INTRODUCTION Medical coding consists of a system designed to uniformly represent and report medical services CPT ( Current Procedural Terminology ) Level I HCPCS ( Healthcare Common Procedure Coding System ) code or an alphanumeric Level II HCPCS code . The process of assigning a CPT code to a procedure or service is dependent on both the supporting documentation and the procedure recorded. Assignment of an ICD-9-CM ( International Classification of Diseases, Ninth Revision, Clinical Modification ) diagnosis code, which must also be well-documented in the medical record, is required to support medical necessity.
Some Common Terms to be Understood: Medical Necessity refers to services rendered to a patient to affect a cure or change in the condition for which the patient is being seen. The medical record should have supporting documentation that the services ordered, rendered, and/or billed were necessary based on current standards of medical care. Medical Record outlines the patient’s care and treatment rendered. All services provided to a patient must be documented in the medical record. NCCI (National Correct Coding Initiative) is a database developed by CMS of CPT coding relationships that identifies CPT services considered inherently included (bundled) in other services. The database also identifies fragmentation or unbundling of services that could be captured with a single CPT code. When once procedure is included in another procedure, it should not be billed separately. Covered Services are those services that are payable in accordance with the terms of the benefit plan contract by the payer.
Diagnosis codes serve to identify and justify the medical necessity of services provided by describing the circumstances of the patient’s condition..
XXX.XX Sub-category Category Sub-classification
Types of ICD-9 codes: Numeric Codes: The selection of codes 001.0 through 999.9 is frequently used to describe the reason for the encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries. Alpha-numeric Codes: V-codes are used to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of factors Influencing Health Status and Contact with Health Services (V01.0 – V83.89) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnoses or problems. E-codes , from the subsection Supplementary Classification of External Causes of Injury and Poisoning (E800 – E999) are used to code how an injury occurred.
Identify something that could affect the patient in the future but is not a current illness or injury.
Identify when a person with a known disease or injury, whether it is current or resolving, meets the provider for a specific treatment of that disease or injury.
Simply state a fact.
V codes are used for describing encounters when a patient presents without a dx, sign or symptom, or for patients suspected of having an abnormal condition or disease, but after examination, the disease is not found.
V codes are also used for general medical exams.
Used to facilitate the classification of environmental events, circumstances & conditions that are the cause of injury, poisoning, & other adverse effects.
5 digit numeric codes contained in CPT-4 published by the AMA.
describes physician and hospital outpatient procedures and services.
Level 2 – National Codes
Alphanumeric codes assigned by CMS.
These 5 digit codes begin with an alphabetical character, A to V and are use to report services or supplies that include ambulance, dental, medical & other unique services, supplies (DME, orthotics, prosthetic), drugs, or procedures not included in CPT-4.
Include codes for non-physician procedures, such as ambulance services, durable medial equipment, specific supplies, and administration of injectable drugs
Level 3 – Local Codes
Alphanumeric codes developed & assigned by the local Medicare carrier or fiscal intermediary.
Local codes are five-digit, alphanumeric codes using the letters S, and W through Z.
Local codes are used to denote new procedures or specific supplies for which there is no national code.
Routinely Bundled – Separate payment is never made for routinely bundled services & supplies.
Injection services (90782 – 90784, 90788, 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.
A service has both technical & professional components, but both components are not applicable.
A service was performed by more than one physician.
A service has been increased or reduced.
Only part of the service was performed.
A bilateral service was performed.
Unusual events occurred.
Physical status of a patient for the administration of anesthesia.
Modifier 24 : Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period
The physician may need to indicate that an E/M service was performed during a postoperative period for a reason(s) unrelated to the original procedure. The circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.
For example, a patient who is being followed by her gynecologist during a pregnancy comes in for an additional visit because she has developed acute bronchitis. The bronchitis is unrelated to the pregnancy and necessitated an additional visit over and above her regular pregnancy check-ups. The E/M code for the visit is billed to the insurance carrier with a –24 modifier and the diagnosis code used is 466.0 for Acute Bronchitis.
