operative session. Add the ⫺50 modifier to the second proce-
dure. Do not use with codes that are performed bilaterally. CPT
codes that can be used with the ⫺50 modifier are 10040–69979,
70010–79999, and 90281–99199.
Explanation
It may be necessary to report a reduced E&M service when a
modifier are 99201–99499, 00100–01999, 10040–69979,
70010–79999, 80049–89399, and 90700–99199. Codes
Staged or related pro- Yes Yes
cedure or service
by same physician
during the post-
operative period
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Explanation
70010–79999, and 90281–99199.
Distinct procedural service Yes Yes
Explanation
can be used with the ⫺59 modifier are 00100–01999, 10040–69979,
70010–79999, 80049–89399, and 90700–99199.
Discontinued outpatient Yes Yes
hospital/ambulatory
surgery center (ASC)
prior to the adminis-
tration of anesthesia
Explanation
Is used when there are extenuating circumstances that may
threaten the well-being of the patient and cause the physician to
cancel or postpone the procedure. The cancellation of the proce-
dure must take place before the administration of anesthesia,
however, may take place after the administration of surgical
prep sedation.
Discontinued outpatient Yes Yes
hospital/ambulatory
surgery center (ASC)
after administration
of anesthesia
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209
Explanation
Is used when there are extenuating circumstances that may
threaten the well-being of the patient and cause the physician
to cancel or postpone the procedure after administration of
anesthesia.
by same physician
Explanation
10040–69979, 70010–79999, and 90281–99199.
by another physician
Explanation
Is used when a procedure is repeated by a different physician,
at a separate time on the same day. CPT codes that can be used
with the ⫺77 modifier are 10040–69979, 70010–79999, and
90281–99199.
room for a related pro-
cedure during the
Explanation
and 90281–99199.
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or service by the
same physician
during the post-
operative period
Explanation
are 10040–69979, 70010–79999, and 90281–99199.
Repeat clinical Yes Yes
diagnostic labo-
ratory test
Explanation
Is used when laboratory tests are performed on specimens from
the same patient source more than one time on the same day.
This code is not used when a test is rerun to confirm results. This
modifier may be used on a patient who has diabetes and
requires multiple glucose tests on the same day. Failure to use
this modifier may result in claim denial as they may be viewed
as duplicate claims. Any laboratory or pathology CPT code could
be used with the ⫺91 modifier.
Teaching Physician Modifiers

The following two modifiers are used in a teaching physician
setting when a resident is involved in the service. These
modifiers have no effect on payment and are only used to track
the medical education funds.
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211
Modifier ⫺GC Description Payment Medicare
The service has been No effect Yes
performed in part
by a resident under
the direction of a
teaching physician
Explanation
When a teaching physician’s services are billed using this
modifier, the physician is certifying that he/she was present for
the key portion of the services and was immediately available
during the other portions of the service.
Modifier ⫺GE Description Payment Medicare
The service has No effect Yes
been performed by
a resident without
the presence of a
teaching physician
Explanation
This modifier is used when services are provided under the
primary care exemption. The primary care exemption must
be obtained prior to following the guidelines for use of this
modifier. Once all criteria have been met, residents may pro-
vide services to patients without the presence of the teaching
physician.

MOD
HCPCS
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Important Numbers
Physician Name:
Home:
Cell:
Car:
Beeper:
Physician Name:
Home:
Cell:
Car:
Pager:
Physician Name:
Home:
Cell:
Car:
Pager:
Physician Name:
Home:
Cell:
Car:
Pager:
Physician Name:
Home:
Cell:
Car:
Pager:
Physician Name:
Home:
Cell:
Car:
Pager:
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213
Important Hospital Numbers:
Main Number:
Laboratory:
X-ray:
PT:
EKG/EEG:
Outpatient Scheduling:
Emergency room:
Admissions:
Billing office:
Medical records:
Medical staff office:
Office manager’s home number:
Office manager’s cell:
Other important numbers:
1.
2.
3.
4.
5.
6.
7
8.
9.
Frequently Called Offices
Dr.
Address:
Phone:
Fax:
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Dr.
