Medicare Correct Coding Guide

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Medicare Correct

Coding Guide

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Contents

Introduction ... Introduction–1 Resource Based Relative Value System (RBRVS) Payment Computation ...Introduction–1 Relative Value Units ...Introduction–1 PE-RVU Transition ...Introduction–1 Conversion Factor ...Introduction–1 Geographical Practice Cost Indices ...Introduction–1 General Formula for Calculating Payment ...Introduction–2 Modifiers ...Introduction–2 Surgical Modifiers ...Introduction–2 Modifiers Affecting Correct Coding Edits ...Introduction–2 Other Payment Indicators ...Introduction–3 Status Indicator ...Introduction–3 Global Period ...Introduction–3 Physician Supervision Level ...Introduction–3 Definitions ...Introduction–3 Levels of Physician Supervision Diagnostic Tests...Introduction–3 Correct Coding Initiative (CCI) ...Introduction–4 The Commercial "Black Box" Edits ...Introduction–4 Manual Organization ...Introduction–5 How to Use ...Introduction–5 Step by Step Instructions ...Introduction–5 Code Pair Additions ... Summary of Changes–1 Code Pair Deletions ...Summary of Changes–13 Modifier Revisions ...Summary of Changes–15 General Correct Coding Policies ...General–1 A. Introduction ...General–1 B. Coding Based on Standards of Medical/Surgical Practice ...General–1 C. Medical/Surgical Package ...General–2 D. Evaluation and Management Services ...General–3 E. Standard Preparation/Monitoring Service ...General–3 F. Anesthesia Service Included in the Surgical Procedure ...General–4 G. Coding Services Supplemental to a Principal Procedure (Add-on Codes) ...General–4 H. Modifiers ...General–4 I. HCPCS/CPT Procedure Code Definition ...General–5 J. HCPCS/CPT Coding Manual Instruction/Guideline ...General–5 K. Separate Procedures ...General–6 L. Family of Codes ...General–6 M. Most Extensive Procedures ...General–6 N. Sequential Procedures ...General–6 O. Laboratory Panels ...General–6 P. Misuse of Column 2 Code with Column 1 Code ...General–6 Q. Mutually Exclusive Procedures...General–7 R. Gender-Specific Procedures (formerly Designation of Sex) ...General–7 S. Excluded Service ...General–7 T. Unlisted Services or Procedures ...General–7 U. Modified, Deleted and Added Code Pairs, Edits

Surgery: Integumentary System (CPT Codes 10000–19999) ... Integumentary–1 Correct Coding Policies ...Integumentary–1 A. Introduction ...Integumentary–1 B. Evaluation and Management ...Integumentary–1 C. Anesthesia... Integumentary–1 D. Incision and Drainage ...Integumentary–1 E. Lesion Removal ...Integumentary–2 F. Repair and Tissue Transfer ...Integumentary–3 G. Grafts and Flaps ...Integumentary–3

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Contents

Radiology Services CPT (Codes 70000–79999) ... Radiology–1 Correct Coding Policies ... Radiology–1 A. Introduction ... Radiology–1 B. Non-interventional Diagnostic Imaging ... Radiology–1 C. Interventional/Invasive Diagnostic Imaging ... Radiology–1 D. Evaluation and Management ... Radiology–1 E. Nuclear Medicine ... Radiology–2 F. General Policy Statements ... Radiology–2 Code Tables ... Radiology–3 Pathology/Laboratory Services (CPT Codes 80000–89999) ...Pathology–1 Correct Coding Policies ... Pathology–1 A. Introduction ... Pathology–1 B. Organ or Disease Oriented Panels ... Pathology–1 C. Evocative/Suppression Testing ... Pathology–1 D. General Policy Statements ... Pathology–1 Code Tables ... Pathology–3 Medicine, Evaluation and Management Services (CPT Codes 90000–99999) ... Medicine–1 Correct Coding Polices ...Medicine–1 A. Introduction ...Medicine–1 B. Therapeutic or Diagnostic Infusions/Injections ...Medicine–1 C. Psychiatric Services ...Medicine–1 D. Biofeedback ...Medicine–1 E. Gastroenterology ...Medicine–1 F. Ophthalmology ...Medicine–1 G. Otorhinolaryngologic Services ...Medicine–2 H. Cardiovascular Services ...Medicine–2 I. Pulmonary Services ...Medicine–2 J. Allergy Testing and Immunotherapy ...Medicine–3 K. Neurology and Neuromuscular Procedures ...Medicine–3 L. Chemotherapy Administration ...Medicine–3 M. Osteopathic Manipulative Treatment...Medicine–4 N. Chiropractic Manipulative Treatment ...Medicine–4 O. Miscellaneous Services ...Medicine–4 P. Evaluation and Management ...Medicine–4 Q. General Policy Statements ...Medicine–4 Code Tables ...Medicine–7 Medicine Services ...Medicine–7 Evaluation and Management Services... Medicine–125 Category III Codes (CPT Codes 0001T–0099T)... Category III–1 Code Tables ... Category III–3 HCPCS Level II (Supplemental Services) (Codes A0000–V9999) ...HCPCS–1 Correct Coding Policies ...HCPCS–1 A. Introduction ...HCPCS–1 B. General Policy Statements ...HCPCS–1 Code Tables ...HCPCS–3 Appendix A: Geographic Practice Cost Indices by Medicare Locality ... Appendix A–1 Appendix B: CPT Modifiers ... Appendix B–1

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Introduction

Procuring reimbursement for health care services is one of the most complex processes of the health care system. The impact of the billing and reim-bursement system certainly permeates the entire health care system. And since the cost of health care has risen dramatically, the federal government has taken the lead in cost containment through a number of legislative enactments affecting the reimbursement system.

On December 19, 1989, the Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239) was enacted. Section 6102 of P.L. 101-239 amended Title XVIII of the Social Security Act (the Act) by adding a new section 1848, Pay-ment for Physicians’ Services. This section of the Act provided for replacing the previous reasonable charge mechanism of actual, customary, and pre-vailing charges with a resource based relative value scale (RBRVS) fee schedule that began in 1992. The intent of this physician payment reform was to establish consistent payment policies as well as payment equity. The Resource Based Relative Value System (RBRVS) was created to accu-rately reflect the skill, time, and resources required for each procedure or office visit. The Centers for Medicare and Medicaid Services (CMS) annually makes revisions to the payment policies and adjustments to the relative value units which is released as the Medicare Physician Fee Schedule Data Base (MPFSDB) published in the Federal Register. These changes are effec-tive January 1st of each year.

With the implementation of the RBRVS system, it was increasingly impor-tant to assure that uniform payment policies and procedures were followed by all carriers. This launched the Correct Coding Initiative. The goal of the Correct Coding Initiative was to develop correct coding methodologies based on the coding conventions in the American Medical Association’s Physi-cians’ Current Procedural Terminology (CPT®) book, in national and local policies and edits, in coding guidelines developed by national societies, in analysis of standard medical and surgical practices, and in review of current coding practices. Initiated in January 1996 and updated quarterly as an ongoing refinement process, the Correct Coding Initiative developed correct coding edits that would ensure uniform payment for the same service ren-dered regardless of carrier jurisdictions. As a result improper coding prac-tices that lead to inappropriate increased payment for services rendered to Medicare Part B beneficiaries would be controlled.

Medicare Correct Coding and Guide is a comprehensive manual which alerts the user to essential information concerning rules, payment restrictions and claim submission edits that are critical for reporting procedures and services correctly. Please note that this manual does not include codes that are excluded from or not covered under the physician fee schedule, unless there are associated correct coding edits. Also be aware that codes with a status indicator of not valid may have relative value units indicated, however Medi-care does not recognize these codes and the indicated RVUs are not used for Medicare payment. The introduction of this manual includes the following explanatory sections: the RBRVS system, the Correct Coding Policies, and step by step instructions to assist in the use of the manual.

Resource Based Relative Value System (RBRVS)

Payment Computation

The major factors for computing the payment amount under the RBRVS sys-tem are:

■ Relative Value Units (RVUs) ■ Conversion Factor (CF)

■ Geographical Practice Cost Indices (GPCIs)

Other factors that can affect the payment amount for services under the Phy-sician Fee Schedule are the use of modifiers, the site of service, global sur-gery periods, and payment status. Each of these factors will be explained in detail under separate headings.

Relative Value Units

The Total Relative Value Unit (RVUt) of a service or procedure is comprised of three components:

Work (RVUw): Physician work RVU reflecting the resources of skill, time, and intensity of effort to furnish the service.

Practice (PE-RVU): Practice RVU reflecting the overhead expenses incurred to provide the space, equipment, supplies, and support per-sonnel cost for providing the services. Malpractice (RVUm): Malpractice RVU reflecting the cost of professional liability insurance as a per-centage of physician revenue.

PE-RVU Transition

The four-year transition from charge-based to resource-based practice expense relative value units (PE-RVUs) became effective Jan. 1, 1999. Pre-vious to this year, PE-RVUs were based on historical physician charge data. The resource-based RVU system, based on a methodology developed by CMS, takes into consideration the staff, supplies and equipment used to pro-vide medical and surgical services in different settings.

For 2001, percentages were 25 percent charge-based and 75 percent resource-based. For 2002 and subsequent years, PE RVUs will be com-pletely resource-based.

There are two types of PE RVUs—facility (PE-f ) (hospital, skilled nursing facility or an ambulatory surgery center ) and non-facility (PE-nf) (physician’s office, patient’s home, or any other facility or institution, such as a residen-tial care setting that is not a hospital, SNF or ASC). This will also eliminate the site-of-service differential, which resulted in the past in the reduction of PE-RVUs by 50 percent for designated codes performed outside of the phy-sician’s office.

Conversion Factor

The Conversion Factor (CF) is a nationally uniform dollar conversion factor for the services that convert the relative values into payment amounts. The conversion factor for fiscal year 2004 is $35.1339.

Note: At the time of printing there was legislation pending that may affect the conversion factor for 2004. If changes are made to the conversion fac-tor, you will be notified via e-mail of the changes and given instructions as to where to locate the revised information on the Ingenix Web site.

Geographical Practice Cost Indices

For each of the relative value units there is a geographical practice cost index (GPCI) that reflects the relative costs for each of the units for that specific geographic area in comparison to the national average for each of the units. This factor is set annually by CMS according to the mechanisms defined in Section 1848(b)(1) of the Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239).

See Appendix A for a complete listing of the Geographic Practice Cost Indi-ces.

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Introduction

expansion of these ideas and concepts is planned for future refinement years.

If you have any questions regarding the National Correct Coding Policy, please contact the provider relations staff of your Medicare carrier or submit your comments in writing to:

CMS Correct Coding Initiative AdminaStar Federal P.O. Box 50469

Indianapolis, IN 46250-0469

The Commercial “Black Box” Edits

Beginning October 1, 1998, CMS implemented the use of additional com-mercial edits in order to improve Medicare’s auditing system for detecting unbundling in procedure coding. These commercial edits (approximately 500) are also known as black box edits or commercial off-the shelf (COTS) edits. The new commercial procedure to procedure edits system will be used concurrently with the National Correct Coding Initiative edits (approxi-mately 108,000). There will be no way of determining the source of the edits since, the same EOMB will apply for both sets of edits.

The new commercial edits were developed by a private commercial claims auditing vendor and CMS intends to protect the proprietary rights attached to these edits. No explicit Medicare policies require the disclosure of the specific edits, therefore, publishing the commercial edits will not be an option. Ingenix will continue to provide you with the most current version of the NCCI edits, but we are prohibited from including the new commercial edits.

Manual Organization

Medicare Correct Coding and Payment Manual was developed with the pro-vider of services in mind. This manual presents the essential information needed to submit claims correctly, completely and accurately every time in a convenient, efficient format. With this information, you will experience more proficient reimbursement, encounter fewer delays, denials and requests for information, and avoid improper coding that may trigger an audit. The initial chapters contain an overview of the prominent legislative enact-ments affecting the reimbursement system, a summary of the major compo-nents of the Medicare physician fee schedule for services rendered, and general information concerning the general correct coding policies including a quick reference section for the coding policy explanations.

Following the introductory chapters, the manual provides a comprehensive summary of the reimbursement factors for each CPT code. Subsequent chapters are arranged by code series arranged in ascending numerical order noted on the individual tabs for quick location of a code or group of codes. Provided at the beginning of each of the code series are the coding policies that apply specifically to that code series. Explicit examples of each of the coding policies specific to each section is included in the section introduc-tion. Immediately following the coding policies and examples are the CPT codes with full description, complete relative value units, payment indica-tors, and the correct coding edits for the code. Some chapters provide fur-ther subdivision of the codes by body system.

A chapter listing the above mentioned information for the HCPCS Level II codes for nonphysician services and supplies complements the previous CPT coding system information to complete the coding process for proce-dures and services.

In order to implement the information presented in the first three sections of this manual accurately, a chapter is devoted to completing the CMS-1500 form with line by line instructions.

To reinforce the importance of following correct coding methodologies, the final chapter presents an overview of fraud and abuse in the health care sys-tem, including a summary of pertinent sections of the Health Insurance Port-ability and AccountPort-ability Act of 1996.

Finally, for your convenience, several reference appendices are supplied to provide you with supplementary information germane to reimbursement issues.

How to Use

Note: The following steps are based on data contained in the 2004 fee schedule as posted on CMS’s Web site. At the time of printing there was leg-islation pending that may affect the conversion factor and GPCIs for 2004. If changes are made to the conversion factor and the GPCI, you will be noti-fied via e-mail of the changes and given instructions as to where to locate the revised information on the Ingenix Web site.

Step by Step Instructions

The steps to follow for successful use of the Medicare Correct Coding and Payment Manual for Procedures and Services are delineated below. Step 1

Assign the initial code using the CPT manual. Locate the section of this manual containing the desired code series. Review the section information concerning the correct coding policies.

Example: You have assigned the CPT code 11450 using the source docu-ment and current CPT manual. Turn to section 10000-19999 in this manual. Review the introductory information.

Step 2

Locate the specific CPT code. Review and verify the code description.

11450

Excision of skin and subcutaneous tissue for hidradenitis,

axillary; with simple or intermediate repair Step 3

Listed directly below the code and narrative are the relative value units for this procedure. The formula for determining the payment amount under the fee schedule is shown below.

[RVUw X GPCI work] + [PE-RVU X GPCIp]+ [RVUm X GPCIm] X CF = Dollar Payment Amount

Refer to Appendix A for component GPCIs, if calculating payment manually. For this example, the clinic which provided the service is located in Ala-bama.

Example:

Work 2.71 X GPCIw 0.978 = 2.650 ADD

Practice Expense 5.20 X GPCIp 0.870 = 4.524 ADD

Malpractice 0.31 X GPCIm 0.779 = 0.241 Subtotal = 7.415

Insert the RVUs for code 11450 into the formula for calculating payment.

RELATIVE VALUE UNITS

Work Malpractice PE–nf PE–f Total–nf Total–f

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General Correct Coding Policies

A. Introduction

The Physicians' Current Procedural Terminology (CPT) developed by the American Medical Association and HCPCS Level II codes developed by the Centers for Medicare and Medicaid Services (CMS) are listings of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. The codes in the CPT Manual are copyrighted by the AMA, and updated annually by the CPT Editorial Panel based on input from the AMA Advisory Committee which serves as a channel for requests from various providers and specialty societies. The purpose of both coding systems and annual updates is to communicate specific services rendered by physicians and other providers, usually for the purpose of claim submis-sion to third party (insurance) carriers. A multitude of codes is necessary because of the wide spectrum of services provided by various medical care providers. Because many medical services can be rendered by different methods and combinations of various procedures, multiple codes describ-ing similar services are frequently necessary to accurately reflect what ser-vice a physician performs. While often only one procedure is performed at a patient encounter, multiple procedures are performed at the same session at other times. In the latter case, the pre-procedure and post-procedure work does not have to be repeated and, therefore, a comprehensive code, describ-ing the multiple services commonly performed together, can be defined. Third party payers have adopted the CPT coding system for use by provid-ers to communicate payable services. It therefore becomes more important to identify the various potential combinations of services to accurately adju-dicate claims.

There are two types of Correct Coding Initiative edits, column 1/column 2 correct coding (formerly known as comprehensive/component) edits and mutually exclusive edits. All edits consist of code pairs that are arranged in column 1 and column 2 of the tables. All edits are included in one table. The column 2 code is not payable with the column 1 code unless the edit permits use of a modifier associated with CCI (Chapter I, Section H). The correct coding edit table contains many edits where the column 2 code is a component of the column 1 comprehensive code. However, there are many edits where there is no comprehensive/component relationship, but the col-umn 1 code and colcol-umn 2 code should not be reported together for other reasons. The following policies encompass general issues/coding principles that are to be applied in all subsequent chapters. Specific examples are stated to clarify the policy but do not represent the only code or service that is included in the policy.

B. Coding Based on Standard of Medical/Surgical Practice

In order for this system to be effective, it is essential that the coding descrip-tion accurately describe what actually transpired at the patient encounter. Because many physician activities are so integral to a procedure, it is impractical and unnecessary to list every event common to all procedures of a similar nature as part of the narrative description for a code. Many of these common activities reflect simply normal principles of medical/surgical care. These “generic” activities are assumed to be included as acceptable medical/surgical practice and, while they could be performed separately, they should not be considered as such when a code descriptor is defined. Accordingly, all services integral to accomplishing a procedure will be con-sidered included in that procedure.

Many of these generic activities are common to virtually all procedures. On other occasions, some are integral to only a certain group of procedures but are still essential to accomplish these particular procedures. Accordingly, it would be inappropriate to separately code these services based on standard medical and surgical principles.

Some examples of generic services integral to standard of medical/surgical services would include:

■ Cleansing, shaving and prepping of skin

■ Draping of patient; positioning of patient

■ Insertion of intravenous access for medication

■ Sedative administration by the physician performing the proce-dure (see Chapter II, Anesthesia section, for the separate policy)

■ Local, topical or regional anesthetic administered by physician performing procedure

■ Surgical approach, including identification of anatomical land-marks, incision, evaluation of the surgical field, simple debride-ment of traumatized tissue, lysis of simple adhesions, isolation of neurovascular, muscular (including stimulation for identification), bony or other structures limiting access to surgical field

■ Surgical cultures

■ Wound irrigation

■ Insertion and removal of drains, suction devices,dressings, pumps into same site

■ Surgical closure

■ Application, management, and removal of postoperative dress-ings including analgesic devices (peri-incisional TENS unit, insti-tution of Patient Controlled Analgesia)

■ Preoperative, intraoperative and postoperative documentation, in-cluding photographs, drawings, dictation, transcription as neces-sary to document the services provided

■ Surgical supplies, unless excepted by existing CMS policy In the case of individual services, there are numerous specific services that may typically be involved in order to accomplish a column 1 procedure. Generally, performance of these services represents the standard of practice for a more comprehensive procedure and the services are therefore to be included in that service.

Because many of these services are unique to individual CPT coding tions, the rationale for correct coding will be described in that particular sec-tion. The principle of the policy to include these services into the column 1 procedure remains the same as the principle applied to the generic service list noted above. Specifically, these principles include:

1. The service represents the standard of care in accomplishing the overall procedure.

2. The service is necessary to successfully accomplish the column 1 procedure; failure to perform the service may compromise the suc-cess of the procedure.

3. The service does not represent a separately identifiable procedure unrelated to the column 1 procedure planned.

Specific examples consist of: Medical:

1. Procurement of a rhythm strip in conjunction with an electrocardio-gram. The rhythm strip would not be separately reported if it was

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Medicare Correct Coding Guide (CCI Version 10.0)

proce-dure is included in the “with” proceproce-dure.

J. HCPCS/CPT Coding Manual Instruction/Guideline

Each of the six major sections of the CPT Manual and several of the major subsections include guidelines that are unique to that section. These direc-tions are not all inclusive or limited to definidirec-tions of terms, modifiers, unlisted procedures or services, special or written reports, details about reporting separate, multiple or starred procedures and qualifying circum-stances. These instructions appear in various places and are found at the beginning of each major section, at the beginning of subsections, and before or after a series of codes or individual codes. They define items or provide explanations that are necessary to appropriately interpret and report the procedures or services and to define terms that apply to a particular section. Notations are made in parentheses when CPT codes are deleted or cross-ref-erenced to another similar code so that the provider has better guidance in the appropriate assignment of a CPT code for the service. Providers should not report CPT codes that are contrary to CPT instructions.

K. Separate Procedure

The narrative for many CPT codes includes a parenthetical statement that the procedure represents a “separate procedure.” The inclusion of this state-ment indicates that the procedure, can be performed separately but should not be reported when a related service is performed. The “separate proce-dure” designation is used with codes in the surgery (CPT codes 10000-69999), radiology (CPT codes 70000-79999) and medicine (CPT codes 90000-99199) sections. When a related procedure is performed, a code with the designation of “separate procedure” is not to be reported with the primary procedure.

Example: If the code identified as a “separate procedure” is reported with a related procedure code, such as when a sesamoidectomy, thumb or finger (CPT code 26185) is reported with an excision or curettage of a bone cyst or benign tumor of the proximal, middle, or distal phalanx of the finger with autograft (CPT code 26215), then the sesamoidectomy (separate procedure) should not be reported. By definition the “separate procedure” is commonly performed as integral and part of a larger service and usually represents a procedure that the physician performs through the same incision or orifice, at the same site, or using the same approach.

In the case where a “separate procedure” is performed on the same day but at a different session, or at an anatomically unrelated site, the “separate pro-cedure” code may be reported in addition to a code for a procedure that would be related if performed at the same patient encounter or at an ana-tomically related site. Modifier -59 should be included indicating that this service was, in fact, a separate service.

In other sections of the CPT Manual, the word “separate” is used in a phrase identified as “separate or multiple procedures” with a different meaning.

L. Family of Codes

In a family of codes, there are two or more component codes that are not reported separately because they are included in a more comprehensive code as members of the code family. Comprehensive codes include certain services that are separately identifiable by other component codes. The component codes as members of the comprehensive code family represent parts of the procedure that should not be listed separately when the com-plete procedure is done. However, the component codes are considered individually if performed independently of the complete procedure and if not all the services listed in the comprehensive codes were rendered to make up the total service. If all multiple services described by a comprehensive code are performed, the comprehensive code should be reported. It is not

appro-priate to report the separate component codes individually nor is it appropri-ate to report the component code (s) with the comprehensive code.

M. More Extensive Procedure

When procedures are performed together that are basically the same, or per-formed on the same site but are qualified by an increased level of complex-ity, the less extensive procedure is included in the more extensive procedure. In the following situations, the procedure viewed as the most complex would be reported:

1. “Simple” and “complex” CPT codes reported; the simple procedure is included in the complex procedure on the same site.

2. “Limited” and “complete” CPT codes reported; the limited procedure is included in the complete procedure on the same site.

3. “Simple” and “complicated” CPT codes reported; the simple proce-dure is included in the complicated proceproce-dure on the same site. 4. “Superficial” and “deep” CPT codes reported; the superficial

proce-dure is included in the deep proceproce-dure on the same site.

5. “Intermediate” and “comprehensive” CPT codes reported; the inter-mediate procedure is included in the comprehensive procedure on the same site.

6. “Incomplete” and “complete” CPT codes reported; the incomplete procedure is included in the complete procedure on the same site. 7. “External” and “internal” CPT codes reported; the external

proce-dure is included in the internal proceproce-dure on the same site.

N. Sequential Procedure

An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach. There may be separate CPT codes describing each service. The second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medi-cally necessary service; these procedures are considered “sequential proce-dures”. Only the CPT code for one of the services, generally the more invasive service, should be reported. An example of this situation is a failed laparoscopic cholecystectomy, followed by an open cholecystectomy at the same session. Only the code for the successful procedure, in this case the open cholecystectomy, should be reported.

O. Laboratory Panel

When all component tests of a specific organ or disease oriented laboratory panel (e.g. CPT codes 80074,80061) are reported separately, they should be reported in the comprehensive panel code that includes the multiple com-ponent tests. The individual tests that make up a panel are not to be sepa-rately reported.

Example: CPT code 80061(Lipid panel) includes the following tests: CPT code 82465: Cholesterol, serum or whole blood, total CPT code 83718: Lipoprotein, direct measurement; high density

cholesterol (HDL cholesterol) CPT code 84478: Triglycerides

When all 3 tests are performed, the panel test (CPT code 80061) should be reported in place of the individual tests.

P. Misuse of Column 2 Code with Column 1 Code

In general, CPT codes have been written as precisely as possible to not only describe a specific service or procedure but to also avoid describing similar services or procedures which are already defined by other CPT codes. When

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Column 1 Column 2 Column 1 Column 2 Column 1 Column 2 Column 1 Column 2

Code Pair Additions

0009T ... 76940 0046T ... 00400 0047T ... 00400 0057T ... 00520, 00740, 43235 0061T ... 00400, 76000, 76001, 76003 10060... 64449 10061 ... 64449 11000 ... 64449 11040... 64449 11041 ... 64449 11042 ... 64449 11043 ... 64449 11044 ... 64449 20982... 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 76360, 76362, 90780 21116 ... J1644 21685 ... 36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 90780 22325 ... 22521 22327 ... 22520 22520 ... 20220, 20225, 20250, 22305, 22310, 22315 22521 ... 20220, 20225, 20251, 22305, 22310, 22315 22532 ... 36000, 36410, 37202, 62310, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 64479, 69990, 90780 22533 ... 36000, 36410, 37202, 62311, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 64483, 69990, 90780 24220 ... J1644 25246 ... J1644 27093 ... J1644 27095 ... J1644 27096 ... J1644 27370 ... J1644 27648 ... J1644 31623 ... 00529 31624 ... 00529 31641 ... 31640 31643 ... 00529 32601 ... 00529 32602 ... 00529 32603 ... 00529 32604... 00529 32605 ... 00529 32606... 00529 32650 ... 00529 32651 ... 00529 32652 ... 00529 32653 ... 00529 32654 ... 00529 32655 ... 00529 32656 ... 00529 32657... 00529 32658 ... 00529 32659 ... 00529 32660 ... 00529 32661 ... 00529 32662 ... 00529 32663 ... 00529 32664 ... 00529 32665 ... 00529 33120 ... 33310, 33315 33130 ... 33310, 33315 33206 ... 36555, 36556, 36568, 36569 33207... 36555, 36556, 36568, 36569 33208 ... 36555, 36556, 36568, 36569 33210 ... 36555, 36556, 36568, 36569 33211 ... 36555, 36556, 36568, 36569 33214 ... 36555, 36556, 36568, 36569 33215 ... 36555, 36556, 36568, 36569 33216 ... 36555, 36556, 36568, 36569 33217 ... 36555, 36556, 36568, 36569 33218 ... 36555, 36556, 36568, 36569 33220 ... 36555, 36556, 36568, 36569 33226 ... 75860 33234 ... 36555, 36556, 36568, 36569 33235 ... 36555, 36556, 36568, 36569 33249 ... 36555, 36556, 36568, 36569 33300 ... 33310, 33315 33305 ... 33310, 33315 33320 ... 33310, 33315 33321 ... 33310, 33315 33322 ... 33310, 33315 33330 ... 33310, 33315 33332 ... 33310, 33315 33335 ... 33310, 33315 33400 ... 33310, 33315 33401 ... 33310, 33315 33403 ... 33310, 33315 33404 ... 33310, 33315 33405 ... 33310, 33315 33406 ... 33310, 33315 33410 ... 33310, 33315 33411 ... 33310, 33315 33412 ... 33310, 33315 33413 ... 33310, 33315 33414...33310, 33315 33415...33310, 33315 33416...33310, 33315 33417...33310, 33315 33420...33310, 33315 33422...33310, 33315 33425...33310, 33315 33426...33310, 33315 33427...33310, 33315 33430...33310, 33315 33460...33310, 33315 33463...33310, 33315 33464...33310, 33315 33465...33310, 33315 33468...33310, 33315 33470 ...33310, 33315 33471...33310, 33315 33472...33310, 33315 33474 ...33310, 33315 33475...33310, 33315 33476 ...33310, 33315 33478 ...33310, 33315 33496...33310, 33315 33500...33310, 33315 33501...33310, 33315 33502...33310, 33315 33503...33310, 33315 33504...33310, 33315 33505...33310, 33315 33506...33310, 33315 33508...33310, 33315 33510...33310 33511...33310 33512...33310, 33315 33513...33310 33514...33310 33516...33310 33517...33310, 33315 33518...33310, 33315 33519...33310, 33315 33521...33310, 33315 33522...33310, 33315 33523...33310, 33315 33530...33310, 33315 33533...33310, 33315 33534...33310, 33315 33535...33310, 33315 33536...33310, 33315 33542...33310, 33315 33545...33310, 33315 33572...33310, 33315 33600...33310, 33315 33602...33310, 33315 33606...33310, 33315 33608...33310, 33315 33610...33310, 33315 33611...33310, 33315 33612...33310, 33315 33615...33310, 33315 33617...33310, 33315 33619 ... 33310, 33315 33641 ... 33310, 33315 33645 ... 33310, 33315 33647 ... 33310, 33315 33660... 33310, 33315 33665... 33310, 33315 33670 ... 33310, 33315 33681... 33310, 33315 33684... 33310, 33315 33688... 33310, 33315 33690... 33310, 33315 33692... 33310, 33315 33694... 33310, 33315 33697 ... 33310, 33315 33702 ... 33310, 33315 33710 ... 33310, 33315 33720 ... 33310, 33315 33722 ... 33310, 33315 33730 ... 33310, 33315 33732 ... 33310, 33315 33735 ... 33310, 33315 33736 ... 33310, 33315 33737 ... 33310, 33315 33750 ... 33310, 33315 33755 ... 33310, 33315 33762 ... 33310, 33315 33764 ... 33310, 33315 33766 ... 33310, 33315 33767 ... 33310, 33315 33770... 33310, 33315 33771 ... 33310, 33315 33774... 33310, 33315 33775 ... 33310, 33315 33776... 33310, 33315 33777... 33310, 33315 33778... 33310, 33315 33779... 33310, 33315 33780 ... 33310, 33315 33781 ... 33310, 33315 33786 ... 33310, 33315 33788 ... 33310, 33315 33800... 33310, 33315 33802... 33310, 33315 33803... 33310, 33315 33813 ... 33310, 33315 33814 ... 33310, 33315 33820 ... 33310, 33315 33822 ... 33310, 33315 33824 ... 33310, 33315 33840... 33310, 33315 33845 ... 33310, 33315 33851 ... 33310, 33315 33852 ... 33310, 33315 33853 ... 33310, 33315 33860... 33310, 33315 33861... 33310, 33315 33863... 33310, 33315 33870 ... 33310, 33315 33875 ... 33310, 33315 33877 ... 33310, 33315

(9)

Code Pair Additions

Column 1 Column 2 Column 1 Column 2 Column 1 Column 2 Column 1 Column 2

47605 ... 43752 47610 ... 43752 47612 ... 43752 47620 ... 43752 47630 ... 43752 47700... 43752 47701... 43752 47711 ... 43752 47712 ... 43752 47715 ... 43752 47716 ... 43752 47720 ... 43752 47721 ... 43752 47740... 43752 47741... 43752 47760 ... 43752 47765... 43752 47780 ... 43752 47785... 43752 47801 ... 43752 47802 ... 43752 47900 ... 43752 48000... 43752 48001... 43752 48005... 43752 48020... 43752 48100 ... 43752 48102 ... 43752 48120 ... 43752 48140... 43752 48145 ... 43752 48146... 43752 48148... 43752 48150... 43752 48152 ... 43752 48153 ... 43752 48154 ... 43752 48155 ... 43752 48180... 43752 48400... 43752 48500... 43752 48510 ... 43752 48511 ... 43752 48520 ... 43752 48540... 43752 48545 ... 43752 48547 ... 43752 48550... 43752 48554 ... 43752 48556... 43752 49000 ... 43752 49002 ... 43752 49010 ... 43752 49020 ... 43752 49021 ... 43752 49040... 43752 49041... 43752 49060... 43752 49061... 43752 49062... 43752 49080... 43752 49081... 43752 49085... 43752 49180 ... 43752 49200 ... 43752 49201 ... 43752 49215 ... 43752 49220 ... 43752 49250 ... 43752 49255 ... 43752 49320 ... 43752 49321 ... 43752 49322 ... 43752 49323 ... 43752 49400 ... 43752 49419 ... 43752, J1642 49420 ... 43752 49421 ... 43752 49422 ... 43752 49423 ... 43752 49424 ... 43752 49425 ... 43752 49426 ... 43752 49427 ... 43752 49428 ... 43752 49429 ... 43752 49560 ... 43752 49561 ... 43752 49565 ... 43752 49566 ... 43752 49568 ... 43752 49570... 43752 49572... 43752 49580 ... 43752 49582 ... 43752 49585 ... 43752 49587... 43752 49590 ... 43752 49600 ... 43752 49605 ... 43752 49606 ... 43752 49610 ... 43752 49611 ... 43752 49905 ... 43752 49906 ... 43752 50562 ... 50557 50684 ... J1644 50690 ... J1644 51605 ... J1644 52325 ... 52005 52327 ... 52005 52330 ... 52005 52334 ... 52005 52347... 52010 52355 ... 52354 53500 ... 00910, 36000, 36410, 37202, 51701, 51702, 51703, 52000, 53660, 53661, 53665, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 90780 55873... 76940 57425 ...36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 90780 58340...J1644 59070...36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 76942, 76986, 90780 59072...36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 76942, 76986, 90780 59074 ...36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 76942, 76986, 90780 59076...36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 76942, 76986, 90780 59400...01958 59409...01958 59410...01958 59412...01958 59510...01958 59514...01958 59610...01958 59612...01958 59614...01958 59618...01958 59620...01958 59622...01958 59897...36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 69990, 76942, 76986, 90780 61215...95991 61537...36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 90780, 95829, 95920 61538...95829, 95920 61539...95829, 95920 61540...36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 90780, 95829, 95920 61566...36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 90780 61567...36000, 36410, 37202, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 90780, 95829, 95920 61720...61863 61735 ... 61863 61750 ... 61863 61751 ... 61863 61760 ... 61863 61770 ... 61863 61791 ... 61863 61793 ... 61863 61795 ... 70557, 70558, 70559 61850 ... 95961 61860... 61863, 95961 61863 ... 36000, 36410, 37202, 61790, 61795, 61850, 61880, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 64550, 64553, 64555, 64560, 64565, 64573, 64575, 64577, 64580, 69990, 90780, 95925, 95926, 95927, 95961, G0173, G0242, G0243, G0251 61867 ... 36000, 36410, 37202, 61720, 61735, 61750, 61751, 61760, 61770, 61790, 61791, 61793, 61795, 61850, 61860, 61870, 61875, 61880, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 64550, 64553, 64555, 64560, 64565, 64573, 64575, 64577, 64580, 69990, 90780, 95925, 95926, 95937, 95961, G0173, G0242, G0243, G0251 61870 ... 61863, 95961 61875 ... 61863, 95961 62350... 95991 62351 ... 95991 62360... 95991 62361... 95991 62362... 95991 63001 ... 20926 63003 ... 20926 63011 ... 20926 63015 ... 20926 63016 ... 20926 63045... 20926 63046... 20926 63101 ... 36000, 36410, 37202, 62310, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 90780 63102 ... 36000, 36410, 37202, 62311, 62318, 62319, 64415, 64416, 64417, 64450, 64470, 64475, 90780 63170 ... 20926 63172 ... 20926 63173 ... 20926 63180 ... 20926 63182 ... 20926

