Telemedicine & Telehealth Reference Guide › 0691bfc6-725a... · emergency department. You can report 99281-99285 even in nonemergency situations for services provided in the ED

A comprehensive resource for every medical coding and billing professional

Coders’ Dictionary & Reference Guide

FIRST EDITION

II Coders’ Dictionary & Reference Guide AAPC | 1-800-626-2633

DisclaimerDecisions should not be made based solely upon information within this reference guide. All judgments impacting career and/or an employer must be based upon individual circumstances including legal and ethical considerations, local conditions, payer policies within the geographic area, and new or pending government regulations, etc.

AAPC does not accept responsibility or liability for any adverse outcome from using this reference guide for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the individual’s misunderstanding or misapplication of topics.

Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s)’ bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers’ interpretations may vary from those in this program. Finally, the law, applicable regulations, payers’ instructions, interpretations, enforcement, etc., may change at any time in any particular area.

AAPC has obtained permission from various individuals and companies to include their material in this reference guide. These agreements do not extend beyond this program. It may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of AAPC and the sources contained within.

No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording or taping) without the expressed written permission from AAPC and the sources contained within.

Medicare DisclaimerThis publication provides situational examples and explanations, of which many are taken from the Medicare perspective. The individual, however, should understand that while private payers typically take their lead regarding reimbursement rates from Medicare, it is not the only set of rules to follow.

While federal and private payers have different objectives (such as the age of the population covered) and use different contracting practices (such as fee schedules and coverage policies), the plans and providers set similar elements of the quality in common for all patients. Nevertheless, it is important to consult with individual private payers if you have questions regarding coverage.

AMA DisclaimerCPT® copyright 2019 American Medical Association. All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT® is a registered trademark of the American Medical Association.

The responsibility for the content of any “National Correct Coding Policy” included in this product is with the Centers for Medicare & Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product.

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Print ISBN: 978-1-626889-811e-Book ISBN: 978-1-646310-012

https://www.supercoder.com/cpt-codes/84120

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Contents

Introduction and Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Section I: Terms and Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Chapter 1: Billing, Coding, and Reimbursement Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 2: Medical Terms Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Chapter 3: Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Chapter 4: Prefixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

Chapter 5: Suffixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Chapter 6: Procedure Eponyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299

Section II: Place of Service and Type of Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303Chapter 7: Place of Service / Type of Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

Place of Service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

Type of Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .308

Section III: Anatomical Illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311Chapter 8: Anatomical Illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

Section IV: Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351Chapter 9: Introduction to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

Surgery Section (10004–69990). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

Surgery Subsections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

Integral Components of a Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356

The Global Surgical Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

Section V: Anesthesiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361Chapter 10: Basic Types of Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363

Local and Regional Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363

Section VI: Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367Chapter 11: Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

Section VII: Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371Chapter 12: CPT® Modifier Lay Terms and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

Chapter 13: HCPCS Level II Modifiers, Lay Descriptions, and Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399

Section VIII: Evaluation and Management (E/M) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535Chapter 14: E/M Survival Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537

Introduction: Evaluation and Management (E/M) Services Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537

What Lies Ahead for 2021: Changes to E/M Office and Other Outpatient Codes 99201-99215. . . . . . . . . . . . . . . . . . 550

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VI Coders’ Dictionary & Reference Guide AAPC | 1-800-626-2633

Contents

Chapter 1: New vs. Established Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563

Chapter 2: Office or Other Outpatient Services (99201-99215) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .566

Chapter 3: Hospital Observation Services (99217-99220, 99224-99225, 99234-99236) . . . . . . . . . . . . . . . . . . . . . . . . . 572

Chapter 4: Initial Hospital Care (99221-99223) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577

Chapter 5: Hospital Discharge Services (99238-99239). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583

Chapter 6: Consultations (99241-99255) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588

Chapter 7: Emergency Department Services (99281-99288). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599

Chapter 8: Critical Care Services (99291-99292). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .605

Chapter 9: Nursing Facility Services (99304-99318). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610

Chapter 10: Domiciliary, Rest Home, or Custodial Care Services (99324-99328, 99334-99337) . . . . . . . . . . . . . . . . . 614

