EDI loop for billing, pay to and rendering provider info

Electronic Data Interchange

The Health Insurance Portability and Accountability Act (HIPAA) requires compliance with the Electronic Data Interchange (EDI) standards. Providers should follow the HIPAA transaction and code set requirements as found in the National Electronic Data Interchange Transaction Set Implementation Guides. The following provides details from the Implementation Guides to accommodate NPI within the 837 and 835 EDI transactions. Failure to comply with the 837 standards will result in a rejection of the claim.

837 Health Care Claim Submissions

PROFESSIONAL
Loop	Segments/Data Elements
Billing Provider Loop 2010aa	NPI:  NM108 = XX and NM109 = NPI Tax ID: REF01 = EI and REF02 = Tax ID Legacy ID not mandated for use
Pay-To Provider Loop 2010ab	NPI:  NM108 = XX and NM109 = NPI Tax ID: REF01 = EI and REF02 = Tax ID Legacy ID not mandated for use
Referring Provider Loop 2310a	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use
Rendering Provider Name Loop 2310b	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use
Purchased Service Provider Loop 2310c	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use
Service Facility Location Loop 2310d	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use
Supervising Provider Name Loop 2310e	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use
Rendering Provider Name Loop 2420a	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use
Purchased Service Provider Name Loop 2420b	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use
Service Facility Location Loop 2420c	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use
Supervising Provider Name Loop 2420d	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use
Ordering Provider Name Loop 2420e	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use
Referring Provider Name Loop 2420f	NPI:  NM108 = XX and NM109 = NPI Tax ID not mandated for use Legacy ID not mandated for use

NDC on ub 04 - where to report

Placement of an NDC when filing a claim:

Paper:

If billing on a paper claim, an original Red & White form must be used - not a copy of an original.

 UB-04 location – Box 43 (Please refer to the NUBC for additional guidelines)

 CMS 1500 location – Box 24A (shaded area) (Please refer to NUCC for additional guidelines)

NDC code report formating CMS 1500 and electronic claim

NDC Reporting Guidelines

An NDC is required for pharmaceuticals that are dispensed from a pharmacy and physician-administered drugs in an office/clinic (i.e. FQHC/RHCs, dialysis facilities) or outpatient facility/hospital setting.

* Provider must submit the 11-digit National Drug Code (NDC), found on the vial of medication, associated with the administered drug.

* NDC codes should be reported according to the format set out by the National Drug Code Directory.

* NDC codes contain 3 segments each with a set number of characters.

* NDC codes MUST be billed with the N4 qualifier before the 11 digit NDC code, when billing on a paper claim

* N4 qualifier also applies to EDI claims. Include on EDI claim, open the loop for NDC in the Practice Management System and enter the 11 digit NDC code. The system will electronically insert the N4 qualifier in the correct location upon activating the loop.


Example:
N400056498000
Seg 1      Seg 2    Seg3
5 Digits 4 Digits 2 Digits
Labeler Product Size

NOTE: Segments are to run together with no spaces, dashes, or hyphens

Segment 1= Labeler Code; this segment will contain a 5 digit labeler code. Code should be preceded by 0’s (zeros) if the code does not equal 5 digits.

Example: Labeler Code is 56 then the segment entry would be 00056. (Padded with 3 zeros to complete the 5 digit label code)

Segment 2= Product Code; this segment will contain a 4 digit product code. The product code will always be 4 digits and will not require padding with zeros.

Segment 3= Trade Package Size; this segment will contain a 2 digit size code. The trade package size code will always be 2 digits and will not require padding with zeros.

Taxonomy guide for CMS 1500 from wellcare insurance

Wellcare -Taxonomy Guide

In accordance with SNIP level 4 edits, a valid taxonomy is a requirement for all providers when submitting both paper and electronic claims. This guide will provide basic information to further instruct and educate all providers in assistance with taxonomy submittals.

Taxonomy code is constructed of 10 digits- numeric and alpha: (see example 1)

Placement of Taxonomy and Qualifier

Tips:
 Qualifiers are to be included on both paper and electronic claims for proper submission of claims
 Provider should be billing with the taxonomy that is filled with DCH

how to bill preventive medicine service during screening service

PREVENTIVE MEDICINE SERVICE PROVIDED AT THE TIME OF COVERED SCREENING SERVICE

A preventive medicine exam includes a comprehensive age and gender appropriate history, examination, counseling/anticipatory guidance/risk-factor reduction interventions, and the ordering of appropriate immunization(s) and laboratory/diagnostic procedures. Sometimes these other elements are performed during the same visit as the Medicare covered services, particularly G0101 and Q0091. The following pie chart illustrates this circumstance.

Medicare will reimburse for the shaded parts of the pie (the collection of the Pap smear and the pelvic exam). The remaining portions of the preventive service are billed to the patient. The amount paid by Medicare is subtracted from the physician’s usual fee for a preventive service. The remaining amount is the patient’s fee. This is referred to as a “carve out,” meaning that Medicare’s covered portion of the preventive service is carved out of the total preventive service. The amount reimbursed by Medicare and the amount reimbursed by the patient will equal the physician’s usual fee.

Example : The “carve out” method for reporting the screening pelvic examination (G0101) with other preventive medicine care:

Bill to:	CPT/HCPCS Code(s)	ICD-9 Codes	Charge
Medicare	G0101-GA	V72.31 or V15.89	$34.60
Patient	99397-GY	V72.31	$65.40
Total amount billed			$100.00

The physician’s usual charge for the preventive visit (99397) is $100. The total billed to the patient and to Medicare equals the physician’s usual charge for the preventive service.

The GA modifier indicates that an ABN has been signed. Modifier GY is reported for a service that is not a Medicare covered benefit. The service is being reported to Medicare to receive a denial. The patient is responsible for the preventive service less the Medicare carve out amount.

Example 2: Preventive visit reported with screening pelvic examination (G0101) and collection of a screening Pap smear specimen (Q0091):

Bill to:	CPT/HCPCS Code(s)	ICD-9 Codes	Charge
Medicare	G0101-GA	V72.31 or V15.89	$34.60
	Q0091-GA	V72.31 or V15.89	$40.00
Patient	99397-GY	V72.31	$25.40
Total amount billed			$100.00

The physician’s usual charge for the preventive visit (99397) is $100. The total billed to the patient and to Medicare equal the physician’s usual charge.

