1. Outpatient Coding: CPT, Evaluation and Management (E/M) and Modifiers
Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA
Manager, HIM Consulting Services, UASI
Laura Barron, RHIA, CCS
Vice President, Coding Services, UASI

2. Objectives Review documentation requirements in the Outpatient setting
Discuss the guidelines for E/M code assignment
Review the components of the Outpatient Code Editor, including the use of modifiers
Review the codeable procedures in the Outpatient setting

3. Outpatient Coding

4. Assignment of Codes
Appropriate diagnosis and procedure codes are extracted from the medical record
Encoder helps with bundling issues and assignment of APCs
Codes may also be assigned in different clinical departments
Charges, and some procedure codes, are added by through the ‘charge description master’ (CDM)

5. Outpatient Coding Guidelines
Guidelines in Section I, Conventions, general coding guidelines and chapter-specific guidelines, should also be applied for outpatient services and office visits.
Selection of first-listed condition:
In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines.
Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.

6. Outpatient Coding Guidelines
Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider.
Conditions that are an integral part of a disease process
Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification

7. Outpatient Coding Guidelines
Signs and symptoms, continued
Conditions that are NOT an integral part of a disease process
Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

8. Outpatient Coding Guidelines
Use of Sign/Symptom/Unspecified Codes
Signs/symptom and ‘unspecified’ code have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

9. Outpatient Coding Guidelines
Use of Sign/Symptom/Unspecified Codes, continued
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

10. Outpatient Coding Guidelines
ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit
List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided.
List additional codes that describe any coexisting conditions.
In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.

11. Outpatient Coding Guidelines
Uncertain diagnosis
Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
Chronic diseases
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)

12. Outpatient Coding Guidelines
Code all documented conditions that coexist
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.
Do not code conditions that were previously treated and no longer exist.
However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

13. Outpatient Coding Guidelines
Patients receiving diagnostic services only
For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test.
For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

14. Outpatient Coding Guidelines
Patients receiving therapeutic services only
For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.

15. CPT and HCPCS
CPT (Current Procedural Terminology) codes used to report outpatient services including surgery, therapeutic treatment, diagnostic testing and other medicine services
HCPCS (Healthcare Common Procedural Coding System) codes are used to report non-surgical outpatient procedures, supplies, products and services
Level II HCPCS codes, 5 position alpha-numeric codes, are used to report medical supplies, items and non-physician services not represented by CPT

16. CPT and HCPCS
CPT and HCPCS codes are used by physicians and healthcare facilities to report the services provided
Accurate and appropriate assignment of CPT and HCPCS codes requires an understanding of the specific rules and guidelines associated with their use
Complete, accurate and timely documentation is necessary to ensure services are captured and reported

17. CPT System Structure Evaluation & Management (E/M) 99201 – 99499
Anesthesia – 01999
Surgery – 69990
Radiology – 79999
Pathology and Laboratory – 89398
Medicine – 99067
Category II Codes F – 0407T
Each section of CPT has specific guidelines for use

18. Surgery Section General Urinary 10021-10022 50010-53899 Integumentary
Musculoskeletal
Respiratory
Cardiovascular
Digestive
Urinary
Male Genital
Female Genital
Nervous
Eye and Ocular Adnexa
Auditory

19. Code Examples Excision – Malignant Lesions
Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less
11601 excised diameter to 1.0 cm
11602 excised diameter to 2.0 cm
11603 excised diameter to 3.0 cm
Endoscopy
45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed
with biopsy, single or multiple
with removal of foreign body(s)
with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps

20. Evaluation & Management (E/M) Codes

21. Evaluation and Management (E/M)
Used to report provider services during a patient encounter
Used primarily by providers to report services including office, hospital and observation visits, and other related patient encounters including consultations, wellness/preventative medicine visits and telephone or telehealth encounters
E/M codes for physician services are assigned as supported by the documentation of key elements of history, examination and medical decision making or, under certain circumstances; codes may be assigned on the basis of the of time required for the encounter
E/M codes for physician visits must have documentation to support the care rendered and level of service billed

22. E/M Point of Service Clinic or Office Visits – (99201-99215)
Inpatient admissions and subsequent care
Nursing homes
Critical care
Emergency department
Psychiatric services

23. Key Components of E/M Codes
History
Chief Complaint (CC)
History of Present Illness (HPI)
Past Family Social History (PFSH)
Review of Systems (ROS)
Examination
1995 documentation guidelines
1997 documentation guidelines
Medical decision making (MDM)
Number of diagnoses
Data to be reviewed
Risk
Time