Address:
Phone:
Fax:
Dr.
Address:
Phone:
Fax:
Dr.
Address:
Phone:
Fax:
Dr.
Address:
Phone:
Fax:

Code Place of Service
11 Doctor’s Office (O)
12 Patient’s Home (H)
21 Inpatient Hospital (IH)
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215
Code Place of Service
22 Outpatient Hospital (OH) (urgent care also)
23 Emergency Dept. Hospital (OH)
24 Ambulatory Surgery Center (ASC)
25 Birthing Center (OL)
26 Military Treatment Facility (OL)
31 Skilled Nursing Facility (SNF)
32 Nursing Facility (NF)
33 Custodial Care Facility (OL)
34 Hospice (OL)
35 Adult Living Care Facility
41 Ambulance – land
42 Ambulance – air, water
50 Federally Qualified Health Center (FQHC)
51 Inpatient Psychiatric Facility (OL)
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Care (CMHC)
54 Immediate Care Facility mentally retarded (STF)
55 Residential Substance Abuse Treatment Facility (RTC)
56 Psychiatric Residential Treatment Center (RTC)
60 Mass Immunization Center
61 Comprehensive Inpatient Rehab Facility (OL)
62 Comprehensive Outpatient Rehab Facility (CORF)(COR)
65 End-stage Renal Disease Treatment Facility (KDC)
71 State or Local Public Health Clinic (OL)
72 Rural Health Clinic (RHC)(OL)
81 Independent Laboratory (IL)
99 Other Unlisted Facility (OL)
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State Medicare Carriers

State Medicare Carrier
Alabama Blue Cross/Blue Shield of Alabama
PO Box 830139, Birmingham, AL 35283–0139
Phone: 205–988–2100 Fax: 205–981–4841
Alaska Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
Arizona Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
Arkansas Arkansas Blue Cross/Blue Shield, A Mutual
Insurance Company
601 Gaines St
Little Rock, AR 72201
Phone: 501–378–2000 Fax: 501–378–2804
California National Heritage Insurance Company
402 Otterson Drive
Chico, CA 95928
Phone: 530–896–7400 Fax: 530–896–7182
Colorado Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
Connecticut Trailblazer Health Enterprises, LLC
PO Box 660156
Dallas, TX 75266
Phone: 972–766–6900 Fax: 972–766–1765
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217
Delaware Trailblazer Health Enterprises, LLC
PO Box 660156
Dallas, TX 75266
Phone: 972–766–6900 Fax: 972–766–1765
District of Trailblazer Health Enterprises, LLC
Columbia PO Box 660156
Dallas, TX 75266
Phone: 972–766–6900 Fax: 972–766–1765
Florida Blue Cross/Blue Shield of Florida, Inc.
532 Riverside Ave
Jacksonville, FL 32202
Phone: 904–791–6111 Fax: 904–905–6020
Georgia Blue Cross/Blue Shield of Alabama
PO Box 830139, Birmingham, AL 35283–0139
Phone: 205–988–2100 Fax: 205–981–4841
Hawaii Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
Idaho Connecticut General Life Insurance
Company
Hartford, CT 06152
Phone: 615–782–4576 Fax: 615–244–6242
Illinois National Heritage Insurance Company
402 Otterson Drive
Chico, CA 95928
Phone: 530–896–7400 Fax: 530–896–7182
Indiana AdminaStar Federal, Inc.
8115 Knue Road
Indianapolis, IN 46250
Phone: 317–841–4400 Fax: 317–841–4691
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Iowa Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
Kansas Blue Cross/Blue Shield of Kansas, Inc.
1133 Topeka Ave
Topeka, KS 66629
Phone: 785–291–7000 Fax: 785–291–7098
Kentucky AdminaStar Federal, Inc.