The GA modifier indicates that an ABN has been signed. Modifier GY is reported for a service that is not a Medicare covered benefit. The service is being reported to Medicare to receive a denial. The patient is responsible for the preventive service less the Medicare carve out amount.

Once Medicare has processed the claim, the patient is billed for her portion of G0101 and Q0091. However, the patient can be billed at the time of service for the portion not covered by Medicare.

ABN notice - GA, GZ, GY modifier

ADVANCED BENEFICIARY NOTIFICATION

Medicare screening services are limited to a specific frequency (e.g., once every 2 years, once every year). A physician may not know whether a patient is eligible for this service in a given year. If she is not eligible, the service will be denied. Therefore, the physician should ask the patient to sign an advance beneficiary notice of noncoverage (ABN) using the form provided by Medicare. For more information on Medicare’s ABN form, visit http://www.cms.hhs.gov/BNI/02_ABN.asp. Claims for
Medicare patients should be submitted with the appropriate HCPCS modifier.

• GA modifier indicates that an ABN form has been signed.
• GZ modifier indicates that an ABN form has not been signed. (Item or service expected to be denied as not reasonable and necessary)
• GY modifier indicates that the service provided is not a covered Medicare benefit. The service is being reported to Medicare in order to receive a denial.

Using the appropriate modifier ensures that the patient will receive the correct information on her Explanation of Benefits (EOB). For example, when a service is reported with a GY modifier, the EOB will state that it is not covered and therefore is the patient’s responsibility.

Medicare covered Screening Services

Medicare Screening Services

Physicians are often confused about how to document and report preventive services provided to their Medicare patients. This document is designed to assist physicians in documenting, reporting and receiving reimbursement for these services.
Medicare does not cover comprehensive preventive visits (99381-99397). However, Medicare does cover certain screening services which are often performed during preventive visits such as:

• Screening pelvic exam
• Collection of screening Pap smear specimen
• Interpretation of the Pap smear test (reported by the laboratory)
• Screening hemoccult
• Screening mammography
• Screening bone mass measurement
• Initial preventive physical examination (Welcome to Medicare examination)
• Diabetes screening
• Cardiovascular blood test
• Tobacco use cessation counseling

The table at the end of this document provides an overview of Medicare screening services. The Centers for Medicare and Medicaid (CMS) have published several educational products that describe covered screening services available to Medicare patients.

CPT definitions - new patient or established patient

Medical services are characterized by face – to – face services for the purposes of classifying new and established patients. A new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past 3 years. An established patient is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past 3 years.

The CPT definitions do not explicitly address the question of cross referral to a subspecialist within a given group. For example, if a headache specialist, whose practice is exclusively limited to the care of headache patients, practices with a group of neurologists who are not headache specialists, is it possible for a patient, who may be referred to the headache subspecialist within the same group, to be considered a new patient. The answer is yes but it would be best if the headache subspecialist had a
separate tax identification number for their subspecialty. Since the question of subspecialty reporting within a given specialty is not precisely addressed in CPT definitions, this type of cross referral would be open to interpretation.

time guideline for 99211, 99212, 99213, 99214, 99215 - E & M code

An important guideline to remember when reporting office visits other than counseling and coordination of care is that only two of the three key components must be reported. 

 The following is a summary of the requirements for codes 99211 – 99215.

99211: 5 minutes and may not require the presence of a physician
99212: 10 minutes
A problem focused history
A problem focused examination
Straight forward decision making

99213: 15 minutes
An expanded problem focused history
An expanded problem focused examination
Medical decision making of low complexity

99214: 25 minutes
A detailed history
A detailed examination
Medical decision making of moderate complexity

99215: 40 minutes
A comprehensive history
A comprehensive examination
Medical decision making of high complexity

History and physical examination skills and documentation guidelines we were taught in medical training tend to produce a very high quality of medical care. But these do not always meet the guidelines in the multiple medical record components that are required by CPT coding system for E/M coding. To be more efficient and improve reimbursements, physicians must have a better understanding of the Current Procedural Terminology requirements. Future discussions in this section of the AHS website will include a comprehensive discussion of the three key components of CPT coding: History, Examination, and Medical Decision Making, as well as a review of the importance of understanding the Nature of the Presenting Problem in ensuring proper coding. The fourth quarterly future topic in this series will be devoted to the International Classification of Diseases (ICD – 9-CM) coding.

Can radiation oncologist bill 99441, 99442, 99443 , 98966 - telephone consult

Coding Question: If a radiation oncologist provides E/M services to his/her patients via telephone, can they bill 99441, 99442 and 99443? Also, can a Medicare Provider bill these CPT codes and, if so, where can the pricing be found on the Medicare Fee Schedule? Can this kind of phone service be billed under any other E/M billing code that is on the Medicare Fee Schedule?

Coding Response:  CPT codes 99441 - 99443 describe telephone evaluation and management services provided by a physician to an established patient. The patient or patient’s parent/guardian must initiate the contact as these codes may not be used for calls initiated by a provider. The codes are differentiated according to the length of the medical discussion with the patient. These codes are used only for services personally performed by a physician. CPT codes 98966-98968 describe telephone services performed by qualified non-physician health care professionals. Medicare has designated all telephone evaluation management codes with a status indicator “N” which indicates the service is not covered by Medicare.  It should be noted that relative value units (RVUs) are listed for these codes in the Medicare Physician Fee Schedule. Therefore, while Medicare does not cover these services, some private payers could potentially cover these services and use the RVUs assigned by Medicare to set payment rates. ASTRO recommends you review the current policies of your major payers to determine their coverage policies regarding telephone evaluation management services. Phone calls during treatment are included in the work captured in CPT code 77427 which includes a 90-day global period after treatment is completed.

CPT® code 77427: Radiation treatment management, 5 treatments

CPT® code 98966: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

CPT® code 98967: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

CPT® code 98968: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

CPT® code 99441: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

CPT® code 99442: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

CPT® code 99443: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

update on hipaa 5010 and ICD 10

What is going on with 5010 and ICD10… I guess not much

Not too many organizations seem to be unduly concerned about the impending conversion which is now less than two and a half year away for 5010. Or so it seems at least by the actions being taken in the industry. Though I have been hearing a lot about how worried they are regarding the lack of time they might have for changing such a complex network of application portfolio, but not many seem to be taking actions commiserate with their concerns.

We have seen quite a lot of semi-structured exercises taking place, either using internal staff or leveraging high-end consulting organizations but they are primarily limited to very high level analysis of what is going to be impacted. While the initial high level assessment is not a bad idea at all, in my opinion we should be way past that stage by now. A seventy page power-point deck highlighting the twenty core areas that are going to be impacted would have been a good idea in March’2009 but may not be sufficient in October’2009.

Let’s try to see the things in perspective:

1) First of all the mandate date of 1st Jan, 2012 is actually a misnomer. The actual date that one needs to be concerned about is really 1st Jan, 2011. The latter is the date when organizations are supposed to be ready to test their compatibility with their trading partners and the year after that is supposed to be focused more on testing rather than real first-time implementation. So basically all we have is around 15 months and in some cases (such as the Blues) that time is even more restricted because the association’s requirement of being prepared by 1st July, 2010. Barely 9 months away.

2) Second, the tactical approach that most of the organizations are thinking about (i.e., using a step down conversion on the inbound 5010 docs and then propagate the resultant 4010 doc all the way through the downstream applications w/o making any change to them) is not a bad idea at all but definitely has its limitations. The most glaring one being the fact that the shelf life of this solution is not much beyond 1st October, 2013, i.e. when ICD10 mandates take hold. Why I say so is because 4010 can not support ICD10 and if we keep on down-converting the inbound 5010s, the propagated 4010s will need to incorporate the down-converted ICD9 and that defeats the whole purpose of going the ICD10 route. Bye, bye granularity. Bye, bye reduced payouts. Bye, bye increased quality of care. After that it might as well be a mandate being pushed down the throat courtesy CMS.

3) Third, the step-down approach itself is not as simple as some people are assuming it to be. Obviously it is relatively easy to down-convert a 5010 to 4010 (notice the use of word ‘relative’. The conversion is not entirely straight-forward, just simpler than up-conversion) but what happens to the attributes that are new in 5010 and are expected to be used for some decision making process in the downstream applications. By ignoring them during down-conversion (as 4010 will not support them) and hence not using them in the decision making process downstream, is the organization still in compliance with the mandate? Or even if one stores that deleted information in some kind of interim repository, what will be the performance impact on core transaction processes if the applications now have to access the interim repository to get the additional data? In any case, even if one makes simple modification to the core application to fetch the addition data from the interim repository, wouldn’t that call for all sort of regression testing and wouldn’t that defeat the whole concept of not touching the downstream applications? Also, how does one handle the 3rd party apps? The vendors will have either a 4010 compliant app or a 5010 compliant app. They are not going to have an in-between app that will allow the end users to configure an interim repository as the source of additional information while maintaining compliance with 4010 standards.

So, the bottom-line is that even if one is thinking about using the interim tactical approach (that of down-conversion variety), one must not be complacent in terms of time frames. There are many considerations even to implement the interim solution and it is definitely not going to be the final game. So my recommendation is start work on the interim solution immediately and when I say ‘work’, I mean a heck of a lot more than the power points. I mean, identification of required attributes to support 5010 specific mandates in the downstream apps. I mean, identifying the code sets that are going to require the additional data and to design an approach for those code sets to get the new data elements. I mean, designing a fool-proof store-and-forward methodology that can support batch as well as real-time transaction processing and is not a resource hog to eat up all your spare processing time. By the way, does anybody have any spare processing time in any case? I did not think so.

evaluation and managment billing basic

E&M Services

When a patient is seen as a consultation or new referral, all three of the key components, History, Examination, and Medical Decision Making, must be reported and meet or exceed the stated requirements to qualify for a particular level of EM service. When an established patient (seen within the past three years) visit is reported, two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service. Although time is not taken into account as a factor for determining the level of E/M care during most patient visits, the CPT codebook includes the inclusion of time as an explicit factor to assist physicians in selecting the most
appropriate level of service. The CPT codebook and the Documentation Guidelines for Evaluation and Management Services do define specific circumstances which permits time to be the sole determining factor in E/M selection. When counseling and / or coordination of care comprises more than 50% of the time spent during an encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M service. This must be “face – to face” time with the patient or the family and may be unit / floor time when in the hospital. The latter includes the time in which the physician establishes and / or reviews the patient’s chart, examines the patient, writes notes, and communicates with other professionals and the patient’s family. This means that the amount of time spent in patient care is permitted to become the sole determining factor of the level of E/M service even if the physician did not perform or report any of the three key components. The physician must document the total length of time of the encounter plus a description of the counseling and / or activities involved in the coordination of care.

The record documentation must also state that more than 50% of the encounter was involved in counseling and / or coordination of care. When the physician defines that more than 50% of the visit time was dedicated to counseling and coordination of care, the E/M code can be determined by the time values that are listed in the CPT codebook for each type of E/M service and each level of care. The CPT codebook also points out that the specific times expressed in the visit code descriptors are averages, and represent a range of times that may be higher or lower depending on the actual clinical situation. In the management of headache patients, office visits are often spent in counseling and coordination of care. Physicians treating headache  patients should consider using the amount of time and effort spent performing this service as a determining factor in defining any particular office or hospital visit.

new patient consultation and new patient referral - what is the difference

It is also important to understand the difference between a new patient Consultation and
a New Patient Referral.

The need for a physician to request advice or expert opinion from a colleague, in the form of a professional consultation, is almost as old as medicine itself. However, physicians must be aware that there have been “clarifications” in the CPT guidelines distinguishing a Consultation (99241 – 99245), versus a New Patient Referral (99201 – 99205). For purposes of CPT, a consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and / or management of a specific problem is requested by another physician or other appropriate source. It appears there had been confusion in reporting consultative services beginning with the terms used to describe the service requested. The terms consultation and referral were mistakenly interchanged. When a physician refers a patient to another physician, it is not automatically a consultation. The revised Medicare Claims Processing Manual, effective Jan 1, 06, listed clarifications in Medicare rules in distinguishing a Consultation verses a New Patient Referral. The latter generally pays a
lower fee. Historically, physicians have known that in reporting a consultation service, the three R’s must be documented: Request, Render, and Report. Starting in 2006, CPT requirements have included one more R requirement: a Reason. There must be a request for consulting services from another physician or health care provider, the suspected or known diagnosis requires determination by a specialist who renders his / her opinion, the referring physician and consultant specifies a reason for the consultation, the treatment is undetermined or may be known, and a written report to the
requesting physician or referring source reiterating the reason for consultation plus the findings and opinions must be forwarded by the consultant. In most cases, a consultation is a one – time visit. A New Patient Referral usually has an identified problem which requires a specialist to provide care, and does not require that a written report be sent to the requesting physician or health care provider.


The policy changes or clarifications also state that a transfer of care occurs when a physician requests another doctor to assume the care of the patient. Ongoing management of the patient by the consultant physician cannot be reported using a consultation service code. Therefore, a referral for evaluation and management (E/M) cannot be considered a consultation because there has been a transfer of care. There also has been concern regarding language that the consulting physician must document the request and reason for the consultation in the patient’s medical record. Without that
documentation, the CPT code for a consultation could not be use. However, according the the E/M documentation guidelines, the consulting physician is not required to confirm that the requesting physician document his / her request. The documentation criteria for a consultation service requires that the requesting physician and consulting physician both document the request for consultation in their medical records, but each physician is required to keep their own accurate records and code accordingly. In the revised Medicare Claims Processing Manual, the section which discusses consultation followed by treatment, there are also rules governing those occasions when it may be necessary for the consulting physician to assume ongoing care of the patient. It should be
emphasized that the above guidelines differentiating a Consultation from a New Patient Referral apply primarily to Medicare patients. Currently it appears that non – Medicare payers have not yet implemented these regulations.

most frequently used evaluation managment code - office, inpatient and outpatient CPTs

The Evaluation and Management codes (99201 – 99499) are used by most physicians in
reporting a significant portion of their services and are divided into broad categories such as office visits, hospital visits, new patient encounters and consultations. Most of these categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital visits (initial and subsequent). To properly define the E/M services, there are seven components recognized: History, Examination, Medical Decision Making (MDM), Nature of the Presenting Problem (NPP),
Counseling, Coordination of Care, and Time. The first three components, History, Examination and Medical Decision Making are recognized as the key components of E/M services. Each of the three key components is further divided into four categories. The History includes: CC, HPI, PFSH and ROS. The four levels of the Physical Examination are: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive. The four elements of Medical Decision Making include: Straight

Forward, Low Complexity, Moderate Complexity and High Complexity. By year end, it is the intent for this part of the AHS website to have thoroughly reviewed the CPT (and ICD) coding system as it applies to the care of the headache patient.

To a large extent physicians use about four or five different types of service codes for the majority of care they provide. The most frequently used outpatient visit CPT codes are:

Initial visits: CPT codes 99201 - 99205
Established patient visits: CPT codes 99211 - 99215
Office consultations, new or established patients: CPT codes 99241 - 99245

The most commonly used hospital care codes are:

Initial hospital care: CPT codes 99221 - 99223
Subsequent hospital care: CPT codes 99231 - 99233
Inpatient consultations, new or established patients: CPT codes 99251 – 99255

Issues in evaluation management billing in headache

General Issues in Evaluation and Management (E&M) in Headache

By better understanding the Evaluation and Management (E/M) coding system and rules, it is the physician’s challenge to meet the demands of a complex health care system while still providing excellent patient care. While physicians are faced with multiple challenges to meet these demands, quality care of our patients is still the central theme and the reason why we became physicians. A working knowledge of the E/M methodology unites the goal of quality patient care and conformity to the Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)
regulations. A thorough understanding of the CPT coding system is essential in order to provide accurate reporting of medical services and procedures and to correctly describe medical, surgical, and diagnostic services among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. Accurate ICD codes provide The Centers for Medicare and Medicaid Services (CMS) and other third – party insurance carriers correct and complete coding to the third, fourth, or fifth digit.

In this series posted on the American Headache Society website, the CPT coding fundamentals and ICD coding recommendations for headache patients will be reviewed.New sections will be posted quarterly. This initial segment will focus on some general and important issues regarding CPT coding.
Identifying the proper CPT code exemplifies the traditional paradigm of documenting the physician’s care then trying to identify the code for the level of service provided. To help insure more accurate coding, there are some key points regarding the CPT coding system which are worth reviewing. When the AMA first developed and published the CPT nomenclature in 1966, a four – digit system was used. The second CPT edition published in 1970 presented an expanded system of terms and codes to designate diagnostic and therapeutic procedures. It was at that time that the five – digit codes
were introduced. Currently, all CPT codes are five digit codes. CPT codes are revised and updated annually by the AMA and the revisions become effective each January 1st. Since hundreds of CPT codes are added, changed, or deleted each year, it is important for all health care professionals to maintain copies of the current code books. The CPT coding system includes thousands of codes and definitions for medical services, procedures and diagnostic tests. Category 1 CPT codes describe a procedure or service identified with a five – digit numeric CPT code and descriptor nomenclature.
These codes are based on the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations. Category 1 CPT codes are restricted to clinically recognized and generally accepted services, not emerging technologies, services, and procedures. All of the E/M codes are included in Category 1. Two additional CPT code categories debuted in 2002. Category 11 CPT codes are a set of optional codes developed principally to support performance measurement. These codes are intended to facilitate data collection, do
not have a relative value associated with them, and are not required for correct E/M coding. Category 11 codes have been developed for following the care and good outcomes in certain clinical conditions such as: asthma, chronic stable coronary artery disease, congestive heart failure, hypertension, osteoarthritis, prenatal care and preventive care. There are also Category 111 CPT codes which are temporary codes used for emerging technology, services and procedures. These codes may be covered by given carriers if prearranged but are not covered by Medicare.

G0328 or 82274? which CPT has to choose,- Rules

G0328 or 82274? Choose Just 1 Fecal Blood Code

NCCI 10.2 bundles all FOBT code combinations

If you didn’t get the message from Medicare’s immunoassay fecal-occult blood test (iFOBT) coverage rules, you’ll get the message from the latest National Correct Coding Initiative (NCCI) edits — you must report either G0328 (Fecal blood screening immunoassay) or 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations) for the iFOBT test.

NCCI 10.2, which took effect July 1, added a mutually exclusive edit pair that bundles G0328 and 82274 together. A”0″ modifier indicator means that you cannot under any circumstances override the edit pair for Medicare payment.

‘Reason for Test’ Drives Coding

Medicare recognizes the two iFOBT codes based on whether the physician orders the test for colorectal cancer screening (G0328) or for a diagnostic purpose (82274).

You should use the HCPCS Level II code if the ordering physician states that the FOBT is for colorectal cancer screening or requests the test with a screening code such as V76.51 (Special screening for malignant neoplasms; colon), according to Anne Pontius, MBA, CMPE, MT (ASCP), president of Laboratory Compliance Consultants Inc., in Raleigh, N.C.