24. Chief Complaint
With the exception of Preventive Medicine services All E/M services should contain a “valid” Chief Complaint
Invalid Chief Complaint
Valid Chief Complaint
Follow-up
Recheck
Patient seen and examined
Patient complains of cough
Follow-up of laceration repair
Recheck of HTN, DM, Lipids
Follow up patient admitted for AMS

25. History HPI ROS PFSH Level of History Location Duration Quality
Severity
Context
Timing
Associated Signs/Symptoms
Symptom Inventory
* Past medical history
* Family history
* Social history
Must meet or exceed all three components of history to qualify for a given level of history
Brief 1-3
+ 0 Systems
+ 0 Areas PFSH
Problem Focus
+ 1 System
Expanded PF
Extended 4-8
+ 2-9 Systems
+ 1 Area PFSH
Detailed
+ 10+ Systems
+ 2 Established /3 New
Comprehensive

26. Common Documentation Deficiencies
Lack of chief complaint
Completely negative ROS in sick patient
Use of “noncontributory”
Missing family history
Documenting PMH as ROS
Inappropriate references to secondary documents
Template issues
Contradicting information
Copy paste / cloned notes

27. Examination Examination 95 Guidelines 97 Guidelines Type of Exam
Limited to affected body area or organ system
One body are or organ system
1-5 bulleted elements
Problem Focused
Affected body area or organ system & other related systems
2-7 body areas and/or organ systems
6-11 bulleted elements
Expanded Problem Focused
Extended exam affected body area or organ system & other related systems
12-17 bulleted elements for 2 more systems
Detailed
General Multi-system
8 or more body areas and/or organ systems
18 or more bulleted elements for 9 or more systems (2 in 9)
Comprehensive
Complete Single system
Not defined
See requirements for individual single system exams

28. Common Documentation Deficiencies
All normal templates
Copy paste / cloned notes
Canned verbiage
Multiple system header with only one system documented
Counting body areas as systems for comprehensive exam (’95 guidelines)
Documentation of exam by ancillary staff
Teaching physician attestations

29. Medical Decision Making
Dx/Mgmt Options
Data
Risk
Level MDM
Minimal - 1point
None/Minimal 0-1point
Minimal
Straightforward
Limited - 2 points
Low
Low Complexity
Multiple - 3 points
Moderate
Moderate Complexity
Extensive - 4 points
High
High Complexity

30. Common Documentation Deficiencies
Missing diagnoses
Copy paste / cloned notes
Inpatient services
Rule out, possible, probable, suspect

31. Time Time spent must be documented
Total time
Time spent in counseling/coordination of care
More than 50% must be documented as counseling/coordination of care
Documentation must include a synopsis of what was discussed

32. Common Documentation Deficiencies
Time documentation missing or incomplete
Time documented does not meet criteria
Missing elements necessary to code based on time
Calculating time for multiple units (critical care, prolonged care, therapy, etc.)

33. E/M Proposed Changes
Eliminate history and exam elements - providers should perform a “medically appropriate history and/or examination”.
Allow physicians to choose whether their documentation is based on Medical Decision Making (MDM) or Total Time:
MDM: No material changes to the three current MDM sub-components with extensive edits to the elements for code selection
Time: Represents total physician time on the date of service. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services like care coordination. These definitions only apply when code selection is primarily based on time and not MDM

34. E/M Proposed Changes
Deletion of code 99201: and are both straightforward MDM and only differentiated by history and exam elements.
Creation of a shorter Prolonged Services code: Shorter prolonged services code that would capture physician time in 15-minute increments. This code would only be reported with and and be used when time was the primary basis for code selection.

35. Evaluation & Management (E/M) Codes Facility-based

36. E/M – Facility-based
The same E/M codes are also used by hospitals and other healthcare settings to report facility resources utilized
The April 2000 OPPS final rule instructed hospitals to develop and apply internal hospital guidelines to determine the level of service reported for each patient encounter
The 2008 final rule further instructs hospitals that “each hospital’s internal guidelines should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes.”
Facilities should have methodology for determining the appropriate clinic visit code based on documentation. This is often times done electronically.