8115 Knue Road
Indianapolis, IN 46250
Phone: 317–841–4400 Fax: 317–841–4691
Louisiana Arkansas Blue Cross/Blue Shield, A Mutual
Insurance Company
601 Gaines St
Phone: 501–378–2000 Fax 501–378–2804
Maine National Heritage Insurance Company
402 Otterson Drive
Chico, CA 95928
Phone: 530–896–7400 Fax: 530–896–7182
Maryland Trailblazer Health Enterprises, LLC
PO Box 660156
Dallas, TX 75266
Phone: 972–766–6900 Fax: 972–766–1765
Massachusetts National Heritage Insurance Company
402 Otterson Drive
Chico, CA 95928
Phone: 530–896–7400 Fax: 530–896–7182
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219
Michigan National Heritage Insurance Company
402 Otterson Drive
Chico, CA 95928
Phone: 530–896–7400 Fax: 530–896–7182
Minnesota Wisconsin Physicians Insurance Corporation
PO Box 8190
Madison, WI 53708
Phone: 608–221–4711 Fax: 608–223–3614
Mississippi Wisconsin Physicians Insurance Corporation
PO Box 8190
Madison, WI 53708
Phone: 608–221–4711 Fax: 608–223–3614
Missouri Blue Cross/Blue Shield of Kansas, Inc.
1133 Topeka Ave
Topeka, KS 66629
Phone: 785–291–7000 Fax: 785–291–7098
Montana Blue Cross/Blue Shield of Montana, Inc.
PO Box 4310, 340 N. Last Chance Gulch
Helena, MT 59604
Phone: 406–444–8350 Fax: 406–442–9968
Nebraska Blue Cross/Blue Shield of Kansas, Inc.
1133 Topeka Ave
Topeka, KS 66629
Phone: 785–291–7000 Fax: 785–291–7098
Nevada Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
New Hampshire National Heritage Insurance Company
402 Otterson Drive
Chico, CA 95928
Phone: 530–896–7400 Fax: 530–896–7182
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New Jersey Highmark, Inc
C/O HGS Administrators
PO Box 8900065
Camp Hill, PA 17089
Phone: 717–763–3151 Fax: 717–975–7045
New Mexico Arkansas Blue Cross/Blue Shield,
A Mutual Insurance Company
601 Gaines St
Phone: 501–378–2000 Fax: 501–378–2804
New York
Counties of Bronx, Empire Medicare Services
Columbia, PO Box 2280
Delaware,
Peekskill, NY 10566
Duchess,
Greene, Kings, Phone: 866–837–0241 Fax: 866–709–1905
Nassau, New York,
Orange, Putnam,
Richmond,
Rockland, Suffolk,
Sullivan, Ulster,
Westchester
Queens Group Health Incorporated
88 West End Avenue
New York, NY 10023
Phone: 212–721–1300 Fax: 212–721–0580
Other parts Healthnow New York, Inc.
of the state Upstate Medicare Division Operations
33 Lewis Road, PO Box 80
Binghampton, NY 13905
Phone: 716–887–6900 Fax: 607–779–6395
Medicare Carriers
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221
State Medicare CarrierQueens
North Carolina Connecticut General Life Insurance
Company
Hartford, CT 06152
Phone: 615–782–4576 Fax: 615–244–6242
North Dakota Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
Ohio Nationwide Mutual Insurance Company
PO Box 16788
Columbus, OH 43216
Phone: 614–249–7111 Fax: 614–249–3732
Oklahoma Arkansas Blue Cross/Blue Shield,
A Mutual Insurance Company
601 Gaines St
Phone: 501–378–2000 Fax: 501–378–2804
Oregon Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
Pennsylvania Highmark, Inc
C/O HGS Administrators
PO Box 8900065
Camp Hill, PA 17089
Phone: 717–763–3151 Fax: 717–975–7045
Rhode Island Blue Cross/Blue Shield of Rhode Island
444 Westminster Street
Providence, RI 02903
Phone: 401–459–1000 Fax: 401–459–1709
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South Carolina PGBA
17 Technology Circle
Columbia, SC
Phone: 803–735–1034 Fax: 803–935–0081
South Dakota Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
Tennessee Connecticut General Life Insurance
Company
Hartford, CT 06152
Phone: 615–782–4576 Fax: 615–244–6242
Texas Trailblazer Health Enterprises, LLC
PO Box 660156
Dallas, TX 75266
