Medicare Correct Coding Guide - · PDF fileStatus Indicator ... how to use the Medicare Correct Coding Guide, please refer to the appropriate pages in the In troduction and General

Medicare Correct Coding Guide

© 2012 OptumInsight January 2012 Contents–1CPT only © 2011 American Medical Association. All Rights Reserved.

ContentsGetting Started with Medicare Correct Coding Guide ................................................................................Introduction–1

Introduction .............................................................................................................................................Introduction–3Resource-Based Relative Value Scale (RBRVS) ..................................................................................................Introduction–3Correct Coding Initiative (CCI) ........................................................................................................................Introduction–3

Medically Unlikely Edits............................................................................................................................Introduction–4Manual Organization .......................................................................................................................................Introduction–4How to Use This Book .....................................................................................................................................Introduction–5

Resource-Based Relative Value Scale (RBRVS) Payment Computation .......................................................Introduction–5Modifiers ..........................................................................................................................................................Introduction–6

Surgery Modifiers .....................................................................................................................................Introduction–6Modifiers Affecting Correct Coding Edits .................................................................................................Introduction–6

Other Payment Indicators ................................................................................................................................Introduction–7Status Indicator ........................................................................................................................................Introduction–7Global Period ...........................................................................................................................................Introduction–7Physician Supervision Level ......................................................................................................................Introduction–7Definitions ...............................................................................................................................................Introduction–7Levels of Physician Supervision of Diagnostic Tests ...................................................................................Introduction–7

Correct Coding Initiative (CCI) ........................................................................................................................Introduction–8Step-by-Step Instructions .................................................................................................................................Introduction–9

Code Pair Additions ................................................................................................................... Summary of Changes–1

Code Pair Deletions .................................................................................................................. Summary of Changes–26

Modifier Revisions .................................................................................................................... Summary of Changes–36

Edit Revisions ............................................................................................................................ Summary of Changes–37

General Correct Coding Policies .......................................................................................................................General–1A. Introduction ............................................................................................................................................... General–1B. Coding Based on Standard of Medical/Surgical Practice ............................................................................... General–2C. Medical/Surgical Package ............................................................................................................................ General–3D. Evaluation and Management Services ......................................................................................................... General–4E. Modifiers and Modifier Indicators ............................................................................................................... General–5F. Standard Preparation/Monitoring Services for Anesthesia ............................................................................ General–7G. Anesthesia Service Included in the Surgical Procedure ................................................................................ General–7H. HCPCS/CPT Procedure Code Definition ..................................................................................................... General–7I. CPT Manual and CMS Coding Manual Instructions ..................................................................................... General–8J. CPT “Separate Procedure” Definition ........................................................................................................... General–8K. Family of Codes .......................................................................................................................................... General–8L. More Extensive Procedure ........................................................................................................................... General–8M. Sequential Procedure .................................................................................................................................. General–9N. Laboratory Panel ......................................................................................................................................... General–9O. Misuse of Column 2 Code with Column 1 Code ......................................................................................... General–9P. Mutually Exclusive Procedures .................................................................................................................... General–9Q. Gender-Specific Procedure (formerly Designation of Sex) ........................................................................... General–9R. Add-on Codes ............................................................................................................................................. General–9S. Excluded Service ....................................................................................................................................... General–10T. Unlisted Service or Procedure ................................................................................................................... General–10U. Modified, Deleted, and Added Code Pairs/Edits ........................................................................................ General–10V. Medically Unlikely Edits ........................................................................................................................... General–10

Surgery: Integumentary System (CPT Codes 10000–19999) ..................................................................Integumentary–iCorrect Coding Policies ..................................................................................................................................Integumentary–i

A. Introduction ......................................................................................................................................Integumentary–iB. Evaluation and Management (E/M) Services ........................................................................................Integumentary–iC. Anesthesia ..........................................................................................................................................Integumentary–iD. Incision and Drainage .......................................................................................................................Integumentary–iiE. Lesion Removal .................................................................................................................................Integumentary–iiF. Mohs Micrographic Surgery .............................................................................................................Integumentary–iii

© 2012 OptumInsight January 2012 Introduction–1CPT only © 2011 American Medical Association. All Rights Reserved.

Getting Started with Medicare Correct Coding Guide

Welcome to Medicare Correct Coding Guide! This page will help you navigate the data within. For more detailed information about this data, or how to use the Medicare Correct Coding Guide, please refer to the appropriate pages in the Introduction and General Correct Coding Policies chapters. Within each section of the book, you will also find detailed information for correct coding within specific sections of CPT® codes. If you have additional questions, please contact Customer Service at 800.464.3649.