37. E/M – Facility-based Describe use of space Describe use of supplies
Describe involvement of hospital staff in E/M services
Cannot be used if…
Patient admitted within 48 hours
Patient taken to surgery
Patient receives other global service (i.e. Dialysis)

38. Status V Codes Only codes used in outpatient settings
Outpatient clinic
Office or Other Outpatient Service (99201 – 99215)
Office or Other Outpatient Consult (99241 – 99245)
Confirmatory Consult (99271 – 99275)
HCPCS exams (G0101, G0175, G0245, G0246, G0264)
Ophthalmology codes for appropriate exams (92002 – 92014)
Patients in observation status
Hospital Observation Services (99217 – and – 99236)
Emergency Room
Emergency Department Services (99281 – )

39. Choosing Level of Service
Systems for choosing the level of E/M are developed by each facility
Facilities must follow their own systems/guidelines
Facility codes would not often match providers
“New" and "established" pertain to whether the patient already has a medical record
Use for screening services in the ER when no treatment is furnished

40. Observation Care Separate payment allowed for 3 diagnostic categories:
Chest pain
Asthma
Congestive heart failure
May use admitting diagnosis
Patient must be in observation for at least 8 hours and no more than 48 hours
Until 2003 bundled into all ER and surgery payments. Policy includes specific payable HCPCS code G0244 for APC 339. Must be associated with another E/M or critical care code for payment. As of 2003 may use admitting diagnosis to justify payment, rather than principal diagnosis

41. Critical Care
Critical care is classified as a "significant procedure" (APC 0620) under OPPS
Hospitals use code to report outpatient critical care services
Used in place of a code for a medical visit or emergency department service.
Use CPT definition of "critical care" and coding guidelines
Exceptions
Facilities only paid for one period time with code 99291
Services usually bundled into Critical Care codes may be billed separately when furnished on the same day

42. Annual Updates and Changes
Required by law and may change
APC groupings
Payment adjustments
Conversion factor
Payment weights
Changes to APCs may result from
Changes in technology
Changes in CPT codes
Codes removed from Inpatient Only List
New procedures or services
CMS publishes Proposed Rule for comments
Final Rule is issued after comment period and any adjustments

43. Ambulatory Patient Classifications (APCs)

44. What are APCs? Outpatient Payment Groups
Groups of codes with a fixed payment amount
Based on HCPCS codes
Level I (CPT) and Level II codes
Codes in the same APC must have
Comparable clinical aspects
Comparable resource consumption
APCs created in effort to control rising costs and still provide adequate reimbursement to hospitals.
Each APC has a fixed reimbursement amount.
Hospitals are encouraged to keep costs down since they know how much they will be reimbursed. Also, hospitals share in the benefit when costs are low and share in the loss when costs are higher than usual.

45. Why APCs? Cost control Efficiency Facilitate payment
Address beneficiary coinsurance issues
Payment rates are determined in advance and are fixed for the fiscal year in which they are incurred.
Prospective payment rates are paid in full
Hospitals retain the profits or suffer losses based on actual vs projected costs
Copayment limited to inpatient coinsurance amount $840 for 2003 where previously copayments remained at 20% and could become very prohibitive in the course of a year for outpatient services

46. How are APC Groups Created?
CPT/HCPCS codes are grouped together . . .
Similar clinical aspects
Pacemakers can’t be grouped with bronchoscopies even if resource usage is similar
Comparable resource consumption
Clinically similar codes are grouped by cost to perform the service

47. What are the Key Components of APCs?
APC payment structure
Comprehensive/Composite APCs
Packaging/Discounting
Payment status indicators
Outpatient Code Editor (OCE)
OCE Edits
NCCI edits
Modifiers
Charge Description Master (CDM)

48. APC Payment Structure Relative weight OPPS conversion factor
Status indicator
Packaging
Discounts
Annual updates affect APC groups, payment adjustments, conversion factor, and payment weights

49. APC Payment Structure
Calculated by multiplying APCs relative weight by the OPPS conversion factor with a minor adjustment for geographic location
The payment is divided into Medicare’s portion and patient co-payment
Multiple APCs can be applied to one account

50. Packaging/Discounting
Services including laboratory, most supplies, anesthesia, intraocular lenses, and observation care are included in the APC payment
Drugs, pharmaceuticals, and biologicals usually not bundled
Discounting
Multiple procedures provided during the same encounter are provided at lower cost than they would be if provided at separate encounters
Applies to services with status indicator T

51. Payment Status Indicators
Description A
Services paid under fee schedule other than OPPS B
Code not recognized by OPPS C
Inpatient-only procedure D
Discontinued code E
Items, codes and services not covered by Medicare F
Corneal tissue acquisition G
Pass-through drugs and biologicals H
Pass-through device categories K
Nonpass-through drugs, biologicals, brachytherapy and blood L
Influenza or pneumococcal pneumonia vaccine M
Items and services not billable to FI
List of status indicators in handout