Phone: 972–766–6900 Fax: 972–766–1765
Utah Regence Blue Cross/Blue Shield of Utah
2890 E. Cottonwood Parkway
Salt Lake City, UT 84121
Phone: 801–333–2000 Fax: 801–333–6510
Vermont National Heritage Insurance Company
402 Otterson Drive
Chico, CA 95928
Phone: 530–896–7400 Fax: 530–896–7182
Virginia Trailblazer Health Enterprises, LLC
PO Box 660156
Dallas, TX 75266
Phone: 972–766–6900 Fax: 972–766–1765
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Washington Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
West Virginia Nationwide Mutual Insurance Company
PO Box 16788
Columbus, OH 43216
Phone: 614–249–7111 Fax: 614–249–3732
Wisconsin Wisconsin Physicians Insurance Corporation
PO Box 8190
Madison, WI 53708
Phone: 608–221–4711 Fax: 608–223–3614
Wyoming Noridian Mutual Insurance Company
4305 13th Ave SW
Fargo, ND 58103
Phone: 701–282–1100 Fax: 701–282–1002
Puerto Rico Triple-S, Inc
PO Box 71391
San Juan, PR 00936
Phone: 787–749–4080 Fax: 787–749–4092
Virgin Islands Triple-S, Inc
PO Box 71391
San Juan, PR 00936
Phone: 787–749–4080 Fax: 787–749–4092
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Websites
Organization/Association Website
Agency for Healthcare www.ahcpr.gov
Policy and Research
Center for Medicare and www.cms.gov
Medicaid Services
Code of Federal www.access.gpo.gov/nara/cfr
Regulations
Department of Health www.dhhs.gov
and Human Services
FDA Medical Bulletin www.fda.gov/medbull
Government Printing www.access.gpo.gov
Office
Joint Commission on www.jcaho.org
Accreditation of
Healthcare
Organizations
Local Carrier Info- www.cms.gov/regions/default.htm
Medicare
National Committee www.ncqa.org
for Quality Assurance
Office of Inspector www.hhs.gov/progorg/wrkpln/
General Workplan index.html
Office of Inspector www.dhhs.gov/progorg/oig
General Compli-
ance Plans
Social Security Online www.ssa.gov/SSA-Home.html
American Academy of www.aapcnatl.org
Professional Coders
American College of www.ache.org
Healthcare Executives
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225
Websites
Organization/Association Website
American Health www.ahima.org
Management Informa-
tion Association
Healthcare Financial www.hfma.org
Management
Association
Medical Group www.mgma.com
Management
Association
Center for Healthcare www.chim.org
Information
Management
Health Hippo Hippo.findlaw.com/hippol.html
Human Anatomy www.mnsu.edu/emuseum/biology/
humananatomy/index.shtml
Medical Abbreviations www.pharma-lexicon.com/
United States Units of Measure

Apothecaries’ Fluid Measure
60 minims ⫽ 1 fluid dram
8 fluid drams ⫽ 1 fluid ounce
16 fluid ounces ⫽ 1 pint
2 pints ⫽ 1 quart
4 quarts ⫽ 1 gallon
Avoirdupois Weight
27 11/32 grains ⫽ 1 dram
16 drams ⫽ 1 ounce
16 ounces ⫽ 1 pound
Troy Weight
24 grains ⫽ 1 pennyweight
20 pennyweights ⫽ 1 ounce
12 ounces ⫽ 1 pound
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Metric Units of Measure

Linear Measure
10 millimeters ⫽ 1 centimeter
10 centimeters ⫽ 1 decimeter
10 decimeters ⫽ 1 meter
Weight
10 milligrams ⫽ 1 centigram
10 centigrams ⫽ 1 decigram
10 decigrams ⫽ 1 gram
U.S. and Metric Equivalents

Linear Measure
U.S. Unit Metric Unit
1 inch ⫽ 2.54 centimeters
1 foot ⫽ 0.3048 meters
0.03937 inch ⫽ 1 millimeter
Liquid Measure
U.S. Unit Metric Unit
1 fluid ounce ⫽ 29.573 millimeters
1 quart ⫽ 0.94635 liter
1 gallon ⫽ 3.7854 liter
0.033814 fluid ounce ⫽ 1 milliliter
1.0567 quarts ⫽ 1 liter
0.26417 ⫽ 1 liter
Weights
U.S. Units Metric Unit
1 grain ⫽ 0.064799 gram
1 avoirdupois ounce ⫽ 28.350 grams
1 troy ounce ⫽ 31.103 grams
1 avoirdupois pound ⫽ 0.453359 kilogram
1 troy pound ⫽ 0.37324
15.432 grains ⫽ 1 gram