Earlier NCCI Bundled Guaiac FOBT

Medicare also covers guaiac-based FOBT (gFOBT) for diagnostic purposes (82270, Blood, occult, by peroxidase activity [e.g., guaiac], qualitative; feces, 1-3 simultaneous determinations) or colorectal cancer screening G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations).

The latest NCCI edits’addition of the G0328/82274 code pair completes FOBT code bundling. NCCI continues to include the following code pairs added in previous NCCI versions: G0107/82270, 82274/82270, G0328/82270 and G0328/G0107.

Bottom line: You must select only one FOBT test code based on the lab method used and the reason for the test (screening or diagnostic).

Medicare policy of billing cpt code g0328

FECAL-OCCULT BLOOD TEST-G0328

Medicare will cover a new colorectal cancer screening for fecal-occult blood test, HCPCS G0328 effective for dates of service on/after January 1, 2004. This article provides coverage, coding, frequency and billing guidelines for this service.


Policy
Medicare will cover the new colorectal cancer screening FOBT G0328 beginning January 1, 2004. G0328 is payable under the clinical lab fee schedule. Medicare patients aged 50 and over can only receive one FOBT per year, either G0107 (gFOBT, or guaiac-based) or G0328 (iFOBT, or immunoassay-based).

A covered screening FOBT is allowed once every 12 months for beneficiaries who have attained age 50 (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was performed). Medicare will allow either one covered G0107 gFOBT or one covered G0328 iFOBT, but not both during a 12-month period.
Screening FOBT means: (1) a guaiac-based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools or, (2) a immunoassay (or immunochemical) test for antibody activity in which the beneficiary completes the test by taking the appropriate number of samples according to the specific manufacturer?s instructions.
This expanded coverage is in accordance with revised regulations at 42 CFR 410.37(a)(2) that includes "other tests determined by the Secretary through a national coverage determination." This screening requires a written order from the beneficiary?s attending physician. (The term "attending physician" is defined to mean a doctor of medicine or osteopathy  who is fully knowledgeable about the beneficiary?s medical condition and who would be responsible for using the results of any examination performed in the overall management of the beneficiary?s specific medical problem.)

This coverage revision is a National Coverage Determination (NCD). NCDs are binding on all Medicare carriers, fiscal intermediaries, quality improvement organizations, health maintenance organizations, competitive medical plans and health care prepayment plans. Under 42 CFR 422.256(b), an NCD that expands coverage is also binding on a Medicare Choice Organization. In addition, an administrative law judge may not review an NCD (See Section 1869(f)(1)(A)(i) of the Social Security Act).
Applies to the state of AK, AZ, CO, HI, IA, ND, NV, OR, SD, WA & WY.

advantages of HIPAA 5010

What are the advantages of HIPAA 5010?

    * Generic enhancements made to all of the HIPAA standards (TR3):
          o Consistent TR3 formats – standardized front matter and appendices
          o Consistent implementation instructions
          o Clearly define situational requirements
          o Approximately 500 industry requested changes
          o Will reduce the need for Companion Guides by providing clearer instructions in the TR3 guides themselves
    * Major Functional Changes
          o Supports ICD-10
                + There is no way to send an ICD-10 diagnosis code in any of the 4010A1 transactions. HIPAA 5010 supports ICD-9 only, ICD-10 only and dual usage of ICD-9 and ICD-10.
          o Clarifies NPI Instructions
                + Always report NPI at the lowest level of specificity
    * Selected Transaction Improvements
          o Eligibility Inquiry/Response 270/271
                + Requires alternate search options to reduce member not found responses
                + Added support for 38 additional Patient Service types on the request
                      # Examples: brand name prescription drug, screening X-ray, lab, burn care
                + Nine categories of benefit information must be reported on the response
                      # Examples: Medical, Dental, Hospital, ER
                + When reporting co-insurance, co-payment and deductible, must also include patient responsibility
                + Overall improvement in the ability to request information and the value of the information returned
          o Health Care Claims (837)
                + Supports ICD-10
                + Clarifies NPI Instructions
                      # Always report NPI at the lowest level of specificity
                + Improves instructions and data content for COB claims
                + Subscriber/patient hierarchy changes
                + Present on admission indicator – Institutional Claims
          o Health Care Request Authorization (278)
                + Significant changes will remove implementation obstacles
                + Medical necessity information added
                + Expect increased use of the transaction once covered entities migrate to 5010
          o New Transactions – 277CA & 999
                + Medicare FFS is replacing proprietary reports with the 277CA – the Claim Acknowledgement transactions
                      # First step to standardizing the payer response to the 837 claim transaction
                      # New reports will need to be written to display the 277CA data
                      # Not a HIPAA mandated transaction, but other payers are following the Medicare lead
                + Medicare FFS is replacing the 997 transaction with the 999
                      # 999 reports syntactical and TR3 guide errors

What is the Timeline for Implementing 5010?


    * Level 1: Internal testing to insure that a covered entity can receive and transmit HIPAA-compliant 5010 transactions
          o CMS advises covered entities to complete Level 1 testing by December 31, 2010
    * Level 2: End-to-end testing with all trading partners
          o CMS mandates Level 2 testing be completed by December 31, 2011
          o 2011 is the year for
                + End-to-end testing with trading partners
                + Conversion to the new standards (Medicare FFS is scheduled to begin accepting 5010 on January 1, 2011)
                + Dual-mode processing (4010 & 5010 depending on trading partner)
          o Full Compliance Date: January 1, 2012
          o What’s next?

ICD-10 Cut-over: October 1, 2013 

SCREENING PAP SMEAR SPECIMEN - Medicare cpt code Q0091

COLLECTION OF SCREENING PAP SMEAR SPECIMEN

Medicare reimburses for collection of a screening Pap smear every two years in most cases. This service is reported using HCPCS code Q0091 (Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory). The patient does not have to meet her Part B deductible, but is responsible for 20% of the Medicare approved amount for the service. For the laboratory’s interpretation of the test, the patient does not need to pay a copay nor meet her deductible.

The collection is reimbursed every year if the patient meets Medicare’s criteria for high risk. Following are the only criteria that are accepted by Medicare to indicate a high risk patient:
• Woman is of childbearing age AND
    o cervical or vaginal cancer is present (or was present) OR
    o abnormalities were found within last 3 years OR
    o is considered high risk (as described below) for developing cervical or vaginal cancer.
• Woman is not of childbearing age AND she has at least one of the following:
    o High risk factors for cervical cancer:
           �� Onset of sexual activity under 16 years of age
           �� Five or more sexual partners in a lifetime
           �� History of sexually transmitted disease (including the human papillomavirus and/or HIV infection);
           �� Fewer than 3 negative Pap smears within previous 7 years
           �� No Pap smears at all within the previous 7 years
   o High risk factor for vaginal cancer:
           �� She had been exposed to DES in utero

Pelvic exam screening - Medicare cpt code g0101

SCREENING PELVIC EXAM

Medicare reimburses for a screening pelvic examination every two years in most cases. This service is reported using HCPCS code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). If the patient meets Medicare’s criteria for high risk, the examination is reimbursed every year. These criteria are the same as the ones listed above for the collection of screening Pap smear specimen. The diagnosis codes for pap smear collection and screening pelvic exam are listed below.

Effective September 23, 2008, Medicare clarified that the clinical breast check is no longer considered a mandatory element of the screening pelvic exam. It is now one of the eleven elements that may be performed as part of the exam.

A screening pelvic examination (HCPCS code G0101) should include documentation of at least seven of the following eleven elements:
• Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge;
• Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses;
• External genitalia (for example, general appearance, hair distribution, or lesions);
• Urethral meatus (for example, size, location, lesions, or prolapse);
• Urethra (for example, masses, tenderness, or scarring);
• Bladder (for example, fullness, masses, or tenderness);
• Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele);
• Cervix (for example, general appearance, lesions or discharge)
• Uterus (for example, size, contour, position, mobility, tenderness, consistency,
descent, or support);
• Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity);and
• Anus and perineum.

HCPCS code G0101 includes only the above examination elements. It does not include many other services normally included in a comprehensive preventive visit.

billing g0101, q0091 (pap smear) cpt code with covered DX

DIAGNOSTIC CODING FOR THE COLLECTION OF PAP SMEAR AND SCREENING PELVIC EXAM

Both the collection of the screening Pap smear specimen (Q0091) and screening pelvic exam (G0101) are reported with one of the following diagnosis codes:

• V72.31 – routine gynecological exam (reported when provider performs a full gyn examination)
• V76.2 - Special screening for malignant neoplasms, cervix (patient has a cervix)
• V76.47 - Special screening for malignant neoplasms, vagina (patient does not have a cervix)
• V76.49 - Special screening for malignant neoplasms, other sites
• V15.89 - Other specified personal history presenting hazards to health. (patient is considered high risk according to Medicare’s criteria)

Collection of a diagnostic Pap smear (performed due to illness, disease, or symptoms indicating a medically necessary reason) is included in the physical examination portion of a problem-oriented E/M service and is not reported or reimbursed separately.

Often, both the G0101 and Q0091 are provided during the same visit. An example follows.

Example 1: Collection of a screening Pap smear (Q0091) reported with the screening pelvic examination (G0101):

Bill to:	HCPCS Codes	ICD-9 Codes	Charge
Medicare	G0101-GA	V76.2, V76.47, V76.49, or V15.89	$34.60
	Q0091-GA	V76.2, V76.47, V76.49, or V15.89	$40.00
Patient	N/A	N/A	$0.00
Total amount billed			$74.60

The assumption is that the physician in this example provided only Medicare covered services with no additional preventive care.

The GA modifier indicates that an ABN has been signed. Note that the charges listed in the example above are Medicare allowable amounts but do not include the geographical adjustment factor.
The patient is not initially billed for either of these services since Medicare covers them. Once Medicare has processed the claim, the physician bills the patient for her portion (20% of the Medicare approved amount).

office visit CPT code - does require referring physician - 99201 - 99205

Coding Question: Is it required by Medicare and Medicaid to have a referring physician in order to be able to bill for a new patient evaluation? If so, what should one do if the patient self refers himself/herself to you because of reputation/friend etc.?

Coding Response: The CMS definition for a new patient states that, “such a patient would be regarded as a new patient, a patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the last three years.” Therefore, any patient presenting him/herself to you would be regarded as a new patient. Effective January 1, 2010, CMS has eliminated payment for the office or other outpatient consultation codes 99241- 99245. The office and other outpatient visit codes for new patients (99201- 99205) are still recognized for reimbursement by CMS and may be used to report any new patient being seen in your practice. As a result of these changes, there is no distinction between a patient who is referred by a physician or one who is self referred; for Medicare they are both considered a new patient.  The E/M codes that can be used are CPT codes 99201 – 99205.

CPT code 99201: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

CPT code 99202: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.

CPT code 99203: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

CPT code 99204: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.

CPT code 99205: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.

CPT code 99241: Office consultation for a new or established patient, which requires these 3 components:  a problem focused history, a problem focused examination, and straightforward medical decision making.
CPT code 99242: Office consultation for a new or established patient, which requires these 3 components:  an expanded problem focused history, an expanded problem focused examination, and straightforward medical decision making.
CPT code 99243: Office consultation for a new or established patient, which requires these 3 components:  a detailed history, a detailed examination, and medical decision making of low complexity.
CPT code 99244: Office consultation for a new or established patient, which requires these 3 components:  a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity.
CPT code 99245: Office consultation for a new or established patient, which requires these 3 components:  a comprehensive history, a comprehensive examination, and medical decision making of high complexity.

time frame for HIPAA 5010 and important dates

5010: Important Changes are Coming

With the implementation of 5010, there will be a few changes in the way you send your electronic claim information. Understanding these changes and how they will affect your practice will prepare you for a smoother transition.  It is recommended that providers start testing for 5010 by January 1, 2011.  This recommendation is for all covered entities (including health care providers, health plans, and health care clearinghouses).


What’s next?

Now is the perfect time to contact your software vendor to determine if they will be providing any upgrades and if they will be testing on your behalf.   There will be practice management system changes that will be required for implementing the 5010 transactions. Depending on the contract with your software vendor, the system upgrades may be included in your current maintenance; however, some vendors may charge for those upgrades.


Questions you may want to ask your software vendor:

    * Can my current system accommodate both the data collection and transaction conduction for 5010?
    * Will you be upgrading my current system to accommodate the 5010 transactions?
    * Will there a charge for the upgrade?
    * When will the upgrades be available?
    * When will the installation to my system be completed?


If your software vendor will not be testing the new format for you, it will be necessary for you to submit test transactions directly to Gateway EDI.  This step will be required to help insure you are able to operate in production mode by the January 1, 2012 compliance date.