52. Payment Status Indicators
Description N
Items and Services packaged into APC rates P
Partial Hospitalization Q
Packaged services subject to separate payment under OPPS S
Significant procedure, not discounted when multiple T
Significant procedure, multiple procedure reduction applies V
Clinic or emergency department visit X
Ancillary service Y
Nonimplantable DME
List of status indicators in handout

53. Status Indicators
Status indicators K, S, T, V, X
Certain drugs and biological (K)
Outpatient surgery (S or T)
Outpatient evaluation and management (V)
Outpatient ancillary services
Radiology services (S and X)
Pathology and laboratory services (X)
Medical testing and evaluations and injections and infusions performed in the outpatient facility (K, S, T and X)
Other services and supplies are either not paid separately, not covered, or paid via other methods

54. Status Indicators
Significant procedures with status (S) are not discounted when multiple procedures are performed
When performed with other procedures, status S procedure receives full reimbursement
Significant procedures with status (T) are paid at a reduced rate when performed with other procedures during the same visit
Services with a status (N) are bundle into other APCs and are considered incidental
A cardiac catheterization code drives the APC payment
Ventriculography, coronary angiography, and S&I codes are all bundled into APC for a heart catheterization

55. Status Indicator C – Inpatient Only Procedures
Services that must be performed in inpatient setting due to:
Invasive nature of procedure
Need for at least 24-hours of recovery or monitoring time before the patient can be safely discharged
Because of underlying condition of patient
Codes removed from list due to re-evaluation and technology changes
Inpatient Only services allowed in outpatient setting for emergencies
An early list had over 1,000 codes on it, but changes in technology and available types of procedures have reduced number and every year more codes are removed from the inpatient only list. Also, as of this year may be paid in outpatient if emergency procedure.

56. IP Only Procedure Sample
22558
Lumbar spine fusion C
22585
Additional spinal fusion
22586
Prescrl fuse w/ instr l5-s1
22590
Spine & skull spinal fusion
22595
Neck spinal fusion
22600
Neck spine fusion
22610
Thorax spine fusion
22630
22632
Spine fusion extra segment
22633
Lumbar spine fusion combined
22634
22800
Post fusion </6 vert seg
22802
Post fusion 7-12 vert seg
22804
Post fusion 13/> vert seg
22808
Ant fusion 2-3 vert seg
22810
Ant fusion 4-7 vert seg
22812
Ant fusion 8/> vert seg
22818
Kyphectomy 1-2 segments
22819
Kyphectomy 3 or more
22830
Exploration of spinal fusion

57. Outpatient Code Editor (OCE)

58. Outpatient Code Editor
Two main functions of OCE:
Edit claims data to identify errors and identify claim and line dispositions
Includes: ICD-10-CM, HCPCS codes and HCPCS modifier(s)
Assign an APC for each service covered under OPPS and return information to calculate the OPPS rate

59. Outpatient Code Editor
An OCE edit can result in one of six dispositions:
Claim rejection
Claim denial
Claim return to provider
Claim suspension
Line item rejection
Line item denial
Rejection: Claim can be resubmitted once error(s) has been corrected
Denial: Payment decision made; can be appealed

60. Outpatient Code Edits 78 edits, including: 1. Invalid diagnosis code
6. Invalid procedure code
12. Questionable covered service
18. Inpatient procedure
22. Invalid modifier
41. Invalid revenue code
48. Revenue center requires HCPCS

61. Outpatient Code Edits
All edits can be found at:

62. National Correct Coding Initiative (NCCI) Edits

63. NCCI
Billing edits to identify coding patterns resulting in overpayment to providers
More than 107,000 CCI edits are incorporated into the outpatient code editor for OPPS
Edits determine what procedures and services cannot be billed together when they are furnished for the same patient on the same day

64. NCCI
With OPPS, it is possible to receive multiple APC payments for a single outpatient encounter
CCI edits prevent fragmenting/unbundling of services
Inappropriate reporting of multiple CPT/HCPCS codes
CCI edits are OCE edits 19, 20, 39, and 40

65. Modifier Indicator 0=not allowed 1= allowed 9= not applicable
NCCI Edits
Column 1
Column 2
Modifier Indicator 0=not allowed 1= allowed 9= not applicable
36475
36479
36478
36476
47531
47544 1
47532