0.032151 troy ounce ⫽ 1 gram
2.2046 avoirdupois ⫽ 1 kilogram
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Index
A CC (Chief complaint), 65, 71

Abdomen, ultrasound examination of, Cellulitis and abscess, 179
129 Checks
ABN (Advance beneficiary notice), 53–54 personal, verification of, 33
Add-on codes, 141–142 returned, 33–34
Adults, treatment of burns in, 117 Chemotherapy, 160–161
Advance beneficiary notice (ABN), 53–54 Chief complaint (CC), 65, 71
Allergy and clinical immunology, 158–159 Children, treatment of burns in, 117
Ambulatory service centers (ASC)/hospi- Claim(s)
tal outpatient modifiers, 206–210 clean, 43
A-mode, in diagnostic ultrasound, 128 denial of, 31–32, 60
Anesthesia unpaid, 35, 36
conscious sedation, 107 Claims submission issues
facts, 103 explanation of benefits, 30
HCPCS modifiers, 105 problems with, 29
medically directed services, 105 Clean claim, 43
moderate (conscious) sedation, 105 Clinical brachytherapy, 132
modifiers, 184–186 Clinical treatment planning, 130–132
monitored care, 104 CMS 1500 form
physical status modifiers, 105–106 completion instructions, 13–22
Annual nursing facility assessment, 89 in Medicare, 52
Arthroscopy, surgical, 119 place of service codes, 22–29
Assistant surgeon, 106 Codes/coding. See also Specific topics
Audiologic function tests, 157 add-on, 141–142
conventions, 166
B E, 169
B scan, in diagnostic ultrasound, 128 easy diagnosis, 165
Bankruptcy, 40 late effect, 169–170
Benefits, explanation of, 30 M, 176
Benign growth, 174 miscellaneous commonly used,
Benign hypertension, 173 179–180
Bilateral surgeries, 107 nonspecific/unspecified, 171–172
Biofeedback, 152 place of service, 22–29, 214–215
Body areas examination, 72 principal vs. primary diagnosis, 173
Brachytherapy, clinical, 132 signs and symptoms, 172
Bronchospasm, acute, 179 V, 168–169
Burns, 116–117 Collections
abbreviations, 38–40
C bankruptcy, 40
Ca in Situ, 174 billing for relatives, 41
Carcinoembryonic antigen (CEA), overpayments, 41
elevated, 180 statute of limitations by state, 36–38
Cardiac catheterization, 156 Colonoscopy, 149
Cardiovascular services, 155–157 Computerized tomography (CT), 123
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Concurrent care, 101 patient visit, 12–13

Consultations SNOCAMP, 101–102
documenting, 102 SOAP, 100
inpatient, 83 Domiciliary care
outpatient, 82 established patient, 93
three Rs of, 102 new patients, 92
types of, 101 Drugs and chemicals table, 177
x-ray, 122
Continuing intensive care, 94 E
Cosurgeon, 106 E codes, 169
CPT (HCPCS Level I) Easy diagnosis coding, 165
codes, 41 Echocardiography, 156–157
CPT book sections, 42 Elective surgery notice, 113
symbols, 42 Electroencephalogram (EEG), 159
Critical care services Electrocardiogram, 156
billing codes examples, 97–98 Electromyography, 159
codes, 97 E&M services. See Evaluation and
conditions for providing, 97 Management (E&M) services
inpatient neonatal and pediatric, 99 Emergency(ies)
preoperative and postoperative, 108 after hours codes, 87
time spent for providing, 97 room services, 86
C-section, 118 X-rays, 122
Endocardiography, 157
D Endoscopy, surgical, 118
Denial of claims, 31–32, 60 End-stage renal disease (ESRD), 153
Diagnostic radiology, 127–128 EOB. See Explanation of benefits
Diagnostic ultrasound (EOB)
clinical brachytherapy, 132 ESRD. See End-stage renal disease
clinical treatment planning, 130 (ESRD)
hyperthermia, 132 Established patient(s)
proton beam definitions, 131 domiciliary care, 92, 93
radiation oncology, 129 home services, 91
terminology, 128–129 office, 7–8, 79
therapeutic radiology simulation defi- preventive medicine services, 95