Modifier 25: Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service
The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above & beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.
Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
For example, consider the simple chest X-ray described in code 71010. If the radiograph of the patient's chest is taken in the physician's office utilizing both the physician's equipment and staff, the charge for the chest X-ray will include the use of the equipment, film, chemicals, and staff time as well as the physician's time to interpret the X-ray itself. As such, the charge for code 71010 will include both the technical and professional components.
In contrast to the above example, suppose that the physician does not have X-ray equipment, and refers the patient to a local hospital where the "picture" will be taken. The hospital, in turn, sends the X-ray to a radiologist who interprets the chest X-ray The radiologist would bill the patient for interpreting the radiograph only and use the "-26" professional component modifier as shown below.
71010-26 Interpretation, single view chest X-ray By the use of this modifier, the radiologist can restrict his or her charge to the professional component -- the interpretation.
When multiple procedures, other than E/M services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).
For example, the repair of a simple neck wound and the closed treatment of a clavicle fracture would be coded as:
23500 Treatment closed clavicle fracture without manipulation
12005-51 Simple closure neck wound
Note that the higher charge procedure (fracture treatment in this case) is listed first and the multiple procedure modifier is added to the lesser or secondary service. If three procedures had been performed, the services would be ranked from highest to lowest charge on the claim form and the "-51" modifier would be added to all but the first (highest charge) procedure.
Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other 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. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.
On Monday, a dermatologist performs a biopsy on the face. On Thursday, following the results of the biopsy, he removes the 2 cm malignant lesion and does another biopsy of a different site on the face. The services performed on Thursday are reported as follows:
Modifier 76: Repeat Procedure by Same Physician
The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure/service.
Modifier 77: Repeat Procedure by Another Physician
The physician may need to indicate that a basic procedure/service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure/service.
A patient is brought to the hospital with internal hemorrhaging that is repaired surgically. Three days after surgery, the patient begins hemorrhaging again and the surgeon must perform the same repair again. Would you use the repeat procedure modifier on the second repair? Yes, assuming that the same procedure code was being reported. If a different physician had performed the second repair, he/she would use the 77 modifier.
Modifier 78: Return to the Operating Room for a Related Procedure During the Postoperative Period
The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding modifier 78 to the related procedure.
A patient’s operative site bleeds after an initial surgery and requires a return to the operating room to stop the bleeding, the same procedure is not repeated. Thus a different code, 35860, exploration for postoperative hemorrhage, thrombosis or infection; extremity, would be reported with the -78 modifier appended. Since the same procedure is not repeated, modifier –76 would not be appropriate to use.
Modifier 79: Unrelated Procedure/Service by the Same Physician During the Postoperative Period
The physician may need to indicate that the performance of a procedure/service during the postoperative period was unrelated to the original procedure. This may be reported by using modifier 79.
A patient has a femoral-popliteal graft (35556) and goes home. The incision and graft heal well. However, the patient develops acute renal failure a week after being home and is hospitalized. The patient does not respond to medical treatment of the renal failure. Hemodialysis is indicated, and a second physician inserts a cannula for hemodialysis (36810).
The services of the second surgeon are reported as 36810-79 because this service is unrelated to the femoral-popliteal bypass graft performed during the previous hospitalization.
If the –79 modifier is not appended to this procedure, the third-party payer may not know that this service is not related to the femoral-popliteal graft (i.e., the computer program used by the third-party payer may not be able to distinguish that this service is not related to the previous surgery and may automatically reject this claim).
Surgical assistant services may be identified by adding modifier 80 to the usual procedure code.
To report a closure of intestinal cutaneous fistula, the primary operating surgeon reports code 44640, and the assistant surgeon reports 44640-80. The individual operative report submitted by each surgeon should indicate the distinct service provided by each surgeon.
Under certain circumstances two or more modifiers may be necessary to completely delineate a service. In such situations modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
Modifier AA: Anesthesia services performed personally by anesthesiologist
Modifier QX: CRNA with medical direction by a physician
Modifier QY: Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist