Sample page. Medicare Correct Coding Guide. A guide to Medicare billing and coding edits for physicians UPDATEABLE

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1 UPDATEABLE Medicare Correct Coding Guide A guide to Medicare billing and coding edits for physicians Power up your coding optum36coding.com

2 Contents Getting Started with Medicare Correct Coding Guide... Introduction 1 Introduction... Introduction 3 Resource-Based Relative Value Scale... Introduction 3 Sequestration Budget Reduction... Introduction 3 Correct Coding Initiative... Introduction 3 Medically Unlikely Edits... Introduction 4 National Correct Coding Initiative (NCCI) Add-On Codes... Introduction 4 Manual Organization... Introduction 5 How to Use This Book... Introduction 5 Resource-Based Relative Value Scale (RBRVS) Payment Computation... Introduction 5 Modifiers... Introduction 5 Surgery Modifiers... Introduction 5 Modifiers Affecting Correct Coding Edits... Introduction 7 Other Payment Indicators... Introduction 7 Status Indicator... Introduction 7 Global Period... Introduction 7 Physician Supervision Level... Introduction 7 Definitions... Introduction 7 Levels of Physician Supervision of Diagnostic Tests... Introduction 7 Correct Coding Initiative (CCI)... Introduction 8 Step-by-Step Instructions... Introduction 8 Symbol/Payment Indicator Key... Introduction 1 Summary of Changes... Summary of Changes 1 Code Pair Additions... Summary of Changes 1 Code Pair Deletions...Summary of Changes 44 Modifier Revisions...Summary of Changes Edit Revisions...Summary of Changes 67 General Correct Coding Policies... General 1 A. Introduction... General 1 B. Coding Based on Standards of Medical/ Surgical Practice... General 2 C. Medical/Surgical Package... General 2 D. Evaluation and Management (E&M) Services... General 4 E. Modifiers and Modifier Indicators... General 4 F. Standard Preparation/Monitoring Services for Anesthesia... General 6 G. Anesthesia Service Included in the Surgical Procedure... General 6 H. HCPCS/CPT Procedure Code Definition... General 7 I. CPT Manual and CMS Coding Manual Instructions... General 7 J. CPT Separate Procedure Definition... General 7 K. Family of Codes... General 7 L. More Extensive Procedure... General 7 M. Sequential Procedure... General 8 N. Laboratory Panel... General 8 O. Misuse of Column Two Code with Column One Code (Misuse of Code Edit Rationale)... General 8 P. Mutually Exclusive Procedures... General 8 Q. Gender-Specific Procedures... General 8 R. Add-on Codes... General 8 S. Excluded Service... General 9 T. Unlisted Procedure Codes... General 9 U. Modified, Deleted, and Added Code Pairs/Edits... General 9 V. Medically Unlikely Edits (MUEs)... General 9 W. Add-on Code Edit Tables... General 11 Surgery: Integumentary System (CPT Codes )... Integumentary i Correct Coding Policies... Integumentary i A. Introduction... Integumentary i B. Evaluation and Management (E&M) Services... Integumentary i C. Anesthesia... Integumentary i D. Incision and Drainage... Integumentary ii E. Lesion Removal... Integumentary ii F. Mohs Micrographic Surgery... Integumentary ii G. Intralesional Injections... Integumentary ii H. Repair and Tissue Transfer... Integumentary iii I. Grafts and Flaps... Integumentary iii J. Breast (Incision, Excision, Introduction, Repair and Reconstruction)... Integumentary iii K. Medically Unlikely Edits (MUEs)... Integumentary iii L. General Policy Statements... Integumentary iv Integumentary System... Integumentary 1 Surgery: Musculoskeletal System (CPT Codes )...Musculoskeletal i Correct Coding Policies... Musculoskeletal i A. Introduction... Musculoskeletal i B. Evaluation and Management (E&M) Services... Musculoskeletal i C. Anesthesia... Musculoskeletal i D. Biopsy... Musculoskeletal i E. Arthroscopy... Musculoskeletal ii F. Spine (Vertebral Column)... Musculoskeletal ii G. Fractures, Dislocations, and Casting/ Splinting/Strapping... Musculoskeletal iii H. Medically Unlikely Edits (MUEs)... Musculoskeletal iv I. General Policy Statements... Musculoskeletal iv Musculoskeletal System... Musculoskeletal 1 Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems (CPT Codes )... Respiratory i Correct Coding Policies... Respiratory i A. Introduction... Respiratory i B. Evaluation and Management (E&M) Services... Respiratory i C. Respiratory System... Respiratory i D. Cardiovascular System... Respiratory iii E. Hemic and Lymphatic Systems... Respiratory vi F. Mediastinum... Respiratory vi G. Medically Unlikely Edits (MUEs)... Respiratory vi H. General Policy Statements... Respiratory vii Respiratory System... Respiratory 1 Cardiovascular System...Respiratory 76 Hemic and Lymphatic System... Respiratory 245 Mediastinum and Diaphragm... Respiratory 258 Surgery: Digestive System (CPT Codes )...Digestive i Correct Coding Policies... Digestive i A. Introduction... Digestive i B. Evaluation and Management (E&M) Services... Digestive i C. Endoscopic Services... Digestive i D. Esophageal Procedures... Digestive ii E. Abdominal Procedures... Digestive ii F. Laparoscopy... Digestive iii G. Medically Unlikely Edits (MUEs)... Digestive iii H. General Policy Statements... Digestive iv Digestive System...Digestive Optum36, LLC January 219 Contents 1 CPT 217 American Medical Association. All Rights Reserved.

3 General Correct Coding Policies A. Introduction Healthcare providers utilize HCPCS/CPT codes to report medical services performed on patients to Medicare Carriers (A/B MACs processing practitioner service claims) and Fiscal Intermediaries (FIs). HCPCS (Healthcare Common Procedure Coding System) consists of Level I CPT (Current Procedural Terminology) codes and Level II codes. CPT codes are defined in the American Medical Association s (AMA s) CPT Manual which is updated and published annually. HCPCS Level II codes are defined by the Centers for Medicare & Medicaid Services (CMS) and are updated throughout the year as necessary. Changes in CPT codes are approved by the AMA CPT Editorial Panel which meets three times per year. Editor s note: CPT Category II and Category III codes are updated twice yearly in January and July and can be found on the AMA website prior to their inclusion in the printed book. CPT and HCPCS Level II codes define medical and surgical procedures performed on patients. Some procedure codes are very specific defining a single service (e.g., CPT code 93 (electrocardiogram)) while other codes define procedures consisting of many services (e.g., CPT code (vaginal hysterectomy with removal of tube(s) and ovary(s) and repair of enterocele)). Because many procedures can be performed by different approaches, different methods, or in combination with other procedures, there are often multiple HCPCS/CPT codes defining similar or related procedures. CPT and HCPCS Level II code descriptors usually do not define all services included in a procedure. There are often services inherent in a procedure or group of procedures. For example, anesthesia services include certain preparation and monitoring services. The CMS developed the NCCI to prevent inappropriate payment of services that should not be reported together. Prior to April 1, 212, NCCI PTP edits were placed into either the Column One/Column Two Correct Coding Edit Table or the Mutually Exclusive Edit Table. However, on April 1, 212, the edits in the Mutually Exclusive Edit Table were moved to the Column One/Column Two Correct Coding Edit Table so that all the NCCI PTP edits are currently contained in this single table. Combining the two tables simplifies researching NCCI PTP edits and online use of NCCI tables. Each edit table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. However, if it is clinically appropriate to utilize an NCCI-associated modifier, both the column one and column two codes are eligible for payment. (NCCI-associated modifiers and their appropriate use are discussed elsewhere in this chapter.) When the NCCI was first established and during its early years, the Column One/Column Two Correct Coding Edit Table was termed the Comprehensive/ Component Edit Table. This latter terminology was a misnomer. Although the column two code is often a component of a more comprehensive column one code, this relationship is not true for many edits. In the latter type of edit the code pair edit simply represents two codes that should not be reported together. For example, a provider shall not report a vaginal hysterectomy code and total abdominal hysterectomy code together. In this chapter, Sections B Q address various issues relating to NCCI PTP edits. Medically Unlikely Edits (MUEs) prevent payment for an inappropriate number/ quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service (UOS) under most circumstances reportable by the same provider for the same beneficiary on the same date of service. The ideal MUE value for a HCPCS/CPT code is one that allows the vast majority of appropriately coded claims to pass the MUE. More information concerning MUEs is discussed in Section V of this chapter. In this Manual many policies are described utilizing the term physician. Unless indicated