CPT or HCPCS code. This code represents the column 1 code within the column 1/column 2 correct coding edits table, (formerly called the “comprehensive” code), which indicates the major service or procedure. Only codes with Correct Coding Initiative (CCI) edits and/or Medicare physician fee schedule (MPFS) relative values are included in this book.

Full CPT or HCPCS Level II description.

RBRVS relative value units (RVUs) from the MPFS.• When billing multiple procedures, the code with the highest

RVU is generally considered the primary procedure. • For more information about RBRVS, see pages

Introduction-3 and 4.• For information about calculating fees, see page Introduction-5.

Global period as listed in the MPFS.• This indicator is sometimes referred to as follow-up days. • For a complete description of this field, see page Introduction-7.

MPFS modifiers.• Medicare coverage for bilateral procedures (50), multiple

procedures (51), cosurgeons (62), team surgery (66), and assistant surgeon (80 and 82).

• For a complete description of MPFS modifiers and indicators, see page Introduction-6.

• For a complete list of CPT modifiers, see Appendix B. • For information about the use of modifiers with CCI, see page

General-5.

Medicare physician fee schedule status indicator. • Indicates codes that are included, excluded, bundled, or not

valid for Medicare payment purposes. • For a complete list of status indicators, see page Introduction-7.

Physician supervision level indicator.• Applies to every diagnostic test paid under the MPFS. • Many codes have 9 to indicate that this concept does not apply.• For a full description of each indicator, see page Introduction-7.

Medically Unlikely Edits• These indicate the maximum units of service (UOS) for a CPT/

HCPCS code for the service provided to the same patient on the same date of service.

Correct Coding Initiative (CCI) edits.• Includes column 2 of the correct coding (column 1/

column 2) edits (previously called “component” codes) as well as the mutually exclusive edits.

• A shaded gray box over an edit code indicates a modifier may be used to bypass a CCI edit, when appropriate.

• A symbol key appears on each page of data in the book. • For a full description of each symbol, see the section “General

Correct Coding Policies.”

Tenolysis, extensor tendon, hand OR finger, each tendon26445OTHERRELATIVE VALUE UNITS

MUEGlobal PTotal-fTotal-nfPE-fPE-nfMPWork—9016.9116.9111.6811.680.784.45

INDICATORSMODIFIERSStatusSuprv80,8266625150A09NPDNPDNPD40

CORRECT CODING EDITS20550n,20527n,20526n,12032f,0230Tf,0228Tf,0216Tn,0213Tn,01810l,26140f,26135f,25295f,25259f,25118f,25000f,20553n,20552n,20551n,29280r,29131r,29130r,29086f,29075r,265463,26460f,26340f,26185m,36430f,36425f,36420f,36410f,36406f,36405f,36400f,36000f,29584r,62310f,51703f,51702f,51701f,43752f,37202n,36640f,36600f,36440f,64412f,64410f,64408f,64405f,64402f,64400f,62319n,62318n,62311f,64430f,64425f,64421f,64420f,64418f,64417n,64416n,64415n,64413f,64483f,64479f,64450n,64449f,64448f,64447f,64446f,64445f,64435f,69990n,64530f,64520f,64517f,64510f,64508f,64505f,64493n,64490n,94200f,94002f,93318f,93042f,93041f,93040f,93010f,93005f,93000f,95819f,95816f,95813f,95812f,94770f,94690f,94681f,94680f,94250f,96376f,96375f,96374f,96372f,96365f,96360f,95955f,95829f,95822f,

99150n99149n,99148n,

Tenolysis, complex, extensor tendon, finger, including forearm, each tendon26449OTHERRELATIVE VALUE UNITS


INDICATORSMODIFIERSStatusSuprv80,8266625150A09DOCNPDNPD40

CORRECT CODING EDITS20551n,20550n,20527n,20526n,0230Tf,0228Tf,0216Tn,0213Tn,01810l,26340f,26185m,26140f,26135f,25259f,25118f,25000f,20553n,20552n,29584r,29280r,29131r,29130r,29086f,29075r,265463,26460f,26445t,36440f,36430f,36425f,36420f,36410f,36406f,36405f,36400f,36000f,62311f,62310f,51703f,51702f,51701f,43752f,37202n,36640f,36600f,64413f,64412f,64410f,64408f,64405f,64402f,64400f,62319n,62318n,64435f,64430f,64425f,64421f,64420f,64418f,64417n,64416n,64415n,64490n,64483f,64479f,64450n,64449f,64448f,64447f,64446f,64445f,93000f,69990n,64530f,64520f,64517f,64510f,64508f,64505f,64493n,94250f,94200f,94002f,93318f,93042f,93041f,93040f,93010f,93005f,95822f,95819f,95816f,95813f,95812f,94770f,94690f,94681f,94680f,99148n,96376f,96375f,96374f,96372f,96365f,96360f,95955f,95829f,