Chapter 11: Home Services (99341-99350). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616

Chapter 12: Prolonged Services: Face-To-Face (+99354-+99357, +99415-+99416) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621

Chapter 13: Prolonged Physician Services: Without Direct Patient Contact (99358, +99359) . . . . . . . . . . . . . . . . . . . 626

Chapter 14: Standby Services (99360). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627

Chapter 15: Case Management Services (99366-99368) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628

Chapter 16: Care Plan Oversight Services (99339-99340, 99374-99380). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629

Chapter 17: Preventive Medicine Services (99381-99429) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636

Chapter 18: Telephone and Online Medical Evaluation Services (99441-#99423) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638

Chapter 19: Special E/M Services (99450-99456) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .640

Chapter 20: Newborn Care Services (99460-99463) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .642

Chapter 21: Pediatric Critical Care Patient Transport (99466, +99467, 99485, +99486) . . . . . . . . . . . . . . . . . . . . . . . .643

Chapter 22: Inpatient Neonatal and Pediatric Critical Care (99468-99476) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .646

Chapter 23: Initial and Continuing Intensive Care Services (99477-99480) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .649

Chapter 24: Chronic Care Management Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654

Chapter 25: Concurrent Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 656

Chapter 26: Family Conferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .660

Chapter 27: Second Opinions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661

Chapter 28: Shared E/M Visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 662

Chapter 29: Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665

Appendix A: E/M Audit Tool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .668

Section IX: CPT® 2020 Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673Chapter 15: New/Revised/Deleted Codes Advice for 2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675

New Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675

Revised Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 723

Deleted Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749

Section X: Reader’s Questions and Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 763Reader’s Questions and Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765

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Introduction and Features

We are pleased to offer you the Coders’ Dictionary & Reference Guide, a unique coding resource compiled by experts for your everyday use. We included in this comprehensive reference guide the most used and trusted resources that provide you with all the supporting information you need to tackle the complexities of medical coding.

Features you’ll benefit from page after page include: l Comprehensive list of thousands of medical terms with definitions written in easy to understand language l Billing, coding, and reimbursement terms and definitions so that you can become familiar with current regulations,

requirements, processes, and regulatory agencies l How-to guidance for coding procedures from the Surgery section, including explanations of common terms l Evaluation and Management (E/M) Survival Guide that walks you through E/M services guidelines to make the right choice

between the various E/M service levels l Anesthesia primer to help you distinguish between various types of anesthesia l Modifiers and lay descriptions for CPT® and HCPCS modifiers in simple-to-read language to clear up the confusion of when

and how to apply modifiers l Lists of prefixes, suffixes, abbreviations, and eponyms commonly used in coding l Anatomical illustrations to guide you as you read descriptions of services and procedures l Place of service (POS) and type of service (TOS) lists

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ChapTEr 1 Billing, Coding, and Reimbursement Terms SECTION I Terms and Definitions

16 Coders’ Dictionary & Reference Guide AAPC | 1-800-626-2633

Billing/Coding/ Reimbursement Term

Definition

COLLEGE OF HEALTHCARE INFORMATION MANAGEMENT EXECUTIVES

A professional organization for healthcare Chief Information Officers (CIOs).

COMMENT Public commentary on the merits or appropriateness of proposed or potential regulations provided in response to an NPRM, an NOI, or other federal regulatory notice.

COMMERCIAL MCO A Commercial MCO is a health maintenance organization, an eligible organization with a contract under 1876 or a Medicare-Choice organization; a provider sponsored organization, or any other private or public organization, which meets the requirements of 1902(w). These MCOs provide comprehensive services to commercial and/or Medicare enrollees, as well as Medicaid enrollees.

COMMUNITY MENTAL HEALTH CENTER

A facility that provides the following services: Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health services area who have been discharge from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other than partial hospitalization services, or psychosocial rehabilitation services screening for patients considered for admission to state mental health facilities to determine the appropriateness of such admission; and consultation and education services.

COMPLAINT (OF FRAUD OR ABUSE)

A statement, oral or written, alleging that a provider or beneficiary received a Medicare benefit of monetary value, directly or indirectly, overtly or covertly, in cash or in kind, to which he or she is not entitled under current Medicare law, regulations, or policy. Included are allegations of misrepresentation and violations of Medicare requirements applicable to persons or entities that bill for covered items and services.

COMPLIANCE DATE Under HIPAA, this is the date by which a covered entity must comply with a standard, an implementation specification, or a modification. This is usually 24 months after the effective data of the associated final rule for most entities, but 36 months after the effective data for small health plans. For future changes in the standards, the compliance date would be at least 180 days after the effective data, but can be longer for small health plans and for complex changes.

COMPREHENSIVE INPATIENT REHABILITATION FACILITY

A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.

COMPREHENSIVE MCO A MCO is a health maintenance organization, an eligible organization with a contract under 1876 or a Medicare-Choice organization; a provider sponsored organization or any other private or public organization, which meets the requirements of 1902(w). These MCOs provides comprehensive services to both commercial and/or Medicare, as well as Medicaid enrollees.

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY (CORF)

A facility that provides a variety of services including physicians’ services, physical therapy, social or psychological services, and outpatient rehabilitation.

COMPUTER MATCHING AGREEMENT

Any computerized comparison of two or more systems of records or a system of records of nonfederal records for the purpose of (1) establishments or verifying eligibility or compliance with law and regulations of applicants or recipients/beneficiaries, or (2) recouping payments or overpayments.

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AbbreviationsCHAPTER 3

AAAA abdominal aortic aneurysm AAROM active assistive range of motion AB abortionABE acute bacterial endocarditisABG arterial blood gasesABN abnormal, or advance beneficiary noticea .c . before eatingAC acromioclavicular joint, or abdominal circumferenceACDF anterior cervical diskectomy with fusion ACI autologous chondrocyte implantation ACL anterior cruciate ligamentACLS advanced cardiac life support Acq . acquiredACS acute coronary syndromes ACTH adrenocorticotropic hormone ACVD acute cardiovascular disease ADD attention deficit disorderADH antidiuretic hormoneADHD attention deficit hyperactivity disorder ADL activities of daily livingAF atrial fibrillationAFI amniotic fluid indexA fib atrial fibrillationAFP alpha-fetoproteinAGA appropriate for gestational age AI aortic insufficiencyAID artificial insemination with donor sperm AIDH artificial insemination with husband’s sperm AIDS acquired immunodeficiency syndromeAKA above-knee amputationAL artificial larynxALA aminolevulinic acidALL acute lymphocytic leukemiaALP alkaline phosphataseALS advanced life supportAMA against medical advice, or advanced maternal age AODM adult-onset diabetes mellitus

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ChapTEr 7 Place of Service / Type of Service SECTION II Place of Service and Type of Service


Code Place of Service Description16 Temporary Lodging A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort

where the patient receives care, and which is not identified by any other POS code.17 Walk-in Retail Health

ClinicA walk-in health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services.

18 Place of Employment- Worksite

A location, not described by any other POS code, owned or operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic or rehabilitative services to the individual.

19 Off Campus-Outpatient Hospital

A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

20 Urgent Care Facility Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

21 Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

22 On Campus-Outpatient Hospital

A portion of a hospital's main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

23 Emergency Room-Hospital

A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

24 Ambulatory Surgical Center

A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.

25 Birthing Center A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate post- partum care as well as immediate care of new born infants.

26 Military Treatment Facility

A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).

31 Skilled Nursing Facility

A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

32 Nursing Facility A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.

33 Custodial Care Facility A facility which provides room, board and other personal assistance services, generally on a long- term basis, and which does not include a medical component.

34 Hospice A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.

41 Ambulance-Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.

42 Ambulance-Air or Water

An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.

49 Independent Clinic A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.

50 Federally Qualified Health Center

A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.

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CHAPTER 8 Anatomical Illustrations

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ChapTEr 14 E/M Survival Guide SECTION VIII Evaluation and Management (E/M)


Table 3: Sample Column from 2021 E/M Table for MDM Level

Code Level of MDM(Based on 2 out of 3 Elements of MDM)

Elements of Medical Decision MakingNumber and Complexity of Problems Addressed

Amount and/or Complexity of Data to be Reviewed and Analyzed*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.