differently the usage of this term does not restrict the policies to physicians only but applies to all practitioners, hospitals, providers, or suppliers eligible to bill the relevant HCPCS/CPT codes pursuant to applicable portions of the Social Security Act (SSA) of 1965, the Code of Federal Regulations (CFR), and Medicare rules. In some sections of this Manual, the term physician would not include some of these entities because specific rules do not apply to them. For example, Anesthesia Rules [e.g., CMS Internet-only Manual, Publication 1-4 (Medicare Claims Processing Manual), Chapter 12 (Physician/ Nonphysician Practitioners), Section 5 (Payment for Anesthesiology Services) and Global Surgery Rules [e.g., CMS Internet-only Manual, Publication 1-4 (Medicare Claims Processing Manual), Chapter 12 (Physician/Nonphysician Practitioners), Section 4 (Surgeons and Global Surgery)] do not apply to hospitals. Providers reporting services under Medicare s hospital outpatient prospective payment system (OPPS) shall report all services in accordance with appropriate Medicare Internet-only Manual (IOM) instructions. Physicians must report services correctly. This manual discusses general coding principles in Chapter I and principles more relevant to other specific groups of HCPCS/CPT codes in the other chapters. There are certain types of improper coding that physicians must avoid. Procedures shall be reported with the most comprehensive CPT code that describes the services performed. Physicians must not unbundle the services described by a HCPCS/CPT code. Some examples follow: A physician shall not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services. For example if a physician performs a vaginal hysterectomy on a uterus weighing less than 25 grams with bilateral salpingo-oophorectomy, the physician shall report CPT code (Vaginal hysterectomy, for uterus 25 g or less; with removal of tube(s), and/or ovary(s)). The physician shall not report CPT code 5826 (Vaginal hysterectomy, for uterus 25 g or less;) plus CPT code 5872 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)). A physician shall not fragment a procedure into component parts. For example, if a physician performs an anal endoscopy with biopsy, the physician shall report CPT code 46 (Anoscopy; with biopsy, single or multiple). It is improper to unbundle this procedure and report CPT code 4(Anoscopy; diagnostic,...) plus CPT code 451 (Biopsy of anorectal wall, anal approach...). The latter code is not intended to be utilized with an endoscopic procedure code. A physician shall not unbundle a bilateral procedure code into two unilateral procedure codes. For example if a physician performs bilateral mammography, the physician shall report CPT code 77 (Diagnostic mammography... bilateral). The physician shall not report CPT code 7765 (Diagnostic mammography... unilateral) with two units of service or 7765LT plus 7765RT. A physician shall not unbundle services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical procedure. A physician shall not report CPT code 49 (Exploratory laparotomy,...) when performing an open abdominal procedure such as a total abdominal colectomy (e.g., CPT code 4415). Physicians must avoid downcoding. If a HCPCS/CPT code exists that describes the services performed, the physician must report this code rather than report a less comprehensive code with other codes describing the services not included in the less comprehensive code. For example if a physician performs a unilateral partial mastectomy with axillary lymphadenectomy, the provider shall report CPT code 1932 (Mastectomy, partial...; with axillary lymphadenectomy). A physician shall not report CPT code 1931 (Mastectomy, partial...) plus CPT code (Axillary lymphadenectomy; complete). Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. For example, if a physician performs a superficial axillary lymphadenectomy (CPT code 3874), the physician shall not report CPT code (Axillary lymphadenectomy; complete). Physicians must report units of service correctly. Each HCPCS/CPT code has a defined unit of service for reporting purposes. A physician shall not report units of service for a HCPCS/CPT code using a criterion that differs from the code s defined unit of service. For example, some therapy codes are reported in fifteen minute increments (e.g., CPT codes ). Others are reported per session (e.g., CPT codes 9257, 9258). A physician shall not report a per 218 Optum36, LLC January 219 General 1 CPT 217 American Medical Association. All Rights Reserved.