(10)

Column 1 Column 2 Column 1 Column 2 Column 1 Column 2 Column 1 Column 2

´

Code Pair Deletions

0018T ... 90871 0019T ... 0020T, 76880, 76977, 76986, 76999 0027T ... 64470, 64479 27093 ... 62318, 64470, 64475 27096 ... 62318, 64470, 64475 31640 ... 31641 33510 ... 93971 33511 ... 93971 33512 ... 93971 33513 ... 93971 33514 ... 93971 33516 ... 93971 33517 ... 93971 33518 ... 93971 33519 ... 93971 33521 ... 93971 33522 ... 93971 33523 ... 93971 34800... 75966 34802... 75966 34804... 75966 34825 ... 75966 34900 ... 75966 35501 ... 93971 35506... 93971 35507 ... 93971 35508... 93971 35509... 93971 35511 ... 93971 35515 ... 93971 35516 ... 93971 35518 ... 93971 35521 ... 93971 35526 ... 93971 35531 ... 93971 35533 ... 93971 35536 ... 93971 35541 ... 93971 35546 ... 93971 35548 ... 93971 35549 ... 93971 35551 ... 93971 35556 ... 93971 35558 ... 93971 35560... 93971 35563 ... 93971 35565 ... 93971 35566... 93971 35571 ... 93971 35582 ... 93971 35583 ... 93971 35585 ... 93971 35587 ... 93971 43247 ... 43450, 43453 43450 ... 43200 45905... 46080 46030... 46080 46050... 46080 46221... 46080 46320 ... 46080 46940 ... 46080 46942 ... 46080 58150 ... 57280 62263 ... 62281, 62310, 62318, 64470, 64475, 64479 62264 ... 62281, 62310, 62318, 64470, 64475, 64479 62281 ... 62319, 64475 62282 ... 62318, 64470 62290 ... 62311, 64470, 64475, 64483 62310 ... 62319 62311 ... 62318 62318 ... 01996 62319 ... 01996 75952 ... 75966 75953 ... 75966 75954 ... 75966 76856 ... 93975 77427... 96155 77431... 96155 77432... 96155 77470 ... 96155 90645 ... 90748 90646 ... 90748 90647 ... 90748 90648 ... 90748 90720 ... 90748 90721 ... 90748 90723 ... 90636, 90700, 90701, 90702, 90703, 90712, 90713, 90718, 90719, 90720, 90721, 90748, 90782 90748... 90636, 90782 90801 ... 96155 90802 ... 96155 90804 ... 96155 90805 ... 96155 90806 ... 96155 90807 ... 96155 90808 ... 96155 90809 ... 96155 90810 ... 96155 90811 ... 96155 90812 ... 96155 90813 ... 96155 90814 ... 96155 90815 ... 96155 90816 ... 96155 90817 ... 96155 90818 ... 96155 90819 ... 96155 90821 ... 96155 90822 ... 96155 90823 ... 96155 90824 ... 96155 90826 ... 96155 90827 ... 96155 90828 ... 96155 90829...96155 90845...96155 90846...90871, 96155 90847...90871, 96155 90849...90871, 96155 90853...90871, 96155 90857...90871, 96155 90862 ...96155 90865...96155 90870...96155 90871...00104, 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90865, 90870, 90880, 96150, 96151, 96152, 96153, 96154, 96155, 97802, 97803, 97804, G0270, G0271 90880 ...96155 90918...97802, 97803, 97804, G0270, G0271 90919...90918, 97802, 97803, 97804, G0270, G0271 90920...90918, 90919, 97802, 97803, 97804, G0270, G0271 90921...90918, 90919, 90920, 97802, 97803, 97804, G0181, G0270, G0271 90922...90918, 90919, 90920, 90921 90923...90918, 90919, 90920, 90921 90924...90918, 90919, 90920, 90921 90925...90918, 90919, 90920, 90921 92002...96155 92004...96155 92012...96155 92014...96155 96150...96155 96153...96155 96155...96151, 96152, 96154 97001 ...96155 97002 ...96155 97003 ...96155 97004 ...96155 99201...96155 99202...96155 99203...96155 99204...96155 99205...96155 99211...96155 99212...96155 99213...96155 99214 ... 96155 99215 ... 96155 99217 ... 90918, 90919, 90920, 90921, 96155 99218 ... 90918, 90919, 90920, 90921, 96155 99219 ... 90918, 90919, 90920, 90921, 96155 99220 ... 90918, 90919, 90920, 90921, 96155 99221 ... 96155 99222 ... 96155 99223 ... 96155 99231 ... 96155 99232 ... 96155 99233 ... 96155 99234 ... 96155 99235 ... 96155 99236... 96155 99238... 96155 99239... 96155 99241 ... 96155 99242 ... 96155 99243 ... 96155 99244 ... 96155 99245 ... 96155 99251 ... 96155 99252 ... 96155 99253 ... 96155 99254 ... 96155 99255 ... 96155 99261 ... 96155 99262... 96155 99263 ... 96155 99271 ... 96155 99272 ... 96155 99273 ... 96155 99274 ... 96155 99275 ... 96155 99281... 96155 99282... 96155 99283... 96155 99284... 96155 99285... 96155 99291 ... 96155 99292 ... 96155 99293 ... 90918, 90919, 90920, 90921, 96155 99294 ... 90918, 90919, 90920, 90921, 96155 99295 ... 90918, 90919, 90920, 90921, 96155 99296... 90918, 90919, 90920, 90921, 96155 99298... 90918, 90919, 90920, 90921, 96155 99299... 90918, 90919, 90920, 90921, 96155 99301... 96155 99302... 96155 99303... 96155

(11)

Column 1 Column 2 MODIFIER 10.0 9.3

Column 1 Column 2 MODIFIER 10.0 9.3

Modifier Revisions

0008T 00740 0 1 10040 01995 0 1 10060 01995 0 1 10061 01995 0 1 10080 01995 0 1 10081 01995 0 1 10120 01995 0 1 10121 01995 0 1 10140 01995 0 1 10160 01995 0 1 10180 01995 0 1 11000 01995 0 1 11010 01995 0 1 11011 01995 0 1 11012 01995 0 1 11040 01995 0 1 11041 01995 0 1 11042 01995 0 1 11043 01995 0 1 11044 01995 0 1 11055 01995 0 1 11056 01995 0 1 11057 01995 0 1 11100 01995 0 1 11200 01995 0 1 11300 01995 0 1 11301 01995 0 1 11302 01995 0 1 11303 01995 0 1 11305 01995 0 1 11306 01995 0 1 11307 01995 0 1 11308 01995 0 1 11310 01995 0 1 11311 01995 0 1 11312 01995 0 1 11313 01995 0 1 11400 01995 0 1 11401 01995 0 1 11402 01995 0 1 11403 01995 0 1 11404 01995 0 1 11406 01995 0 1 11420 01995 0 1 11421 01995 0 1 11422 01995 0 1 11423 01995 0 1 11424 01995 0 1 11426 01995 0 1 11440 01995 0 1 11441 01995 0 1 11442 01995 0 1 11443 01995 0 1 11444 01995 0 1 11446 01995 0 1 11450 01995 0 1 11451 01995 0 1 11462 01995 0 1 11463 01995 0 1 11470 01995 0 1 11471 01995 0 1 11600 01995 0 1 11601 01995 0 1 11602 01995 0 1 11603 01995 0 1 11604 01995 0 1 11606 01995 0 1 11620 01995 0 1 11621 01995 0 1 11622 01995 0 1 11623 01995 0 1 11624 01995 0 1 11626 01995 0 1 11640 01995 0 1 11641 01995 0 1 11642 01995 0 1 11643 01995 0 1 11644 01995 0 1 11646 01995 0 1 11719 01995 0 1 11720 01995 0 1 11721 01995 0 1 11730 01995 0 1 11740 01995 0 1 11750 01995 0 1 11752 01995 0 1 11755 01995 0 1 11760 01995 0 1 11762 01995 0 1 11765 01995 0 1 11770 01995 0 1 11771 01995 0 1 11772 01995 0 1 11900 01995 0 1 11901 01995 0 1 11920 01995 0 1 11921 01995 0 1 11950 01995 0 1 11951 01995 0 1 11952 01995 0 1 11954 01995 0 1 11960 01995 0 1 11970 01995 0 1 11971 01995 0 1 11976 01995 0 1 11980 01995 0 1 11981 01995 0 1 11982 01995 0 1 11983 01995 0 1 12001 01995 0 1 12002 01995 0 1 12004 01995 0 1 12005 01995 0 1 12006 01995 0 1 12007 01995 0 1 12011 01995 0 1 12013 01995 0 1 12014 01995 0 1 12015 01995 0 1 12016 01995 0 1 12017 01995 0 1 12018 01995 0 1 12020 01995 0 1 12021 01995 0 1 12031 01995 0 1 12032 01995 0 1 12034 01995 0 1 12035 01995 0 1 12036 01995 0 1 12037 01995 0 1 12041 01995 0 1 12042 01995 0 1 12044 01995 0 1 12045 01995 0 1 12046 01995 0 1 12047 01995 0 1 12051 01995 0 1 12052 01995 0 1 12053 01995 0 1 12054 01995 0 1 12055 01995 0 1 12056 01995 0 1 12057 01995 0 1 13100 01995 0 1 13101 01995 0 1 13120 01995 0 1 13121 01995 0 1 13131 01995 0 1 13132 01995 0 1 13150 01995 0 1 13151 01995 0 1 13152 01995 0 1 13160 01995 0 1 14000 01995 0 1 14001 01995 0 1 14020 01995 0 1 14021 01995 0 1 14040 01995 0 1 14041 01995 0 1 14060 01995 0 1 14061 01995 0 1 14300 01995 0 1 14350 01995 0 1 15000 01995 0 1 15050 01995 0 1 15100 01995 0 1 15120 01995 0 1 15200 01995 0 1 15220 01995 0 1 15240 01995 0 1 15260 01995 0 1 15342 01995 0 1 15350 01995 0 1 15400 01995 0 1 15570 01995 0 1 15572 01995 0 1 15574 01995 0 1 15576 01995 0 1 15600 01995 0 1 15610 01995 0 1 15620 01995 0 1 15630 01995 0 1 15650 01995 0 1 15732 01995 0 1 15734 01995 0 1 15736 01995 0 1 15738 01995 0 1 15740 01995 0 1 15750 01995 0 1 15756 01995 0 1 15757 01995 0 1 15758 01995 0 1 15760 01995 0 1 15770 01995 0 1 15775 01995 0 1 15776 01995 0 1 15780 01995 0 1 15781 01995 0 1 15782 01995 0 1 15783 01995 0 1 15786 01995 0 1 15788 01995 0 1 15789 01995 0 1 15792 01995 0 1 15793 01995 0 1 15810 01995 0 1 15811 01995 0 1 15819 01995 0 1 15820 01995 0 1 15821 01995 0 1 15822 01995 0 1 15823 01995 0 1 15824 01995 0 1 15825 01995 0 1 15826 01995 0 1 15828 01995 0 1 15829 01995 0 1 15831 01995 0 1 15832 01995 0 1 15833 01995 0 1 15834 01995 0 1 15835 01995 0 1 15836 01995 0 1 15837 01995 0 1 15838 01995 0 1 15839 01995 0 1 15840 01995 0 1 15841 01995 0 1 15842 01995 0 1 15845 01995 0 1 15851 01995 0 1 15852 01995 0 1 15860 01995 0 1 15876 01995 0 1 15877 01995 0 1 15878 01995 0 1