nitions, 130–131 Evaluation and Management
Dialysis (E&M) services
end-stage renal disease (ESRD), 153 billing, 119
hemodialysis, 153 code modifiers, 182–184
miscellaneous procedures, 154 codes, 60, 61
training, 154 components of, 63
Discharge services examination in, 72–74
decision matrix for, 89 history in, 64–68
hospital discharge day, 82 list of services, 61–62
Documentation time in, 63–64
of consultations, 102 Examination, in E&M services
medical record, 62–63 body areas, 72
operative report, 109 1995 guidelines, 72
228
229
1997 guidelines, 73–74 Home services
organ systems, 73 established patient, 91
Explanation of benefits (EOB), 30 new patient, 90
External causes effects, 170, 177 Hospital observation or inpatient care,
84
F Hospital observation services, 85
Fact-oriented V code, 169 HPI (History of present illness), 65–68,
Financial hardship, patients with, 34 71
Foreign bodies removal, 115 Hypertension/hypertensive table, 173
Form(s) Hyperthermia, 132
CMS 1500 form, 13–22 Hyperventilation and/or phonic stimula-
frequently called offices, 213–214 tion, 159
important hospital numbers, 213 Hysterectomies, 119
important numbers, 212
patient encounter form, 3 I
patient registration form, 1–3 ICD-10, 167
Fracture(s) ICD-9-CM
coding, 117 about, 163
types of, 178–179 coding and reporting guidelines,
172–173
G surgical and postoperative codes,
Gait, abnormality of, 180 112
Gastroenterology three volumes, 163–165
important definitions, 149–151 vs. ICD-10, 167
surgical codes, 149 Immunization administration codes for
General late effect codes, 170 vaccines, 144
Global surgeries, 106–107 Incision and drainage, 114
Guarantor, 59 Infusions, diagnostic, 146
Initial hospital patients, 80
H Initial nursing facility, 87
HCPCS anesthesia services modifiers, Injections of immune globulins, 143–146
105 Injuries, late effects of, 170
Health Maintenance Organization Injury-related late effect codes, 169
(HMO), Medicaid plans and, 55–56 Inpatient pediatric critical care, 94
Hearing examination, 180 Inpatient(s). See also Outpatient(s)
Hemodialysis, 153 consultations, 83
History extension of days, Medicaid and, 56
chief complaint (CC), 65, 71 hospital observation, 84–85
in evaluation and management serv- neonatal critical care, 94, 99
ices, 64–68 pediatric critical care services, 94,
levels and types of, 64 99
past, family, social history, 69–71 prolonged care services, 96
of present illness, 65–68, 71 Insurance commissioner, 36
review of systems, 68–69, 71 Insurance form life cycle
summary, 71 established patient, office, 7–8
History of present illness (HPI), 65–68, new patient, office, 4–6
71 patient discharge, 8–11
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Integumentary system coding, 114–117 domiciliary care, 92, 93

International Classification of Diseases, emergency room services, 86
9th edition, Clinical Modifications established office patients, 79
(ICD-9-CM). See ICD-9-CM home services, 90, 91
Interventional radiology procedures, hospital observation or inpatient care,
132–133 84–85
initial hospital patients, 80
L inpatient consultation, 83
Laboratory inpatient neonatal critical care, 94
areas of, 134–136 inpatient pediatric critical care, 94
modifiers, 198–201 new office patients, 78
Late effect codes outpatient consultation, 82
of external causes, 170 preventive medicine services, 95
general, 170 prolonged care services, 96
types of, 169–170 subsequent hospital patients, 81
Locum tenens providers, 43 subsequent nursing facility, 88
Medical record documentation, 62–63
M Medically directed anesthesia services,