Risk of Complications and/or Morbidity or Mortality of Patient Management

99203

99213

Low Low l 2 or more self-limited

or minor problems; or

l 1 stable chronic illness; or

l 1 acute, uncomplicated illness or injury

Limited

(Must meet the requirements of at least 1 of the 2 categories)

Category 1: Tests and documents l Any combination of 2 from the following:

| Review of prior external note(s) from each unique source*;

| review of the result(s) of each unique test*; | ordering of each unique test*

or

Category 2: Assessment requiring an independent historian(s)

(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)

Low risk of morbidity from additional diagnostic testing or treatment

Number and Complexity of Problems Addressed at the EncounterThe 2021 CPT® guidelines will include a heading for Number and Complexity of Problems Addressed at the Encounter. This part of the guidelines includes a brief discussion about how the problems addressed may affect code level selection. Under this header, there are also many definitions, explained in the next section, that are important to MDM.

One important point the 2021 guidelines make is that the final diagnosis isn’t the only factor when you determine the complexity or risk. A patient may have several lower severity problems that combine to cause higher risk, or the provider may have to perform an extensive evaluation in certain cases to determine the problem is one of lower severity.

The 2021 guidelines also take a 2020 rule and expand it, clarifying that you should not consider comorbidities and underlying diseases when you select the E/M level “unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.”

2021 MDM Terms and DefinitionsFor you to use the 2021 level of MDM table properly, you will need to know CPT®’s definitions for many terms. In fact, you’ll need to know about two and a half pages of definitions. Below is an overview of those terms, but you should review the actual guidelines to prepare for the 2021 E/M transition.

NOTES

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SECTION VIII Evaluation and Management (E/M) ChapTEr 14 E/M Survival Guide

NOTESChapter 7: Emergency Department Services (99281-99288)You may report 99281-99285 only for services the physician provides in the ED.

An ED, as defined by the IOM (Publication 100-4, Chapter 12, Section 30.6.11B), is an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. CPT® defines an ED similarly as an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention.

You should not report 99281-99285 Emergency department visit for the evaluation and management of a patient… Counseling and/or coordination of care with other physicians, other qualified healthcare professionals … for services (even emergency services) the physician provides in the office or outpatient setting other than an emergency department.

You can report 99281-99285 even in nonemergency situations for services provided in the ED. The only requirement for using the emergency department codes is that the patient be seen in the emergency department for an unanticipated service, the IOM states.

Any physician — not only those assigned to the ED — can report 99281-99285. Nothing in the ED service codes definitions limits you to reporting them for physicians assigned to the ED.

Medicare specifically states in the IOM (Publication 100-4, Chapter 12, Section 30.6.11), “Any physician seeing a patient in the ED may use ED visit codes for services matching the code description. It is not required that the physician be assigned to the emergency department to use ED visit codes.”

Use Key Components to Choose Service LevelWhen assigning 99281-99285, you must rely on the key E/M components of history, exam, and MDM, as recorded in the physician’s documentation of the patient encounter. You must meet (or exceed) all three requirements to report a given service level, as follows:

Code History Exam MDM99281 Problem focused Problem focused Straightforward99282 Expanded problem

focusedExpanded problem focused

Low complexity

99283 Expanded problem focused

Expanded problem focused

Moderate complexity

99284 Detailed Detailed Moderate complexity

99285 Comprehensive Comprehensive High complexity

Example: A mildly disoriented patient presents to the ED with several lacerations suffered during a fall from a ladder.

The physician examines the patient and records an expanded problem-focused history, a detailed exam, and MDM of moderate complexity.

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ChapTEr 14 E/M Survival Guide SECTION VIII Evaluation and Management (E/M)

NOTES


Returning to the above example, if the physician spends at least 90 minutes with the patient and reports 99231, you may also code for prolonged services using +99356 (for the first hour beyond the 15-minute reference time of 99213) and +99357 (for the additional 15 minutes, which qualifies for the add-on code of an additional 30 minutes of prolonged services beyond the first hour).