(12)

Medicare Correct Coding Guide (CCI—Version 10.0)

9.3 9.2

Column 1 Column 2 MODIFIER 9.3 9.2

Column 1 Column 2 MODIFIER 9.3 9.2

Column 1 Column 2 MODIFIER 9.3 9.2 28092 01995 0 1 28100 01995 0 1 28102 01995 0 1 28103 01995 0 1 28104 01995 0 1 28106 01995 0 1 28107 01995 0 1 28108 01995 0 1 28110 01995 0 1 28111 01995 0 1 28112 01995 0 1 28113 01995 0 1 28114 01995 0 1 28116 01995 0 1 28118 01995 0 1 28119 01995 0 1 28120 01995 0 1 28122 01995 0 1 28124 01995 0 1 28126 01995 0 1 28130 01995 0 1 28140 01995 0 1 28150 01995 0 1 28153 01995 0 1 28160 01995 0 1 28171 01995 0 1 28173 01995 0 1 28175 01995 0 1 28190 01995 0 1 28192 01995 0 1 28193 01995 0 1 28200 01995 0 1 28202 01995 0 1 28208 01995 0 1 28210 01995 0 1 28220 01995 0 1 28222 01995 0 1 28225 01995 0 1 28226 01995 0 1 28230 01995 0 1 28232 01995 0 1 28234 01995 0 1 28238 01995 0 1 28240 01995 0 1 28250 01995 0 1 28260 01995 0 1 28261 01995 0 1 28262 01995 0 1 28264 01995 0 1 28270 01995 0 1 28272 01995 0 1 28280 01995 0 1 28285 01995 0 1 28286 01995 0 1 28288 01995 0 1 28289 01995 0 1 28290 01995 0 1 28292 01995 0 1 28293 01995 0 1 28294 01995 0 1 28296 01995 0 1 28297 01995 0 1 28298 01995 0 1 28299 01995 0 1 28300 01995 0 1 28302 01995 0 1 28304 01995 0 1 28305 01995 0 1 28306 01995 0 1 28307 01995 0 1 28308 01995 0 1 28309 01995 0 1 28310 01995 0 1 28312 01995 0 1 28313 01995 0 1 28315 01995 0 1 28320 01995 0 1 28322 01995 0 1 28340 01995 0 1 28341 01995 0 1 28344 01995 0 1 28345 01995 0 1 28360 01995 0 1 28400 01995 0 1 28405 01995 0 1 28406 01995 0 1 28415 01995 0 1 28420 01995 0 1 28430 01995 0 1 28435 01995 0 1 28436 01995 0 1 28445 01995 0 1 28450 01995 0 1 28455 01995 0 1 28456 01995 0 1 28465 01995 0 1 28470 01995 0 1 28475 01995 0 1 28476 01995 0 1 28485 01995 0 1 28490 01995 0 1 28495 01995 0 1 28496 01995 0 1 28505 01995 0 1 28510 01995 0 1 28515 01995 0 1 28525 01995 0 1 28530 01995 0 1 28531 01995 0 1 28540 01995 0 1 28545 01995 0 1 28546 01995 0 1 28555 01995 0 1 28570 01995 0 1 28575 01995 0 1 28576 01995 0 1 28585 01995 0 1 28600 01995 0 1 28605 01995 0 1 28606 01995 0 1 28615 01995 0 1 28630 01995 0 1 28635 01995 0 1 28636 01995 0 1 28645 01995 0 1 28660 01995 0 1 28665 01995 0 1 28666 01995 0 1 28675 01995 0 1 28705 01995 0 1 28715 01995 0 1 28725 01995 0 1 28730 01995 0 1 28735 01995 0 1 28737 01995 0 1 28740 01995 0 1 28750 01995 0 1 28755 01995 0 1 28760 01995 0 1 28800 01995 0 1 28805 01995 0 1 28810 01995 0 1 28820 01995 0 1 28825 01995 0 1 29805 01995 0 1 29806 01995 0 1 29807 01995 0 1 29819 01995 0 1 29820 01995 0 1 29821 01995 0 1 29822 01995 0 1 29823 01995 0 1 29824 01995 0 1 29825 01995 0 1 29826 01995 0 1 29830 01995 0 1 29834 01995 0 1 29835 01995 0 1 29836 01995 0 1 29837 01995 0 1 29838 01995 0 1 29840 01995 0 1 29843 01995 0 1 29844 01995 0 1 29845 01995 0 1 29846 01995 0 1 29847 01995 0 1 29848 01995 0 1 29850 01995 0 1 29851 01995 0 1 29855 01995 0 1 29856 01995 0 1 29860 01995 0 1 29861 01995 0 1 29862 01995 0 1 29863 01995 0 1 29870 01995 0 1 29871 01995 0 1 29874 01995 0 1 29875 01995 0 1 29876 01995 0 1 29877 01995 0 1 29879 01995 0 1 29880 01995 0 1 29881 01995 0 1 29882 01995 0 1 29883 01995 0 1 29884 01995 0 1 29885 01995 0 1 29886 01995 0 1 29887 01995 0 1 29888 01995 0 1 29889 01995 0 1 29891 01995 0 1 29892 01995 0 1 29893 01995 0 1 29894 01995 0 1 29895 01995 0 1 29897 01995 0 1 29898 01995 0 1 29900 01995 0 1 29901 01995 0 1 29902 01995 0 1 31623 00528 0 1 31624 00528 0 1 31643 00528 0 1 32997 00520 0 1 32997 00524 0 1 35207 69990 1 0 36100 69990 1 0 36120 69990 1 0 36140 69990 1 0 36215 69990 1 0 36216 69990 1 0 36217 69990 1 0 52320 52005 0 1 52332 52005 0 1 52341 52005 0 1 52342 52005 0 1 52343 52005 0 1 52344 52005 0 1 52345 52005 0 1 52346 52005 0 1 52351 52005 0 1 52352 52005 0 1 52353 52005 0 1 52354 52005 0 1 52355 52005 0 1 61105 69990 1 0 61107 69990 1 0 61108 69990 1 0 61120 69990 1 0 61140 69990 1 0 61150 69990 1 0 61151 69990 1 0 61154 69990 1 0 61156 69990 1 0 61210 69990 1 0 64702 01995 0 1 64704 01995 0 1 64708 01995 0 1 64712 01995 0 1 64718 01995 0 1 64719 01995 0 1 64721 01995 0 1 64722 01995 0 1 64726 01995 0 1 64774 01995 0 1

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Surgery: Integumentary System (CPT Codes 10000–19999)

IMPORTANT – There are instances when an appropriate modifier used correctly can be reported with a code pair contained in the Correct Coding Initiative. This will advise the carrier of specific circumstances that may affect the application of the edits and allow for separate payment of some code pairs. The code pairs for which modifier use is allowed are identified by a gray color bar.

