Rheumatology Coding Manual

Rheumatology-specific information to help code with confidence

Published by American College of Rheumatology • 2200 Lake Boulevard NE • Atlanta, Georgia 30319

Copyright © 2010, Sixth Edition, American College of Rheumatology

 ACR Rheumatology Coding Manual

Copyright Acknowledgement
Any five digit numeric Physicians’ Current Procedural Terminology (CPT®), fourth edition codes, service descriptions,
and numeric modifiers are copyright 2010 (or such other date of publication of CPT® as defined in the federal
copyright laws), American Medical Association.

CPT® is a listing of descriptive terms and five digit numeric identifying codes and modifiers for reporting medical
services performed by physicians. This manual includes only CPT® descriptive terms, numeric identifying codes,
modifiers for reporting medical services and procedures that were selected by the American College of Rheumatology
for inclusion in this publication.

The most current CPT® is available from the American Medical Association.

No fee schedules, basic unit values, relative value units, conversion factors or scales, or components thereof are
included in CPT®. The American Medical Association is not recommending any specific relative values, fees, fee
schedule, or related listings, be attached to CPT®. Any relative value scales or related listings assigned to the CPT®
codes are not those of the American Medical Association, and the American Medical Association is not recommending
use of these relative values.

The American Medical Association has selected certain CPT® codes and service/procedure descriptions and
assigned them to various specialty groups. The listing of a CPT® service or procedure in this publication does not
restrict its use to a particular specialty group. Any procedure or service in this publication may be used to designate
the services rendered by any qualified physician.

The American Medical Association assumes no responsibility for the consequences attributable to or related to any
use or interpretation of any information or views contained in or not contained in this publication.

Some sections found in the appendix of this publication are taken from the Medicare Carrier Review: What Every
Physician Should Know About “Medically Unnecessary” Denials. It describes the Medicare carrier review process
in detail and is copyrighted by the American Medical Association. The documentation guidelines outlined in Chapter
Two incorporate information and materials developed by the American Medical Association, the Centers for Medicare
and Medicaid Services and the American College of Physicians.

The American College of Rheumatology does not guarantee, warrant or endorse any commercial product or service.

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 ACR Rheumatology Coding Manual

Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Illustrated Anatomy and Physiology

Chapter 1 : Coding 101 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Coding Guidelines
Documentation
Advance Beneficiary Notice
Medical Necessity

Chapter 2 : Documentation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

The Components
Examination
Complexity of Medical Decision Making

Chapter 3 : Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Office or Other Outpatient Services
Consultation and Special Services
Office or Other Outpatient Consultations
Services for Inpatient Visits
Critical Care Services
Prolonged Services
Telephone Services

Chapter 4 : Rheumatology Technical Procedures . . . . . . . . . . . . . . . . . . . . . . . 64

Minor Surgical Procedures
Drug Administration
Modifiers

Chapter 5 : Radiologic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Magnetic Resonance Imaging
Radiologic Guidance

Chapter 6 : Pathology and Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Clinical Laboratory Improvement Amendments

Chapter 7 : Diagnostic Codes for Rheumatology . . . . . . . . . . . . . . . . . . . . . . . 78

ICD-9 Clinical Modification – Diagnosis Codes
HCPCS

Chapter 8 : Resource-based Relative Value Scale . . . . . . . . . . . . . . . . . . . . . . 91

Chapter 9 : Physician Quality Reporting Initiative . . . . . . . . . . . . . . . . . . . . . . 93

Individual Measure Reporting Options
Measures Reporting Options
Exclusions

Chapter 10 : Sample Letters and Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Appendix A : Sample Advance Notice to Beneficiary . . . . . . . . . . . . . . . . . . . . 98

Appendix B : Medicare Part B Carriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Appendix C : Centers for Medicare and Medicaid Services Regional Offices . . . . . . 106

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 ACR Rheumatology Coding Manual

Introduction

This reference is a practical guide for rheumatologists and their staff to communicate effectively with third party
payors regarding the medical services provided to patients. The American College of Rheumatology has developed
this reference guide for rheumatologists as an adjunct to the American Medical Association’s Current Procedural
Terminology manual. It provides an overview of the codes most applicable to rheumatology practices as well as
their effective and appropriate use. It should not be regarded as a substitute for an understanding of the entire
CPT® coding system. Rather, it is meant to increase understanding of the system and to enhance its usefulness
to rheumatologists and their staffs. The revisions of the CPT® codes published in this reference guide have been
adopted by Medicare and by most private insurance carriers.

It is extremely important that the communication about this information be both precise and timely in light of CPT®
coding changes which take place each year. It is important to remain abreast of these changes to ensure accurate
coding and appropriate reimbursement.

Themes
Throughout this manual, you will note recurring themes. They are summarized below:

1. P
 recise and accurate coding is the most important factor in the CPT® evaluation and management codes.

2. R
 egardless of the level or intensity of service provided by the physician, one of the critical elements in justifying
a CPT® code is documentation of the service provided. The physician’s record must accurately document the
components of all the services provided. Documentation is critical and should be legible. One caveat: No matter
how well you document the services provided, if Medicare (or other payor) deem that the services were not
medically necessary, you will not be reimbursed for the service.