99150n99149n,

Tenotomy, flexor, palm, open, each tendon26450OTHERRELATIVE VALUE UNITS



CORRECT CODING EDITS20550n,20527n,20526n,110103,0230Tf,0228Tf,0216Tn,0213Tn,01810l,265463,26340f,26185m,26145f,26055f,25259f,20553n,20552n,20551n,36405f,36400f,36000f,29584r,29280r,29131r,29130r,29086f,29075r,37202n,36640f,36600f,36440f,36430f,36425f,36420f,36410f,36406f,64400f,62319n,62318n,62311f,62310f,51703f,51702f,51701f,43752f,64417n,64416n,64415n,64413f,64412f,64410f,64408f,64405f,64402f,64447f,64446f,64445f,64435f,64430f,64425f,64421f,64420f,64418f,64508f,64505f,64493n,64490n,64483f,64479f,64450n,64449f,64448f,93040f,93010f,93005f,93000f,69990n,64530f,64520f,64517f,64510f,94690f,94681f,94680f,94250f,94200f,94002f,93318f,93042f,93041f,96360f,95955f,95829f,95822f,95819f,95816f,95813f,95812f,94770f,

99150n99149n,99148n,96376f,96375f,96374f,96372f,96365f,

Tenotomy, flexor, finger, open, each tendon26455OTHERRELATIVE VALUE UNITS



CORRECT CODING EDITS20550n,20527n,20526n,110103,0230Tf,0228Tf,0216Tn,0213Tn,01810l,265463,26340f,26185m,26145f,26055f,25259f,20553n,20552n,20551n,36405f,36400f,36000f,29584r,29280r,29131r,29130r,29086f,29075r,37202n,36640f,36600f,36440f,36430f,36425f,36420f,36410f,36406f,64400f,62319n,62318n,62311f,62310f,51703f,51702f,51701f,43752f,64417n,64416n,64415n,64413f,64412f,64410f,64408f,64405f,64402f,64447f,64446f,64445f,64435f,64430f,64425f,64421f,64420f,64418f,64508f,64505f,64493n,64490n,64483f,64479f,64450n,64449f,64448f,93040f,93010f,93005f,93000f,69990n,64530f,64520f,64517f,64510f,94690f,94681f,94680f,94250f,94200f,94002f,93318f,93042f,93041f,96360f,95955f,95829f,95822f,95819f,95816f,95813f,95812f,94770f,

99150n99149n,99148n,96376f,96375f,96374f,96372f,96365f,

Tenotomy, extensor, hand or finger, open, each tendon26460OTHERRELATIVE VALUE UNITS


INDICATORSMODIFIERSStatusSuprv80,8266625150A09NPDNPDNPD40

CORRECT CODING EDITS20550n,20527n,20526n,110103,0230Tf,0228Tf,0216Tn,0213Tn,01810l,26140f,26135f,25295f,25259f,25118f,25116f,20553n,20552n,20551n,29584r,29280r,29131r,29130r,29086f,29075r,265463,26340f,26185m,36440f,36430f,36425f,36420f,36410f,36406f,36405f,36400f,36000f,62311f,62310f,51703f,51702f,51701f,43752f,37202n,36640f,36600f,64413f,64412f,64410f,64408f,64405f,64402f,64400f,62319n,62318n,64435f,64430f,64425f,64421f,64420f,64418f,64417n,64416n,64415n,64490n,64483f,64479f,64450n,64449f,64448f,64447f,64446f,64445f,93000f,69990n,64530f,64520f,64517f,64510f,64508f,64505f,64493n,94250f,94200f,94002f,93318f,93042f,93041f,93040f,93010f,93005f,95822f,95819f,95816f,95813f,95812f,94770f,94690f,94681f,94680f,99148n,96376f,96375f,96374f,96372f,96365f,96360f,95955f,95829f,

99150n99149n,

Tenodesis; of proximal interphalangeal joint, each joint26471OTHERRELATIVE VALUE UNITS