The chart below illustrates proper coding for prolonged services with direct patient contact for the outpatient setting:

Total Duration of Prolonged Services Beyond E/M Time

Codes

Less than 30 minutes Not reported separately30-74 minutes 99354 x175-104 minutes 99354 x 1, 99355 x 1105-134 minutes 99354 x 1, 99355 x 2135-164 minutes 99354 x 1, 99355 x 3165-194 minutes 99254 x1, 99355 x 4

Remember: You should report only a single unit of either +99354 or +99356 per date of service, but you can report multiple units of +99355 or +99357 per day. Also, you cannot report +99355 without first reporting +99354, nor can you report +99357 without first reporting +99356.

Document Time With CareTo gain reimbursement for prolonged services, you must document all time the physician spends face-to-face with the patient for outpatient coding, and all the unit/floor time the physician spends treating the patient in the inpatient setting. Without an actual minute value stated in the physician notes, prolonged service codes are not valid no matter how much time the physician actually spent.

Time needn’t be uninterrupted: The time you count toward prolonged services need not be continuous, although it should occur on the same date of service. The physician may consult with a patient in the hospital, spend 30 minutes discussing their condition, leave to perform regular rounds, and return to the original patient for another 40 minutes of counseling. The time spent with the patient both before and after the physician made rounds can contribute toward prolonged services.

Give a reason: You must explain why the physician provided prolonged services, according to IOM instructions (Publication 100-04, Chapter 12, Section 30.6.15.1 C), which state, to support billing for prolonged services, the medical record must document the duration and content of the E/M code billed.

Simply noting that the physician spent an extra 42 minutes with the patient, for instance, is not adequate. You must prove, in the medical record, the medical necessity for the extra time spent.

Don’t Overuse Prolonged ServicesYou must be careful not to use prolonged services codes too frequently. On average, you should report +99354 only once every 1,000 claims, while you should report +99356 only once every 100,000 claims, according to CMS estimated usage rates.

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New/Revised/Deleted Codes Advice for 2020CHAPTER 15

New CodesCPT® Code Description Advice

Evaluation and Management Services99421 Online digital evaluation and

management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

CPT® 2020 adds three new Evaluation and Management (E/M codes (99421, 99422, 99423) to report online digital evaluation and management services for an established patient. Report 99421 for 5 to 10 minutes of cumulative time over a 7-day period, 99422 for 11 to 20 minutes, and 99423 for 21 or more minutes providing online digital E/M services for an established patient by a physician or other qualified healthcare professional. CPT® 2020 also deletes 99444 and adds a new E/M subsection. In addition, the 2020 code set adds three new Medicine codes (98970, 98971, 98972) to report online digital evaluation and management services provided by a qualified nonphysician healthcare professional. Report 98970 for 5 to 10 minutes of cumulative time spent with an established patient over a 7-day period, 98971 for 11 to 20 minutes, and 98972 for 21 or more minutes. The code set also deletes 98969 and adds a new Medicine subsection. Effective date of this code: January 1, 2020.

99422 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes


99423 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes


99458 Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure)

CPT® 2020 adds +99458 to report each additional 20 minutes in a calendar month of remote physiologic monitoring treatment management services requiring interactive communication with the patient or caregiver by clinical staff, physician, or other qualified healthcare professional and revised existing code 99457 to represent the first 20 minutes of the same services. The 2020 code set also revises Remote Physiologic Monitoring Treatment Management Services guidelines. Effective date of this code: January 1, 2020.

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ChapTEr 15 New/Revised/Deleted Codes Advice for 2020 SECTION IX CPT® 2020 Updates


CPT® Code Description Advice CrosswalksCategory III Codes, cont .

0206T Computerized database analysis of multiple cycles of digitized cardiac electrical data from two or more ECG leads, including transmission to a remote center, application of multiple nonlinear mathematical transformations, with coronary artery obstruction severity assessment

CPT® 2020 deletes 0206T. The AMA did not give a reason for this deletion, but over- or under-reporting may have been a factor. The AMA also did not provide an alternative code to report. Effective date of deletion of this code: January 1, 2020.

The AMA does not provide crosswalk codes for this deleted code.