66. NCCI
OCE Edit 19: Mutually exclusive procedure that is not allowed by NCCI even if appropriate modifier is present
The procedure is one of a pair of mutually exclusive procedures in the NCCI table coded on the same day, where the use of a modifier in not appropriate. Only the code in column 2 of a mutually exclusive pair is rejected; the column 1 code of the pair is not marked as an edit

67. NCCI
OCE Edit 20: Code2 of a code pair that is not allowed by NCCI even if appropriate modifier is present
The procedure is identified as part of another procedure on the claim coded on the same day, where the use of a modifier is not appropriate. Only the code in column 2 of a code pair is rejected; the column 1 code of the pair is not marked as an edit

70. NCCI
OCE Edit 39: Mutually exclusive procedure that would be allowed by NCCI if appropriate modifier were present.
The procedure is one of a pair of mutually exclusive procedure in the NCCI table coded on the same day, where the modifier was either not coded or is not an NCCI modifier. Only the code in column 2 of a mutually exclusive pair is rejected; the column 1 code of the pair is not marked as an edit.

71. NCCI
OCE Edit 40: Code2 of a code pair that would be allowed by NCCI if appropriate modifier were present
The procedure is identified as part of another procedure on the claim coded on the same day, where the modifier was either not coded or is not an NCCI modifier. Only the code in column 2 of a code pair is rejected; the column 1 code of the pair is not marked as an edit.

75. Modifiers

76. Modifiers
A CPT or HCPCS level II modifier may be needed to indicate a service or procedure has been performed has been altered by some specific circumstance(s)
The correct use of modifiers reduces the need for separate procedure listings to describe the modifying circumstance
When needed, the two-digit modifier is placed after the procedure code
Bilateral inguinal hernia repair:

77. Modifiers
Modifiers are required to meet at least one of the following criteria:
Payment implications
Future need for payment data for constructing an outpatient PPS
Coding consistency and editing

78. Modifiers – Hospital OP Use25
Significant, separately identifiable E/M service by the same physician on the same day of a procedure or other service 27
Multiple outpatient hospital E/M encounters on the same date 50
Bilateral procedure 52
Reduced services 58
Stages or related procedure or service by the same physician during the postoperative period 59
Distinct procedural service 73
Discontinued outpatient procedure prior to anesthesia administration 74
Discontinued outpatient procedure after anesthesia administration

79. Modifiers – Hospital OP Use76
Repeat procedure or service by same physician 77
Repeat procedure by another physician 78
Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period 79
Unrelated procedure or service by the same physician during the postoperative period 91
Repeat clinical diagnostic laboratory test XE
Separate encounter XS
Separate structure XP
Separate practitioner XU
Unusual non-overlapping service

80. Other Modifiers 22 Increased procedural services 23 Unusual anesthesia24
Unrelated E/M service by the same physician during a post-operative period 26
Professional component 32
Mandated services 33
Preventive services 47
Anesthesia by surgeon 51
Multiple procedures 53
Discontinued procedure

81. Other Modifiers 54 Surgical care only 55
Post-operative management only 56
Pre-operative management only 57
Decision for surgery 62
Two surgeons 63
Procedure performed on infants less than 4 kg 66
Surgical team 99
Multiple modifiers

82. HCPCS Level II ModifiersLT
Left side RT
Right side CA
Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission GA
Waiver of liability statement issued as required by payer policy, individual case LC
Left circumflex coronary artery LD
Left anterior descending coronary artery LM
Left main coronary artery RC
Right coronary artery RI
Ramus intermedius coronary artery

83. HCPCS Level II ModifiersFA
Left hand, thumb F1
Left hand, second digit F2
Left hand, third digit F3
Left hand, fourth digit F4
Left hand fifth digit F5
Right hand, thumb F6
Right hand, second digit F7
Right hand, third digit F8
Right hand, fourth digit F9
Right hand, fifth digit TA
Left foot, great toe T1
Left foot, second digit T2
Left foot, third digit T3
Left foot, fourth digit T4
Left foot, fifth digit T5
Right foot, great toe T6
Right foot, second digit T7
Right foot, third digit T8
Right foot, fourth digit T9
Right foot, fifth digit

84. Modifier ‘59

85. Modifier ‘59 Definition
Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier ‘59 is used to identify procedures/services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier ‘59. Only if no more descriptive modifier is available, and the use of modifier ‘59 best explains the circumstances, should modifier ‘59 be used.