Correct Coding Policies

A. Introduction

CPT coding of the integumentary system includes coding narrative for ser-vices performed by a number of specialties. While the coding system is ori-ented toward dermatological procedures, the dermatological aspects of the practice of plastic surgery are covered as are the dermatologic elements (particularly closure, tissue transfer, grafts, adjacent and distant flaps) of multiple surgical procedures, especially radical or mutilative surgical proce-dures. Integumentary procedures are also often performed in staged fash-ions due to the sophistication of services rendered.

Generally, integumentary procedures include incision, biopsy, removal, par-ing/curettement, shaving, destruction (multiple methodologies), excision, repair, adjacent tissue rearrangement, grafts, flaps, and specialized services such as burn management and Mohs' Micrographic Surgery.

When a column 1 code describes other column 2 codes, all of which were performed, the column 1 code should be used rather than listing the individ-ual column 2 codes. Additionally, because of the technical advances and changes in technology, standard medical practice should be as accurately reflected in CPT coding as possible. The CPT code should reflect what tran-spires in a standard surgical setting. Necessary services performed in order to accomplish a more comprehensive service are included in the CPT code describing the more complex service.

B. Evaluation and Management

Evaluation and Management (E & M) of integumentary disorders may repre-sent a separately identifiable service, serve as a prelude to a decision to per-form a service, or be perper-formed in follow-up of previously perper-formed procedures. Policies referable to the appropriateness of reporting evaluation and management codes in conjunction with surgical procedures are well established in the standard CMS Global Surgery Policy. In essence, if the evaluation and management service provided is for the purpose of deciding that a major surgical procedure is to be performed, this service is a signifi-cant, separately identifiable service and may be reported separately, by attaching modifier -57 to the appropriate level of evaluation and manage-ment service code. Surgical procedures have a “global period” following surgery (generally 0, 10 or 90 days); during this time E & M services pro-vided in follow-up to the surgical procedure have been calculated into the relative value units for the surgery and are not to be separately reported. On the occasion when a separate condition is evaluated and a significant, sepa-rately identifiable service for a different problem is provided postoperatively, a separate E & M code may be reported and indicated with the -24 modifier. Surgical dressings, supplies, and local anesthetics used for a procedure are not to be separately reported as routine. There are some exceptions to this policy (e.g. surgical tray used for some office procedures). Wound closures using adhesive strips, topical skin adhesive, or tape alone do not represent a separately identifiable surgical procedure and are, therefore, included in the appropriate E & M service.

C. Anesthesia

Anesthesia for dermatologic procedures, when provided by the physician performing the procedure, is considered part of the procedure. This would include local infiltration, regional block, sedation, etc. performed by the phy-sician doing the procedure. Local anesthesia or local anesthesia with seda-tion is often accomplished by the physician providing the primary services. General anesthesia or monitored anesthesia care may be required for more extensive dermatologic procedures (extensive debridement, flaps, grafts, etc.). In these cases, if anesthesia services are performed by another pro-vider, the different physician may bill separately for his/her services. Billing for “anesthesia” services rendered by a nurse or other office personnel (unless the nurse is an independent certified nurse anesthetist, CRNA, etc.) is inappropriate as these services are “incident” to the physician’s services. Use of injection codes for therapeutic injection or aspiration of lesions is inappropriate if the injection is administered for local anesthesia for a spe-cific procedure. CPT codes such as 10160 (puncture aspiration), 20500-20501 (injection of sinus), 20550 (injection(s)of tendon sheath, ligament, etc.), 20600-20610 (arthrocentesis) are not to be reported separately if they are used to reflect local anesthetic techniques for another procedure. In the postoperative state, patients treated with epidural or subarachnoid continuous drug administration will require daily hospital adjustment/man-agement of the catheter, dosage, etc. (CPT code 01996). This service may be coded by the anesthesiologist for payment. The management of postop-erative pain by the surgeon, including epidural or subarachnoid drug administration, is included in the global period associated with the opera-tive procedure. If no surgery is performed but a catheter is placed for pain control (e.g. burn injury not requiring surgery), CPT code 01996 (daily hos-pital management of epidural or subarachnoid continuous drug administra-tion) is appropriately reported by the managing physician.

D. Incision and Drainage

Incision and drainage services, as related to the integumentary system, gen-erally involve cutaneous or subcutaneous drainage of cysts, pustules, infec-tions, hematomas, seromas or fluid collections. In cases where, in the course of an excision of a lesion, an area of involvement is identified which requires drainage, either as a part of the procedure or in order to gain access to the area of interest, coding/billing for incision and drainage of this fluid collection would be inappropriate if the excision or other procedure is per-formed in the same session.

Example: A patient who presents with a pilonidal cyst may require simple incision/drainage or may require an extensive excision. In the former case, the appropriate CPT coding is 10080 (or 10081 if complicated). If the pilonidal cyst is excised, while it is obvious that drainage from the cyst will occur in the course of its excision, the appropriate coding is CPT code 11770 (or 11771 or 11772, depending on the complexity), not CPT codes 10080 and 11770. If it is evident that an extensive cellulitis is present around the cyst preventing the complete procedure from being accom-plished, it may be reasonable to bill for CPT code 10080, then, after

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per-Surgery: Integumentary System

12020 - 12021 (Treatment of wound dehiscence) 12031 - 12057 (Repair - intermediate)

13100 - 13160 (Repair - complex)

11719 - 11762 (Trimming, debridement and excision of nails) 11770 - 11772 (Excision of pilonidal cysts)

11765 (Wedge excision)

F. Repair and Tissue Transfer

When lesional excision is of such an extent that closure cannot be accom-plished by simple, intermediate, or complex closure, other methodology must be employed. Frequently adjacent tissue transfer or tissue rearrange-ment is employed (Z-plasty, W-plasty, flaps, etc.). This family of codes, (CPT codes 14000-14350), involves excision with adjacent tissue transfer and correlates to excision codes. Excision CPT codes (11400-11646) and repair CPT codes (12001 – 13160) are not to be separately reported when CPT codes 14000-14350 are reported. On the other hand, skin grafting per-formed in conjunction with these codes may be separately reported if it is not included in the specific code definition. In the case of closure of trau-matic wounds, these codes are appropriate only when the closure requires the surgeon to develop a specific adjacent tissue transfer; lacerations that coincidentally are approximated using a tissue transfer technique (e.g. Z-plasty, W-plasty) should be reported with the more simple closure code. Debridement necessary to accomplish these tissue transfer procedures is part of the column 1 procedure performed. Separate debridement CPT codes (11000-11042) or repair CPT codes (12001-13160) would be inappropri-ately reported with these CPT codes (14000-14350) for the same lesion/ injury. Procurement of cultures or tissue samples as a part of a closure are included in the closure code and are not to be separately reported.

G. Grafts and Flaps

Free skin grafts are coded by type (split or full), location, and size. For a spe-cific location, a primary code is defined and followed by a supplemental code for additional coverage area. As a result of this coding scheme, for a given area of involvement, the initial code is limited to one unit of service; the supplemental code may have multiple units of service depending on the area to be covered. Because, for a specific area, only one type of skin graft is typically applied, the primary free skin graft CPT codes (15100, 15120, 15200, 15220, 15240, 15260) are mutually exclusive to one another. If multiple areas require different grafts, a modifier indicating different sites should be used (anatomic or -59 modifier).

Generally, debridement of non-intact skin (CPT codes 11000-11042) in anticipation of a skin graft is necessary prior to application of the skin graft and is included in the skin graft (CPT codes 15050-15400). When skin is intact, however, and the graft is being performed after excisional prepara-tion of intact skin, the CPT code 15000 (Excisional preparaprepara-tion) is sepa-rately reported. CPT code 15000 is not to be used to describe debridement of non-intact, necrotic or infected skin, nor is its use indicated with other lesion removal codes.

1. CPT codes 15350 (application of allograft) and 15400 (application of xenograft) are part of all other graft codes and are not to be sepa-rately reported with other grafts (CPT codes 15050 - 15261) for graft placement on the same site.

2. The CPT code 67911 describes the “Correction of lid retraction;” a parenthetical notation is added advising that, if autogenous graft materials are used, tissue graft codes 20920, 20922 or 20926 can be reported. Accordingly, all other procedures necessary to accom-plish the service are included.