M codes, 176 105
Magnetic resonance imaging (MRI), 123 Medicare
Major Medical, 59 advance beneficiary notice (ABN),
Malignancies 53–54
primary, 175 billing summary, 52
secondary, 174–176 covered/noncovered services, 51
Malignant hypertension, 173 deductibles and co-pays, 46–47
Managed care emergency department x-rays, 122
dos and don’ts of working with, 45 fee schedule, 50
quick guide to, 46 medical supplies and equipment
summary of plans, 44–46 billing, 51
Medicaid MSP billing guide, 47–48
billing summary, 57 nonparticipating providers billing, 46
confirming eligibility, 55 nurse practitioner billing, 50
extension of inpatient days, 56 patient’s out-of pocket expenses,
nurse practitioner billing, 57 113–114
physician assistant billing, 56 physical medicine and, 147–148
preauthorization, 55–56 physician assistant billing, 48–49
services available, 54 review process, 52–53
Medical decision-making state carriers, 216–223
components of, 75 surgical tray, 108
four levels of, 75–76 Medicare secondary payor (MSP), 47
table of tasks, 76–77 billing guide, 47–48
Medical necessity physician assistance billing, 48–49
about, 77 Medicine modifiers, 201–206
after hour codes for emergencies, 87 Minimum (word), in billing, 129
annual nursing facility assessment, 89 Minor surgeries, 107
continuing intensive care, 94 M-mode, in diagnostic ultrasound, 128
discharge services, 82, 89 Modifiers
230
231
about, 181 Nurse practitioner (NP) billing
ambulatory service centers/hospital in Medicaid, 57
outpatient, 206–210 in Medicare, 50
anesthesia, 184–186
anesthesia services, HCPCS, 105 O
evaluation and management services Office patients
code, 182–184 established, 7–8, 79
with global surgery, 107 new, 4–6, 78
laboratory, 198–201 visit steps, 7–8
medicine, 201–206 Offices, frequently called, 213–214
pathology, 138–140, 198–201 Operative report
physical status, 103–104 components in coding from, 109–112
radiology, 125–129, 193–198 documenting, 109
surgery, 112, 186–193 surgical and postoperative codes,
teaching physician, 210–211 112–114
types of, 181–182 Ophthalmology, 151–152
MSP. See Medicare secondary payor Organ systems examination, 73
(MSP) Organization/association Web sites,
Multiple diagnosis codes, 171 224–225
Multiple procedure services, 143 Otorhinolaryngologic services, 154–155
Multiple surgeries, 108 Outpatient(s)
ambulatory service centers/hospital
N modifiers, 206–210
Neonatal critical care consultations, 82
inpatient, decision matrix for, 94 prolonged care services, 96
inpatient services, 99 Overpayments, 41
Neoplasm table, 174–176
Nerve conduction, 161, 162 P
Neurology, 159–160 Pacemaker replacement code, 118
Neuromuscular procedures, 159–160 Pain
New patient(s) acute, 179
domiciliary care, 92 chronic, 179
home services, 90 postoperative, 108
office visit, 4–6, 78 Past, family, social history (PFSH), 69–71
1995 examination guidelines, 72 Pathology
1997 examination guidelines, 73–74 areas of, 134–136
Nonspecific/unspecified codes, 171–172 modifiers, 138–140, 198–201
Nonsufficient funds (NSF), 33 surgical, 137–138
NP (Nurse practitioner) billing, 50 Patient(s). See also Established
NSF. See Nonsufficient funds (NSF) patient(s); Inpatient(s); New patient(s);
Nuclear medicine Outpatient(s)
diagnostic, 132 discharge of, 8–11
procedures, 123 encounter form, 3
therapeutic, 133 initial hospital, 80
Numbers out-of-pocket expenses, 113–114
hospital, 213–214 registration form, 1–3
physicians, 212 visit documentation, 12–13
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Pediatric critical care services, inpa- diagnostic ultrasound, 128–132