86. Correct Coding Modifier Indicator (CCMI)
CCMI of ‘0’ – the codes should never be reported together by the same provider for the same beneficiary on the same date of service
If reported on the same date: column 1 code eligible for payment; column 2 code denied
CCMI of ‘1’ – the codes may be reported together only in defined circumstances which are identified on the claim by the use of specific NCCI-associated modifiers
Modifier ‘59 is an important NCCI-associated modifier that is often used incorrectly

87. Modifier ‘59
Modifier ‘59 should only be used to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edits
Modifier ‘59 should only be used if no other modifier more appropriately describes the relationship of the two procedure codes
“Modifier of last resort”

88. Appropriate Use of Modifier ‘59
For two services described by timed codes provided during the same encounter only when performed sequentially
For a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure
For a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure

89. Appropriate Use of Modifier ‘59
Use of modifier ‘59 does not require a different diagnosis for each HCPCS/CPT coded procedures
Conversely, different diagnoses are not adequate criteria for use of modifier ‘59

90. XE, XS, XP XU
Modifiers XE, XS, XP, XU were developed to provider greater specificity in situations where modifier 59 was previously reported and may be utilized in lieu of modifier 59 whenever possible.
XE – Separate encounter. A service that is distinct because it occurred during a separate encounter. Should only be used to describe separate encounters on the same date of service

91. XE, XS, XP XU, continued
XS – Separate structure. A service that is distinct because it was performed on a separate organ/structure.
XP – Separate practitioner. A service that is distinct because it was performed by a different practitioner
XU – Unusual non-overlapping service. The use of a service that is distinct because it does not overlap usual components of the main service

92. Modifier ‘59 Example Column 1 code 67210/Column 2 code 67220
67210 – Destruction of localized lesion of retina, 1 or more sessions; photocoagulation
67220 – Destruction of localized lesion of choroid; photocoagulation, 1 or more sessions
CPT code should not be reported and modifier 59 should not be used if both procedures are performed during the same operative session because the retina and choroid are contiguous structure of the same organ

93. Modifier ‘59 Example Column 1 code 29827/Column 2 code 29820
29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair
29820 – Arthroscopy, shoulder, surgical; synovectomy, partial
CPT code should not be reported and modifier ‘59 should not be used if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure. If the procedure are performed on different shoulders, modifier RT and LT should be used, not modifier ‘59

94. Modifier ‘59 Example Column 1 code 32551/Column 2 code 71020
32551 – Tube thoracostomy, includes connection to drainage system, when performed, open
71020 – Radiologic examination, chest, 2 views, frontal and lateral
Modifier ‘59 may be reported if, later in the day following the insertion of a chest tube, the patient develops a high fever and a chest x-ray is performed to rule out pneumonia. CPT code should not be reported and modifier 59 should not be used for a chest x-ray that is performed following insertion of a chest tube in order to verify correct placement of the tube

95. Charge Description Master (CMD)
A computerized master price list of everything the facility can provide to patients
Includes supplies, diagnostic tests, pharmaceuticals, procedures, and other room time
Hundreds of thousands of items are included in chargemaster to link services provided in a hospital and the generation of claim forms
Maintained by the Chargemaster Coordinator including
Annual updates (e.g., code changes)
Updates specific to the CDM
Monthly audits to determine whether bills follow billing regulations

96. CDM, continued
Some claims are generated almost entirely from the Chargemaster
Chemotherapy
Interventional radiology
Radiation therapy
Some services that previously were chargemaster driven require coding to be performed by the HIM department under APCs

97. Medical Necessity

98. Medical Necessity
Defined by CMS, as “services or supplies that are proper and needed for the diagnosis or treatment of a patient’s medical condition, are provided for the diagnosis, direct care, and treatment of the patient’s medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of the patient or the physician” (Centers for Medicare and Medicaid, 2006)
Clinical documentation in the medical record must clearly communicate the care provided during a patient-physician encounter is medically reasonable and necessary to support proper coding, billing and reimbursement purposes

99. Medical Necessity
Medical necessity concerns span all aspects of outpatient care and apply in all settings
Medicare Administrative Contractors (MACs) and private payers rely on coverage policies such as CMS National Coverage Determination policies (NDCs) to inform healthcare practitioners of appropriate or covered diagnosis codes associated with specific procedures
Clinical documentation that clearly and completely supports the necessity for medical services can be challenging for healthcare professionals and the opportunity for documentation professionals to work collaboratively with the providers helps to ensure the capture of quality documentation

100. QUESTIONS?
Thank you! Kathy DeVault Laura Barron