3. Flap grafts (CPT codes 15570-15576) include excision of lesions at the same site (CPT codes 11400-11646).

H. Breast (Incision, Excision, Introduction, Repair and

Reconstruction)

Because of the unique nature of procedures developed to address breast dis-ease, a section of CPT (19000-19499) is set aside for such services. Fine needle aspiration biopsies, core biopsies, open incisional or excisional biopsies, and related procedures performed to procure tissue from a lesion for which an established diagnosis exists are not to be reported separately at the time of a lesion excision unless performed on a different lesion or on the contralateral breast. However, if a diagnosis is not established, and the decision to perform the excision or mastectomy is dependent on the results of the biopsy, then the biopsy is separately reported. The -58 modifier may be used appropriately to indicate that the biopsy and the excision or mastec-tomy are staged or planned procedures.

Because excision of lesions occur in the course of performing a mastectomy, breast excisions are not separately reported from a mastectomy unless per-formed to establish the malignant diagnosis before proceeding to the mas-tectomy. Specifically CPT codes 19110-19126 (breast excision) are in general included in all mastectomy CPT codes 19140-19240 of the same side. However, if the excision is performed to obtain tissue to determine pathologic diagnosis of malignancy prior to proceeding to a mastectomy, the excision is separately reportable with the mastectomy. The –58 modi-fier should be utilized in this situation.

Use of other integumentary codes for incision and closure are included in the codes describing various breast excision or mastectomy codes. Because of the frequent need to biopsy lymph nodes or remove muscle tissue in con-junction with mastectomies, these procedures have been included in the CPT coding for mastectomy. It would be inappropriate to separately bill for ipsilateral lymph node dissection in conjunction with the appropriate mas-tectomy codes. In the circumstance where a breast lesion is identified and treated and it is determined to be medically necessary to biopsy the con-tralateral nodes, use of the biopsy or lymph node dissection codes (using the appropriate anatomic modifier, -LT or -RT for left or right, to indicate this) would be acceptable. Additionally, breast reconstruction codes that include the insertion of a prosthetic implant are not to be reported with CPT codes that describe the insertion of a breast prosthesis only.

The CPT coding for breast procedures generally refers to unilateral proce-dures; when performed bilaterally, the -50 modifier would be appropriate. This is identified parenthetically, where appropriate, in the CPT narrative.

I. Add-on Codes

There are a number of supplemental CPT codes defined in the CPT Manual. The following is a listing of supplemental codes present in the integumen-tary section of the CPT Manual. Although, not all-inclusive, the supplemen-tal code must be used in combination with the primary CPT code or the supplemental code cannot be reported.

Primary CPT code

Add-on CPT code

11000 (Debridement up to 10%)

11001 (Each additional 10%)

11200 (Removal of skin tags, up to and including 15 lesions)

11201 (Each additional 10 lesions)

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Medicare Correct Coding Guide (CCI Version 10.0)

❐ “With” versus “Without” Procedures ▲ Laboratory Panels

✓ Mutually Exclusive Procedures ■ Misuse of Column 2 with Column 1

✰ Standard Preparation/Monitoring Services

<<<<¥¥¥¥>>>> Modifier use may allow separate payment

11101

Biopsy of skin, subcutaneous tissue and/or mucous membrane (including

simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for primary procedure)

RELATIVE VALUE UNITS

Work MP PE–nf PE–f Total–nf Total–f Global P

0.41 0.02 0.34 0.19 0.77 0.62 INC

MODIFIERS INDICATORS

-50 -51 -62 -66 -80, -82 Suprv Status

2 NA NPD NPD NPD 09 A

CORRECT CODING EDITS

NA

11200

Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

RELATIVE VALUE UNITS

Work MP PE–nf PE–f Total–nf Total–f Global P

0.77 0.05 1.07 0.78 1.89 1.60 10

MODIFIERS INDICATORS

-50 -51 -62 -66 -80, -82 Suprv Status

2 4 NPD NPD NPD 09 A

CORRECT CODING EDITS

01995●, <<<<¥¥¥¥>>>> 10060❆, <<<<¥¥¥¥>>>> 10061❆, <<<<¥¥¥¥>>>> 11057✓, <<<<¥¥¥¥>>>> 11100✚, <<<<¥¥¥¥>>>> 11301✓, <<<<¥¥¥¥>>>> 11302✓, <<<<¥¥¥¥>>>> 11303✓, <<<<¥¥¥¥>>>> 11306✓, <<<<¥¥¥¥>>>> 11307✓, <<<<¥¥¥¥>>>> 11308✓, <<<<¥¥¥¥>>>> 11310✓, <<<<¥¥¥¥>>>> 11311✓, <<<<¥¥¥¥>>>> 11312✓, <<<<¥¥¥¥>>>> 11313✓, <<<<¥¥¥¥>>>> 11400✓, <<<<¥¥¥¥>>>> 11401✓, <<<<¥¥¥¥>>>> 11402✓, <<<<¥¥¥¥>>>> 11403✓, <<<<¥¥¥¥>>>> 11404✓, <<<<¥¥¥¥>>>> 11406✓, <<<<¥¥¥¥>>>> 11420✓, <<<<¥¥¥¥>>>> 11421✓, <<<<¥¥¥¥>>>> 11422✓, <<<<¥¥¥¥>>>> 11423✓, <<<<¥¥¥¥>>>> 11424✓, <<<<¥¥¥¥>>>> 11426✓, <<<<¥¥¥¥>>>> 11440✓, <<<<¥¥¥¥>>>> 11441✓, <<<<¥¥¥¥>>>> 11442✓, <<<<¥¥¥¥>>>> 11443✓, <<<<¥¥¥¥>>>> 11444✓, <<<<¥¥¥¥>>>> 11446✓, <<<<¥¥¥¥>>>> 11450✓, <<<<¥¥¥¥>>>> 11451✓, <<<<¥¥¥¥>>>> 11462✓, <<<<¥¥¥¥>>>> 11463✓, <<<<¥¥¥¥>>>> 11470✓, <<<<¥¥¥¥>>>> 11471✓, <<<<¥¥¥¥>>>> 11600✓, <<<<¥¥¥¥>>>> 11601✓, <<<<¥¥¥¥>>>> 11602✓, <<<<¥¥¥¥>>>> 11603✓, <<<<¥¥¥¥>>>> 11604✓, <<<<¥¥¥¥>>>> 11606✓, <<<<¥¥¥¥>>>> 11620✓, <<<<¥¥¥¥>>>> 11621✓, <<<<¥¥¥¥>>>> 11622✓, <<<<¥¥¥¥>>>> 11623✓, <<<<¥¥¥¥>>>> 11624✓, <<<<¥¥¥¥>>>> 11626✓, <<<<¥¥¥¥>>>> 11640✓, <<<<¥¥¥¥>>>> 11641✓, <<<<¥¥¥¥>>>> 11642✓, <<<<¥¥¥¥>>>> 11643✓, <<<<¥¥¥¥>>>> 11644✓, <<<<¥¥¥¥>>>> 11646✓, <<<<¥¥¥¥>>>> 11900■, <<<<¥¥¥¥>>>> 11901■, <<<<¥¥¥¥>>>> 12001✚, <<<<¥¥¥¥>>>> 12002✚, <<<<¥¥¥¥>>>> 12004✚, <<<<¥¥¥¥>>>> 12005✚, <<<<¥¥¥¥>>>> 12006✚, <<<<¥¥¥¥>>>> 12007✚, <<<<¥¥¥¥>>>> 12011✚, <<<<¥¥¥¥>>>> 12013✚, <<<<¥¥¥¥>>>> 12014✚, <<<<¥¥¥¥>>>> 12015✚, <<<<¥¥¥¥>>>> 12016✚, <<<<¥¥¥¥>>>> 12017✚, <<<<¥¥¥¥>>>> 12018✚, <<<<¥¥¥¥>>>> 17004✓, <<<<¥¥¥¥>>>> 17111✓, <<<<¥¥¥¥>>>> 17250✚, <<<<¥¥¥¥>>>> 36000❆, <<<<¥¥¥¥>>>> 36410❆, <<<<¥¥¥¥>>>> 37202■, <<<<¥¥¥¥>>>> 62318■, <<<<¥¥¥¥>>>> 62319■, <<<<¥¥¥¥>>>> 64415■, <<<<¥¥¥¥>>>> 64416■, <<<<¥¥¥¥>>>> 64417■, <<<<¥¥¥¥>>>> 64450■, <<<<¥¥¥¥>>>> 64470■, <<<<¥¥¥¥>>>> 64475■, 69990■, <<<<¥¥¥¥>>>> 90780❆, <<<<¥¥¥¥>>>> 96405■, <<<<¥¥¥¥>>>> 96406■, <<<<¥¥¥¥>>>> G0168❆

11201

Removal of skin tags, multiple fibrocutaneous tags, any area; each addi-tional ten lesions (List separately in addition to code for primary proce-dure)

RELATIVE VALUE UNITS

Work MP PE–nf PE–f Total–nf Total–f Global P

0.29 0.02 0.16 0.12 0.47 0.43 INC

MODIFIERS INDICATORS

-50 -51 -62 -66 -80, -82 Suprv Status

2 NA NPD NPD NPD 09 A

CORRECT CODING EDITS

NA

11300

Shaving of epidermal or dermal lesion, single lesion, trun