0249T Ligation, hemorrhoidal vascular bundle(s), including ultrasound guidance

CPT® 2020 deletes Category III code 0249T for ligation of hemorrhoidal vascular bundle with ultrasound guidance and replaces it with 46948, expanding on the definition of the technique and including mucopexy when performed. Ultrasound-guided transanal hemorrhoidal dearterialization is a minimally invasive procedure that consists of ligating (tying off) the hemorrhoid column or group. Mucopexy involves plication, lifting up prolapsed mucosa and suturing tucks or pleats in it to shorten it so that it no longer prolapses out of the rectum. Effective date of deletion of this code: January 1, 2020.

To report, use 46948

0254T Endovascular repair of iliac artery bifurcation (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma, dissection) using bifurcated endograft from the common iliac artery into both the external and internal iliac artery, including all selective and/or nonselective catheterization(s) required for device placement and all associated radiological supervision and interpretation, unilateral

CPT® 2020 deletes Category III code 0254T and adds two new codes (+34717 and 34718) to report unilateral endovascular iliac artery repairs. Both codes expand on the definition of the temporary code. Code +34717 is for an add-on procedure. In addition to deployment of a branched endograft to repair the iliac artery on one side of the body and all extensions from the aortic bifurcation to the internal and external iliac and common femoral arteries, +34717 covers all ipsilateral iliac artery selective catheterization, pre-procedure sizing and device selection, RS&I, and angioplasty or stenting in the treatment zone, when performed. The code specifies that the procedure is performed for rupture or other than rupture, with numerous parenthetical examples of same. As an add-on code, it must be reported in conjunction with an acceptable primary code for aortoiliac artery endograft placement (see notes or guidelines for acceptable primary codes). Use 34718 to report the same procedure not performed in conjunction with aortoiliac artery endograft placement. Effective date of deletion of this code: January 1, 2020.

To report, see 34717, 34718

0341T Quantitative pupillometry with interpretation and report, unilateral or bilateral

CPT® 2020 deletes 0341T. The AMA did not give a reason for this deletion, but over- or under-reporting; duplicative or misreported may have been a factor. The AMA also did not provide an alternative code to report. Effective date of deletion of this code: January 1, 2020.


0357T Cryopreservation; immature oocyte(s) CPT® 2020 deletes 0357T. The AMA did not give a reason for this deletion, but over- or under-reporting or misreporting may have been a factor. The AMA also did not provide an alternative code to report. Effective date of deletion of this code: January 1, 2020.


0375T Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels

CPT® 2020 deletes 0375T. The AMA did not give a reason for this deletion, but over- or under-reporting; duplicative or misreported may have been a factor. The AMA also did not provide an alternative code to report. Effective date of deletion of this code: January 1, 2020.


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NOTES

Reader’s Questions and Answers

Billing/Compliance/Reimbursement

ADHDQuestion: We have patients who have instructions from their employer to get a 90-day supply for their prescription for ADHD in order to save the employer and the employee money. My doctors are wanting to help our patients and save them money. Are there restrictions in Georgia against this? Nationwide?

Answer: Schedule II drugs have a high potential for abuse and are considered dangerous by the Drug Enforcement Agency. Schedule II drugs do have certain restrictions on prescription management issued by the Department of Justice Office of Diversion. Certain ADD and ADHD medications fall under the category of Schedule II drugs.

The Office of Diversion does not place any limitations on the quantity of medications prescribed, but refills are prohibited. States and insurance companies may place limits of up to 30 days for Schedule II prescriptions. The Georgia Drugs and Narcotics Agency does not issue specific guidance on the length of prescriptions for Schedule II drugs. You can find more information at the Georgia Drugs and Narcotics Agency at gdna.georgia.gov and the Office of Diversion (pract_manual012508.pdf at www.deadiversion.usdoj.gov).

Assistant Surgeon Question: CPT® +11046 is an add-on code for the primary code 11043. The assistant surgeon (modifier AS) is applicable for the add-on code (+11046) but not the primary code (11043). How can we report both codes for an assis-tant surgeon who is a PA?

Answer: Code 11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq. cm or less, does not allow assistant surgeon reimbursement, which is why you are unable to use the AS modifier with this procedure code. Procedure code 11046 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq. cm, or part thereof, does allow for assistant surgeon reimbursement when supported. This code would be the only option for billing an assistant surgeon.