HIPPA 5010 and changes in CMS 1500 CLAIM box 33

5010: Important Changes to Provider Information on Claims


With the implementation of 5010, there will be changes required for the way you send your electronic claim information. Understanding these changes and how they will affect your practice will prepare you for a smoother transition.

The Billing Provider Information sent in box 33 of a CMS 1500 form will need to be sent differently for 5010 electronic transactions.   The Billing Provider Information can no longer contain a PO Box or Lock Box and you must send the physical address of the practice.

If you use a PO Box or Lock Box to receive payment, it can still be sent on 5010 electronic transactions.  However, that information will need to be sent in the Pay-to Provider loop.


Here are common questions and answers for handling these changes to the electronic Billing Provider address and Pay-to Provider information:

Will I have to submit a physical address on a claim (street number and name) in the billing provider address?

    * Yes, all payers, including Medicare, will no longer allow a post office box or lock box address for the Billing Provider information (2010AA loop for ANSI claims).
    * Providers must submit a physical address (street number and name) for the billing provider address.
    * The Billing Provider zip code must be nine digits.
    * This rule applies to both professional and institutional claim formats.
    * Providers should work with their software vendors to ensure that the correct addresses are captured and sent in the correct locations for the 5010 implementation deadline.

Can I still have payments sent to a lock box or post office box?

    * Providers that have remittances delivered to a lock box or post office box address must send Pay-To Provider information (2010AB loop for ANSI claims).
    * The Pay-To Provider address is only needed if it is different than that of the Billing Provider.
    * This rule applies to both professional and institutional claim formats.
    * Providers should work with their software vendors to ensure that the post office box or lock box is sent in the correct location for the 5010 implementation deadline.

Medicare - Bundled Services/Supplies - routinely, injection.global surgical package

There are a number of services/supplies that are covered under Medicare and that have HCPCS codes, but they are services for which Medicare bundles payment into the payment for other related services. If carriers receive a claim that is solely for a service or supply that must be mandatorily bundled, the claim for payment should be denied by the carrier.

A. Routinely Bundled

Separate payment is never made for routinely bundled services and supplies. The CMS has provided RVUs for many of the bundled services/supplies. However, the RVUs are not for Medicare payment use. Carriers may not establish their own relative values for these services.

B. Injection Services
Injection services (codes 90782, 90783, 90784, 90788, and 90799) included in the fee schedule are not paid for separately if the physician is paid for any other physician fee schedule service rendered at the same time. Carriers must pay separately for those injection services only if no other physician fee schedule service is being paid. In either case, the drug is separately payable. If, for example, code 99211 is billed with an injection service, pay only for code 99211 and the separately payable drug. Injection services that are immunizations with hepatitis B, pneumococcal, and influenza vaccines are not included in the fee schedule and are paid under the drug pricing methodology.

C. Global Surgical Packages

The MPFSDB lists the global charge period applicable to surgical procedures.

D. Intra-Operative and/or Duplicate Procedures

Chapter 23 and §30 of this chapter describe the correct coding initiative (CCI) and policies to detect improper coding and duplicate procedures.

E. EKG Interpretations
For services provided between January 1, 1992, and December 31, 1993, carriers must not make separate payment for EKG interpretations performed or ordered as part of, or in conjunction with, visit or consultation services. The EKG interpretation codes that are bundled in this way are 93000, 93010, 93040, and 93042. Virtually, all EKGs are performed as part of or ordered in conjunction with a visit, including a hospital visit.

If the global code is billed for, i.e., codes 93000 or 93040, carriers should assume that the EKG interpretation was performed or ordered as part of a visit or consultation. Therefore, they make separate payment for the tracing only portion of the service, i.e., code 93005 for 93000 and code 93041 for 93040. When the carrier makes this assumption in processing a claim, they include a message to that effect on the Medicare Summary Notice (MSN).

For services provided on or after January 1, 1994, carriers make separate payment for an
EKG interpretation.

Use of Evaluation management CPT codes 99201 - 99499

Evaluation and Management Service Codes - General (Codes 99201 - 99499)

A. Use of CPT Codes Advise physicians to use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management services. Medicare will pay for E/M services for specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service, however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. The service provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices. Do not pay for CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in independent practice.

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

B. Selection of Level Of Evaluation and Management Service

Instruct physicians to select the code for the service based upon the content of the service. The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care as described in subsection C. Any physician or non-physician practitioner (NPP) authorized to bill Medicare services will be paid by the carrier at the appropriate physician fee schedule amount based on the rendering UPIN/PIN.

"Incident to" Medicare Part B payment policy is applicable for office visits when the requirements for "incident to" are met.

Deleted DX code from oct 1 2010

INVALID DIAGNOSIS CODES - Effective October 1, 2010



Diagnosis Code   Description

275.0   Disorders of iron metabolism

276.6   Fluid overload

287.4   Secondary thrombocytopenia

488.0*  Influenza due to identified avian influenza virus

488.1*  Influenza due to identified novel H1N1 influenza virus

752.3   Other anomalies of uterus

786.3   Hemoptysis

787.6   Incontinence of feces

970.8   Poisoning by other specified central nervous system stimulants

999.6   ABO incompatibility reaction

999.7   Rh incompatibility reaction

V25.1   Encounter for insertion of intrauterine contraceptive device

V85.4   Body Mass Index 40 and over, adult


Notes:  * These diagnosis codes were discussed at the March 9-10, 2010 ICD-9-CM Coordination and  Maintenance Committee meeting and were not finalized in time to include in the proposed rule. However, they will be deleted on October 1, 2010.

newly added diagnosis code from oct 1 2010

NEW DIAGNOSIS CODES  - Effective October 1, 2010

The final addendum providing complete information on changes to the diagnosis part of ICD-9-CM