tient, 94, 99 emergency department x-rays, 122
PET scan (Positron emission tomogra- interventional procedures, 132–133
phy), 124 magnetic resonance imaging, 123
PFSH (Past, family, social history), 69–71 modifiers, 125–129, 193–198
Physical medicine, 147–148 nuclear medicine, 123, 132–133
Physical status modifiers, 103–104 positron emission tomography, 122
Physician assistant (PA) billing ultrasound procedures, 123
Medicaid, 56 Real-time scan, in diagnostic ultrasound,
Medicare Secondary Payor (MSP) 128
billing, 48–49 Re-excision, 176
Tricare, 58 Rehabilitation, 147–148
Place of service codes, 22–29, 214–215 Relatives, billing for, 41
Poisoning Repairs
late effect codes, 172 burns, 116–117
late effects of, 170 coding for wound, 116
Positron emission tomography (PET considerations for, 115
scan), 122 types of, 115
Postnasal drip, 180 Restless leg syndrome (RLS), 179
Preauthorization, 11 Retroperitoneum, ultrasound examina-
Precertification, 11 tion of, 129
Pregnancy, spotting complicating, 180 Returned checks, 33–34
Preventive medicine services, 95 Review of systems (ROS), 68–69, 71
Primary diagnosis code, principal vs., Rule of nines, in burns, 116
173
Primary malignancies, 174, 175 S
Principal vs. primary diagnosis code, 173 Secondary malignancies, 174, 175–176
Problem-oriented V code, 168 Sedation, moderate (conscious), 105,
Prolonged care services, 96 161–162
Prolonged intravenous injections, 146 Separate procedures, 143
Proton beam definitions, 131 Service-oriented V code, 168
Providers Sigmoidoscopy, 149
locum tenens, 43 Signs and symptoms codes, 172
nonparticipating in Medicare, 46 Sleep studies, 119
Psychiatry, 146–147 SNOCAMP documentation, 100–101
Pulmonary, 157–158 SOAP documentation, 100
State Medicare carriers, 216–223
R Subsequent hospital patients, 81
Radiation oncology, 129–130 Subsequent nursing facility, 88
Radiology Surgery(ies)
basic definitions, 133–134 bilateral, 107
billing and coding, 120–127 elective notice, 115
computerized tomography, 123 global, 106–107
consultations, 122 important definitions, 106
with contrast, 121 integumentary system coding,
diagnostic, 127–128 114–117
diagnostic procedures, 122 minor, 107
232
233
modifiers, 112, 186–193 physician assistant billing, 58–59
multiple, 108 workers’ compensation, 59
patient’s out-of-pocket expenses, Truncated diagnosis code, 171
113–114
physical status modifiers, 103–104 U
postoperative pain, 108 Ultrasound
preoperative and postoperative diagnostic, terminology, 128–129
billing, 108 procedures, 123, 125
Surgical and postoperative codes, Unbundling, 141
112–114 Underweight, abnormal loss of, 180
Surgical arthroscopy, 119 United States
Surgical endoscopy, 118 metric equivalents, 226
Surgical pathology, 137–138 units of measure, 225
Surgical tray, 108 Units of measure
Sutures, 180 metric, 226
Symbols, CPT, 42 United States, 225
Unpaid claims, 35, 36
T Unspecified hypertension, 173
Teaching physician modifiers,
210–211 V
Team surgery, 106 V codes
Terminology, diagnostic ultrasound, fact-oriented, 169
128–129 problem-oriented, 168
Therapeutic diagnostic infusions service-oriented, 168
(excludes chemotherapy), 146 Vaccines, common, 147
Therapeutic radiology simulation
definitions, 130–131 W
Time, in E&M services, 63–64 Web sites, organization/association,
Tobacco use disorder, 179 224–225
Toxic effects codes, 170 Weight, abnormal loss of, 180
Toxoids, 147 Workers’ compensation, in
Transcatheter services, 128 Tricare, 59
Treatment planning, for radiation Wound repairs, coding, 116
oncology, 130
Tricare X
definition and plans, 58 X-rays, 122
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