You should bill both codes with the AS modifier and allow the insurance company to process the claim according to their policy. You should bill it because there was an assistant, although you know the primary code will more than likely be denied.

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Reader’s Questions and Answers SECTION X Reader’s Questions and Answers

NOTES


Question: The physician injectable drug list shows: J2791 Microgram ultra-filtered plus Rho(D) immune globulin greater than 100 units. Does this mean we should be billing 100 units every time this code is billed, for example J2791 x100?

Answer: The code J2791 Injection, Rho(D) immune globulin (human), (Rhophylac®), intramuscular or intravenous, 100 IU, includes billing for up to 100 IU. You should code J2791 per 100 IU. IU stands for international units. A conversion calculator may be used to convert IU to another form of measurement if needed. For example, if your provider gives 200 IU of J2791, you would bill J2791 x 2.

INR Monitoring Question: Can you clarify billing on code G0249? My understanding is that four tests must be performed, and results returned to the physician before it can be billed? So, the date of service would be the date the fourth result is reported to the physician? I understand it can be billed once per week or is this a global code?

Answer: Code G0249 Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria requires documentation of provision of materials for use in the home and reporting of test results to physician. You are correct that the testing should not occur more frequently than once a week. The billing units of service include four tests and the date of service reported will be the date when you receive the results.

Medication Administration Question: How should I code for medicine and administration of dexameth-asone oral dose? The NDC is 0054-3176-44 oral dose 1 mL.

Answer: The HCPCS Level II code that you should bill is J8540 Dexamethasone, oral, 0.25 mg. If you have only provided a tablet, you would not bill an administration code.

Question: What is the HCPCS Level II code for Bydureon®? This is a diabetes drug with the generic name of exenatide.

Answer: The most appropriate code for Bydureon® is J3490 Unclassified drugs.

Pain Pump Refill Question: When filling a pain pump with J3010 400 mg, how many units should be billed?

Answer: If the dosage is 400 mg, bill 4000 units of HCPCS Level II code J3010 Injection, fentanyl Citrate, 0.1 mg. If the dosage is 400 mcg, bill four units of HCPCS Level II code J3010.

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SECTION X Reader’s Questions and Answers Reader’s Questions and Answers

NOTESInternal Medicine

Annual Exam Question: The patient comes in for an annual yearly checkup with diagnoses of hypertension (HTN), hyperlipidemia (HLD), and diabetes mellitus (DM). The yearly exam is done, and chronic conditions were managed. Should this be coded in ICD-10-CM as Z00.00, annual with no abnormalities, since nothing new appeared at this annual or Z00.01 since the patient carries the chronic diseases currently?

Answer: ICD-10-CM code Z00.00 Encounter for general adult medical examination without abnormal findings seems appropriate since there is no new finding. And don’t forget to report the appropriate diagnosis codes for HTN, HLD, and DM along with Z00.00.

Asthma Control Test Question: Should we code separately for the asthma control test (ACT)?

Answer: Completion and scoring of the asthma control test is included in the E/M for asthma visits. There is no specific representation for this service to code. ACT is more of a questionnaire given to the patient or parent to complete rather than a test.

B-12 Injection Question: Is there an administration code that we should use when giving B-12 injections?

Answer: The administration code that you should use with a B-12 injection is 96372 Therapeutic, prophylactic, or diagnostic injection [specify substance or drug; subcutaneous or intramuscular. This is billed in conjunction with J3420 Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg.

Blood Pressure Question: If a patient was seen for just a blood pressure check, should I code I10?

Answer: The correct diagnosis code would depend on the reason that the patient is having his blood pressure checked. If the patient has hypertension, then you would use the appropriate hypertension code. You can select from Z01.31 Encounter for examination of blood pressure with abnormal findings or Z01.30 Encounter for examination of blood pressure without abnormal findings, depending on your documentation. Your provider will definitely need to have appropriate documentation within the patient’s chart in order for you to assign a code.

Chemotherapy Question: Could you please tell me the proper way to bill for chemotherapy education? Our NP often codes an office visit for this. This is the only reason the patient is being seen.

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