Diagnosis Code Description 237.73 Schwannomatosis 237.79* Other neurofibromatosis 275.01 Hereditary hemochromatosis 275.02 Hemochromatosis due to repeated red blood cell transfusions 275.03 Other hemochromatosis 275.09 Other disorders of iron metabolism 276.61 Transfusion associated circulatory overload 276.69 Other fluid overload 278.03 Obesity hypoventilation syndrome 287.41 Posttransfusion purpura 287.49 Other secondary thrombocytopenia 315.35* Childhood onset fluency disorder 447.70 Aortic ectasia, unspecified site 447.71 Thoracic aortic ectasia 447.72 Abdominal aortic ectasia 447.73 Thoracoabdominal aortic ectasia 488.01* Influenza due to identified avian influenza virus with pneumonia 488.02* Influenza due to identified avian influenza virus with other respiratory manifestations 488.09* Influenza due to identified avian influenza virus with other manifestations 488.11* Influenza due to identified novel H1N1 influenza virus with pneumonia 488.12* Influenza due to identified novel H1N1 influenza virus with other respiratory manifestations 488.19* Influenza due to identified novel H1N1 influenza virus with other manifestations 560.32 Fecal impaction 724.03 Spinal stenosis, lumbar region, with neurogenic claudication 752.31 Agenesis of uterus 752.32 Hypoplasia of uterus 752.33 Unicornuate uterus 752.34 Bicornuate uterus 752.35 Septate uterus 752.36 Arcuate uterus 752.39 Other anomalies of uterus 752.43 Cervical agenesis 752.44 Cervical duplication 752.45 Vaginal agenesis 752.46 Transverse vaginal septum 752.47 Longitudinal vaginal septum 780.33 Post traumatic seizures 780.66 Febrile nonhemolytic transfusion reaction 784.52* Fluency disorder in conditions classified  elsewhere 784.92 Jaw pain 786.30 Hemoptysis, unspecified 786.31 Acute idiopathic pulmonary hemorrhage in infants [AIPHI] 786.39 Other hemoptysis 787.60 Full incontinence of feces 787.61 Incomplete defecation 787.62 Fecal smearing 787.63 Fecal urgency 799.51 Attention or concentration deficit 799.52 Cognitive communication deficit 799.53 Visuospatial deficit 799.54 Psychomotor deficit 799.55 Frontal lobe and executive function deficit 799.59 Other signs and symptoms involving cognition 970.81 Poisoning by cocaine 970.89 Poisoning by other central nervous system stimulants 999.60 ABO incompatibility reaction, unspecified 999.61 ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed 999.62 ABO incompatibility with acute hemolytic transfusion reaction 999.63 ABO incompatibility with delayed hemolytic transfusion reaction 999.69 Other ABO incompatibility reaction 999.70 Rh incompatibility reaction, unspecified 999.71 Rh incompatibility with hemolytic transfusion reaction not specified as acute or delayed 999.72 Rh incompatibility with acute hemolytic transfusion reaction 999.73 Rh incompatibility with delayed hemolytic transfusion reaction 999.74 Other Rh incompatibility reaction 999.75 Non-ABO incompatibility reaction, unspecified 999.76 Non-ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed 999.77 Non-ABO incompatibility with acute hemolytic transfusion reaction 999.78 Non-ABO incompatibility with delayed hemolytic transfusion reaction 999.79 Other non-ABO incompatibility reaction 999.80 Transfusion reaction, unspecified 999.83 Hemolytic transfusion reaction, incompatibility unspecified 999.84 Acute hemolytic transfusion reaction, incompatibility unspecified 999.85 Delayed hemolytic transfusion reaction, incompatibility unspecified E000.2 Volunteer activity V11.4 Personal history of combat and operational stress reaction V13.23 Personal history of vaginal dysplasia V13.24 Personal history of vulvar dysplasia V13.62 Personal history of other (corrected) congenital malformations of genitourinary system V13.63 Personal history of (corrected) congenital malformations of nervous system V13.64 Personal history of (corrected) congenital malformations of eye, ear, face and neck V13.65 Personal history of (corrected) congenital malformations of heart and circulatory system V13.66 Personal history of (corrected) congenital malformations of respiratory system V13.67 Personal history of (corrected) congenital malformations of digestive system V13.68** Personal history of (corrected) congenital malformations of integument, limbs, and musculoskeletal systems V15.53 Personal history of retained foreign body fully removed V25.11 Encounter for insertion of intrauterine contraceptive device V25.12 Encounter for removal of intrauterine contraceptive device V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device V49.86 Do not resuscitate status V49.87* Physical restraints status V62.85 Homicidal ideation V85.41 Body Mass Index 40.0-44.9, adult V85.42 Body Mass Index 45.0-49.9, adult V85.43 Body Mass Index 50.0-59.9, adult V85.44 Body Mass Index 60.0-69.9, adult V85.45 Body Mass Index 70 and over, adult V88.11 Acquired total absence of pancreas V88.12 Acquired partial absence of pancreas V90.01 Retained depleted uranium fragments V90.09 Other retained radioactive fragments V90.10 Retained metal fragments, unspecified V90.11 Retained magnetic metal fragments V90.12 Retained nonmagnetic metal fragments V90.2 Retained plastic fragments V90.31 Retained animal quills or spines V90.32 Retained tooth V90.33 Retained wood fragments V90.39 Other retained organic fragments V90.81 Retained glass fragments V90.83 Retained stone or crystalline fragments V90.89 Other specified retained foreign body V90.9 Retained foreign body, unspecified material V91.00 Twin gestation, unspecified number of placenta, unspecified number of amniotic sacs V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac) V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs) V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs) V91.09 Twin gestation, unable to determine number of placenta and number of amniotic sacs V91.10 Triplet gestation, unspecified number of placenta and unspecified number of amniotic sacs V91.11 Triplet gestation, with two or more monochorionic fetuses V91.12 Triplet gestation, with two or more monoamniotic fetuses V91.19 Triplet gestation, unable to determine number of placenta and number of amniotic sacs V91.20 Quadruplet gestation, unspecified number of placenta and unspecified number of amniotic sacs V91.21 Quadruplet gestation, with two or more monochorionic fetuses V91.22 Quadruplet gestation, with two or more monoamniotic fetuses V91.29 Quadruplet gestation, unable to determine number of placenta and number of amniotic sacs V91.90 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs V91.91 Other specified multiple gestation, with two or more monochorionic fetuses V91.92 Other specified multiple gestation, with two or more monoamniotic fetuses V91.99 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs
Notes:
* These diagnosis codes were discussed at the March 9-10, 2010 ICD-9-CM Coordination and Maintenance Committee meeting and were not finalized in time to include in the proposed rule. However, they will be implemented on October 1, 2010. Please note that new code 237.78, Other neurofibromatosis, that was listed as a new diagnosis code in the proposed rule has been modified to new code 237.79. New code 799.50, Unspecified signs and symptoms involving cognition, that was listed in the proposed rule as a new code has been deleted and will not be implemented on October 1, 2010. **The code title has changed from the proposed rule.