4 Incision and drainage of soft tissue abscess, subfascial (ie, involves the soft 25 tissue below the deep fascia) (3) ,82 Suprv Status A CORRECTCODING EDITS 213T n 216T n 228T f 23T f 1142 f 1143 f 121 n 122 n 124 n 125 n 126 n 127 n 1211 n 1213 n 1214 n 1215 n 1216 n 1217 n 1218 n 122 n 1221 n 1231 n 1232 n 1234 n 1235 n 1236 n 1237 n 1241 n 1242 n 1244 n 1245 n 1246 n 1247 n 1251 n 1252 n 1253 n 1254 n 1255 n 1256 n 1257 n 131 n 1311 n 1312 n 1312 n n n n n n n n n 25 m 36 f 364 f 3645 f 3646 f 3641 f 3642 f f 3643 f 3644 f r r3 f 34 f f 5171 f 5172 f 5173 f 6232 f f f f n n n n 644 f 6442 f 6445 f 6448 f 6441 f f n n n f 6442 f f f 6443 f f f f f f f 6445 n n n n f 6448 n f n n n n n 6449 n n n n n n 6455 f 6458 f 6451 f f 6452 f 6453 f 6999 n 9212 r9214 r93 f 935 f 931 f 934 f 9341 f 9342 f f f 942 f 942 f 9425 f 9468 f f 9469 f 9477 f f f f f f f f 9636 f n f 963 n n n f f f f f f f 9762 f 9765 f 97 f 9767 f 9768 f u u u r99212 r99213 r99214 r99215 r r99218 r99219 r9922 r99221 r99222 r99223 r99231 r99232 r99233 r99234 r r99236 r99238 r99239 r99241 r99242 r99243 r99244 r99245 r99251 r99252 r r99254 r99255 r99291 r99292 r9934 r9935 r9936 r9937 r9938 r9939 r 9931 r99315 r99316 r99334 r99335 r99336 r99337 r99347 r99348 r99349 r9935 r r99375 r99377 r99378 r99446 r99447 r99448 r99449 r99495 r99496 rg463 r G471f J67 n J21 n 21 Exploration of penetrating wound (separate procedure); neck (3) ,82 Suprv Status A CORRECTCODING EDITS 213T n 216T n 228T f 23T f 11 r1111 f 1112 f 1142 r 1143 r1144 r121 r122 r124 r125 r126 r127 r1211 n 1213 n 1214 n 1215 n 1216 n 1217 n 1218 n 122 r1221 r1231 n 1232 n 1234 n 1235 n 1236 n 1237 n 1241 r1242 r1244 r1245 r1246 r1247 r1251 n 1252 n 1253 n 1254 n 1255 n 1256 n 1257 n 131 n 1311 n 1312 r1312 n n r13131 r13132 r r13151 n f r1316 r36 f 364 f 3645 f 3646 f 3641 f 3642 f f 3643 f 3644 f r36592 r3 f 34 f f f 5171 f 5172 f 5173 f 6232 f f f f n n n n 644 f 6442 f 6445 f 6448 f 6441 f f n n n f 6442 f f f 6443 f f f f f f f 6445 n n n n f 6448 n f n n n n n 6449 n n n n n n 6455 f 6458 f 6451 f f 6452 f 6453 f 6999 n 9212 r 9214 r93 f 935 f 931 f 934 f 9341 f 9342 f f f 942 f 942 f 9425 f 9468 f f 9469 f 9477 f f f f f f f f 9636 f n f 963 n n n f f f f f f f 9762 f 9765 f 97 f 9767 f 9768 f u u u r99212 r99213 r99214 r99215 r99217 r99218 r99219 r9922 r99221 r99222 r r99231 r99232 r99233 r99234 r99235 r99236 r99238 r99239 r99241 r99242 r r99244 r99245 r99251 r99252 r99253 r99254 r99255 r99291 r99292 r9934 r 9935 r9936 r9937 r9938 r9939 r9931 r99315 r99316 r99334 r99335 r99336 r r99347 r99348 r99349 r9935 r99374 r99375 r99377 r99378 r99446 r99447 r r99449 r99495 r99496 rg168 f G463 rg471 f J21 n 211 Musculoskeletal System Exploration of penetrating wound (separate procedure); chest (3) ,82 Suprv Status A CORRECTCODING EDITS 213T n 216T n 228T f 23T f 11 r1142 r1143 r1144 r 121 r122 r124 r125 r126 r127 r1211 n 1213 n 1214 n 1215 n 1216 n 1217 n 1218 n 122 r1221 r1231 r1232 r1234 r1235 r1236 r1237 r1241 n 1242 n 1244 n 1245 n 1246 n 1247 n 1251 n 1252 n 1253 n 1254 n 1255 n 1256 n 1257 n 131 r1311 r1312 r1312 n n r13131 n n r13151 n n 1316 r36 f 364 f 3645 f 3646 f 3641 f 3642 f f 3643 f 3644 f r36592 r3 f 34 f f 5171 f 5172 f 5173 f 6232 f f f f n n n n 644 f 6442 f 6445 f 6448 f 6441 f f n n n f 6442 f f f 6443 f f f f f f f 6445 n n n n f 6448 n f n n n n n 6449 n n n n n n 6455 f 6458 f 6451 f f 6452 f 6453 f 6999 n 9212 r9214 r93 f 935 f 931 f 934 f 9341 f 9342 f f f 942 f 942 f 9425 f 9468 f f 9469 f 9477 f f f f f f f f 9636 f n f 963 n n n f f f f f f f 9762 f 9765 f 97 f 9767 f 9768 f u u u r99212 r99213 r99214 r r99217 r99218 r99219 r9922 r99221 r99222 r99223 r99231 r99232 r99233 r r99235 r99236 r99238 r99239 r99241 r99242 r99243 r99244 r99245 r99251 r r99253 r99254 r99255 r99291 r99292 r9934 r9935 r9936 r9937 r9938 r 9939 r9931 r99315 r99316 r99334 r99335 r99336 r99337 r99347 r99348 r99349 r 9935 r99374 r99375 r99377 r99378 r99446 r99447 r99448 r99449 r99495 r99496 r G168 f G463 rg471 f J67 n J21 n 212 Exploration of penetrating wound (separate procedure); abdomen/flank/back (3) ,82 Suprv Status A CORRECTCODING EDITS 213T n 216T n 228T f 23T f 11 r1142 r1143 r1144 r 121 r122 r124 r125 r126 r127 r1211 n 1213 n 1214 n 1215 n 1216 n 1217 n 1218 n 122 r1221 r1231 r1232 r1234 r1235 r1236 r1237 r1241 n 1242 n 1244 n 1245 n 1246 n 1247 n 1251 n 1252 n 1253 n 1254 n 1255 n 1256 n 1257 n 131 r1311 r1312 r1312 n n r13131 n n r13151 n n 1316 r36 f 364 f 3645 f 3646 f 3641 f 3642 f f 3643 f 3644 f r36592 r3 f 34 f f 5171 f 5172 f 5173 f 6232 f f f f n n n n 644 f 6442 f 6445 f 6448 f 6441 f f n n n f 6442 f f f 6443 f f f f f f f 6445 n n n n f 6448 n f n n n n n 6449 n n n n n n 6455 f 6458 f 6451 f f 6452 f 6453 f 6999 n 9212 r9214 r93 f 935 f 931 f 934 f 9341 f 9342 f f f 942 f 942 f 9425 f 9468 f f 9469 f 9477 f f f f f f f f 9636 f n f 963 n n n f f f f f f f 9762 f 9765 f 97 f 9767 f 9768 f u u u r99212 r99213 r99214 r r99217 r99218 r99219 r9922 r99221 r99222 r99223 r99231 r99232 r99233 r r99235 r99236 r99238 r99239 r99241 r99242 r99243 r99244 r99245 r99251 r r99253 r99254 r99255 r99291 r99292 r9934 r9935 r9936 r9937 r9938 r 9939 r9931 r99315 r99316 r99334 r99335 r99336 r99337 r99347 r99348 r99349 r 9935 r99374 r99375 r99377 r99378 r99446 r99447 r99448 r99449 r99495 r99496 r G168 f G463 rg471 f J67 n J21 n r CPT/CMS Coding Manual Instructions u CPT/HCPCS Procedure Code Definition 218 Optum36, LLC Designation of Gender-specific Procedures m CPT Separate Procedure Definition MUE 1 Line Edit MUE 2 DOS Edit: Policy CPT 217 American Medical Association. All Rights Reserved. January=219 t More Extensive Procedure MUE 3 DOS Edit: Clinical Musculoskeletal 1

5 Medicare=Correct=Coding=Guide=(CCI=Version=24.) Radiology Ultrasound, breast, unilateral, real time with image documentation, including 741 axilla when performed; complete XXX 2(2) ,82 Suprv Status 1 9 A CORRECTCODING EDITS r36592 r742 u r76942 n 7697 n n TC XXX 2(2) 8,82 Suprv Status 9 A XXX 2(2) 8,82 Suprv Status 1 A Ultrasound, breast, unilateral, real time with image documentation, including 742 axilla when performed; limited XXX 2(2) ,82 Suprv Status 1 9 A CORRECTCODING EDITS r36592 r76882 r76942 n 7697 n n TC XXX 2(2) 8,82 Suprv Status 9 A XXX 2(2) 8,82 Suprv Status 1 A Ultrasound, abdominal, real time with image documentation; complete XXX 1(3) ,82 Suprv Status 4 9 A CORRECTCODING EDITS r36592 r5171 f 5172 f 7675 u n 7697 n n G471 f TC XXX 1(3) 8,82 Suprv Status 9 A XXX 1(3) 8,82 Suprv Status 1 A Ultrasound, abdominal, real time with image documentation; limited (eg, 7675 single organ, quadrant, follow-up) XXX 2(3) ,82 Suprv Status 4 9 A CORRECTCODING EDITS r36592 r5171 f 5172 f n 7697 n n G471 f TC XXX 2(3) 8,82 Suprv Status 9 A XXX 2(3) 8,82 Suprv Status 1 A Ultrasound, abdominal aorta, real time with image documentation, screening 7676 study for abdominal aortic aneurysm (AAA) XXX 1(2) ,82 Suprv Status 9 A CORRECTCODING EDITS r36592 r5171 f 5172 f r76942 n 7697 n n rg471 f TC XXX 1(2) 8,82 Suprv Status 9 A XXX 1(2) 8,82 Suprv Status 9 A Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image 7677 documentation; complete XXX 1(3) ,82 Suprv Status 4 9 A CORRECTCODING EDITS r36592 r5171 f 5172 f r u n 7697 n n G471 f XXX 1(3) 8,82 Suprv Status 9 A r CPT/CMS Coding Manual Instructions u CPT/HCPCS Procedure Code Definition 218 Optum36, LLC Designation of Gender-specific Procedures m CPT Separate Procedure Definition MUE 1 Line Edit MUE 2 DOS Edit: Policy CPT 217 American Medical Association. All Rights Reserved. January=219 t More Extensive Procedure MUE 3 DOS Edit: Clinical Radiology 63