CORRECT CODING EDITS20551n,20550n,20527n,20526n,0230Tf,0228Tf,0216Tn,0213Tn,01810l,26746f,265463,26340f,26185m,261803,26055f,25259f,20553n,20552n,36400f,36000f,29584r,29280r,29131r,29130r,29086f,29075r,26785f,36640f,36600f,36440f,36430f,36425f,36420f,36410f,36406f,36405f,62319n,62318n,62311f,62310f,51703f,51702f,51701f,43752f,37202n,64416n,64415n,64413f,64412f,64410f,64408f,64405f,64402f,64400f,64446f,64445f,64435f,64430f,64425f,64421f,64420f,64418f,64417n,64505f,64493n,64490n,64483f,64479f,64450n,64449f,64448f,64447f,93010f,93005f,93000f,69990n,64530f,64520f,64517f,64510f,64508f,94681f,94680f,94250f,94200f,94002f,93318f,93042f,93041f,93040f,95955f,95829f,95822f,95819f,95816f,95813f,95812f,94770f,94690f,99150n99149n,99148n,96376f,96375f,96374f,96372f,96365f,96360f,

Designation of Gender-specific Procedures´CPT/CMS Coding Manual InstructionsrAnesthesia Included in Surgical Procedurel

More Extensive ProceduretCPT Separate Procedure DefinitionmStandards of Medical/Surgical PracticefCPT/HCPCS Procedure Code Definitionu

Musculoskeletal — 159January 2012© 2011 OptumInsight

CPT only © 2011 American Medical Association. All Rights Reserved.

Surgery: Musculoskeletal SystemMedicare Correct Coding Guide (CCI Version18.0)

Hemoglobin-oxygen affinity (pO2 for 50% hemoglobin saturation withoxygen)82820

OTHERRELATIVE VALUE UNITSMUEGlobal PTotal-fTotal-nfPE-fPE-nfMPWork1NA0.000.000.000.000.000.00

INDICATORSMODIFIERSStatusSuprv80,8266625150NON09NANANANANA

CORRECT CODING EDITS80502f80500f,

Gastric acid analysis, includes pH if performed, each specimen82930OTHERRELATIVE VALUE UNITS

MUEGlobal PTotal-fTotal-nfPE-fPE-nfMPWork—NA0.000.000.000.000.000.00


CORRECT CODING EDITS83986u

Glucose, body fluid, other than blood82945OTHERRELATIVE VALUE UNITS



CORRECT CODING EDITS829483829473,

Glucose; quantitative, blood (except reagent strip)82947OTHERRELATIVE VALUE UNITS



CORRECT CODING EDITS829533829513,82948t,80502f,80500f,

Glucose; blood, reagent strip82948OTHERRELATIVE VALUE UNITS



CORRECT CODING EDITS829533829523,829503,

Glucose; post glucose dose (includes glucose)82950OTHERRELATIVE VALUE UNITS

MUEGlobal PTotal-fTotal-nfPE-fPE-nfMPWork3NA0.000.000.000.000.000.00


CORRECT CODING EDITS829533829513,

Glucose; tolerance test (GTT), 3 specimens (includes glucose)82951OTHERRELATIVE VALUE UNITS



CORRECT CODING EDITS82953382948f,80502f,80500f,

Glucose; tolerance test, each additional beyond 3 specimens (List separatelyin addition to code for primary procedure)82952

OTHERRELATIVE VALUE UNITSMUEGlobal PTotal-fTotal-nfPE-fPE-nfMPWork3NA0.000.000.000.000.000.00


CORRECT CODING EDITS829533829473,80502f,80500f,

Glucose; tolbutamide tolerance test82953OTHERRELATIVE VALUE UNITS




Glucose, blood by glucose monitoring device(s) cleared by the FDAspecifically for home use82962

OTHERRELATIVE VALUE UNITSMUEGlobal PTotal-fTotal-nfPE-fPE-nfMPWork—NA0.000.000.000.000.000.00


CORRECT CODING EDITS829533829523,829513,829503,829483,829473,

Glycated protein82985OTHERRELATIVE VALUE UNITS




Gonadotropin; follicle stimulating hormone (FSH)83001OTHERRELATIVE VALUE UNITS




Designation of Gender-specific Procedures´CPT/CMS Coding Manual InstructionsrAnesthesia Included in Surgical Procedurel

More Extensive ProceduretCPT Separate Procedure DefinitionmStandards of Medical/Surgical PracticefCPT/HCPCS Procedure Code Definitionu

Pathology — 9January 2012© 2011 OptumInsight

CPT only © 2011 American Medical Association. All Rights Reserved.

Pathology and Laboratory ServicesMedicare Correct Coding Guide (CCI Version18.0)

Documents

Medicare Correct Coding Guide - · PDF fileStatus Indicator ... how to use the Medicare Correct Coding Guide, please refer to the appropriate pages in the In troduction and General