3. The CPT® system is a communication service in which codes serve as symbols indicating the service provided
to patients. The symbols also communicate to third party payors the level and intensity of the services. Fee
schedules are developed independently by the rheumatologist who assigns a separate fee for each service and
code in CPT®. The same fee should not be used for different CPT® codes within a series. To do so would not
reflect the resource-based amount of work required for increasing intensity of service. It should also be noted
that charging different fees for the same CPT® code should be avoided. You may choose to accept less than your
fee for a particular plan, but this should not affect what you have chosen as your fee. On the other hand, if you
charge the same payor different fees for a particular code, then a modifier should be added to explain a reason
for that difference.

4. The importance of establishing communication between your office and local carriers cannot be underestimated.
By doing so, you will save time and avoid frustrations with coding problems down the road.

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We hope this reference guide is of benefit. It is important that you and your staff attend CPT® workshops and talk
with your colleagues about coding issues. Please be accurate in coding your visits, and use the examples in this
manual only as a guide.

Educational Resources from the American College of Rheumatology:

• If you have a coding question, contact the ACR coding and reimbursement specialist Melesia Tillman, CPC,
CRHC, CHA at (404) 633-3777 ext. 820 or at [email protected].

• S
 tates societies can join the Affiliate Society Council - The ACR Affiliate Society Council is designed to address the
practical needs of community rheumatologists by offering a range of services to state/local affiliates. The program
includes state/local rheumatology groups who benefit from the ACR on ways to strengthen their organizations,
enhance their educational activities, and provide support for their members. Each state/local affiliate serves as a
bridge between local rheumatologists and the ACR.

Benefits of joining include:

– Yearly presentation from the ACR Certified Professional Coder

– Yearly presentation from an ACR Board member providing an ACR update

– P
 olicy analysis from the Health Policy department

– Information on Federal legislation

– Access to the ACR’s Certified Professional Coder regarding reimbursement and insurance issues

– Assistance in model bylaws for associations that are being established

– L
 ist serve for the society

– S
 tate or local specific mailing labels once per year

– W
 ebsite development using the ACR designed template

– C
 omplimentary health professional speakers/materials available for your state and local society meetings

For more information on the affiliate program, visit the ACR website at www.rheumatology.org/practice.

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Illustrated Anatomy and Physiology

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Chapter One

Coding 101
CPT® is a set of codes, descriptions, and guidelines that were created to describe procedures services performed by
physicians and other health care professionals. Each procedure and/or service is identified by a five-digit code and
simplifies the reporting of these services. CPT® is a trademark of the American Medical Association.

The CPT® codes where created to have a universal language for health care providers to properly communicate
with insurance companies. Health care providers are reimbursed based on the codes that are submitted for services
rendered to a beneficiary.

Coding Guidelines
CPT® guidelines are regularly updated to reflect the changes in medical practice. It is very important that physician
coders and billers are familiar with the manual and any changes to verify correct coding for procedures.

The AMA updates the CPT® manual annually so please refer to your CPT® book for additions, deletions and
revisions. The AMA has assigned certain symbols throughout the manual to easily recognize changes and updates.

Important Symbols:
– Indicates a new code and will be placed before the code number

– Indicates a code revision that has substantially altered the description of the code

+ – Indicates an add-on code (can only be used with primary codes and should never be reported alone)

– Indicates new and revised text other than the procedure descriptor

There are two types of code sets in the CPT® manual: evaluation and management service codes and procedural
codes. At the beginning of each section in the manual are specific guidelines to help you appropriately interpret and
report the procedure and services contained in each section.

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Documentation
Concise documentation in a patient’s medical records is critical to provide quality care as well as to receive accurate
and timely reimbursement for services rendered. It chronologically documents the care of the patient and is required
to record relevant facts, findings and observations about the patient’s health history including past and present
illnesses, examinations, tests, treatments and outcomes. Medical record documentation assists physicians and other
health care professionals in evaluating and planning treatment of the patient as well as monitoring his or her health
and care over time.

Payors sometimes require rationale that services rendered to

patients are consistent with the insurance coverage provided in
order to validate:

• The site of service – the place of service

• The medical necessity and appropriateness of the diagnostic “If it isn’t documented, it hasn’t
and/or therapeutic services provided; and/or been done” is an old adage that
is frequently heard in the health
• That services furnished have been accurately reported
care setting.
To ensure the documentation in a medical record is accurate,
adhere to following principles:

• M
 edical records should be complete and legible

• The documentation of each patient encounter should include:

– Reason for the encounter

– Relevant history, physical examination findings, and prior diagnostic test results

– Diagnosis, assessment or clinical impression

– Medical plan of care

– Date and legible identity of the observer

• If no documentation, the rationale for ordering diagnostic and other ancillary services should be inferred

• P
 ast and present diagnoses should be accessible to the treating and/or consulting physician

• The patient’s progress, response to and changes in treatment, and the revision of diagnosis should be documented

• The CPT® and ICD-9 codes should be reported on the health insurance claim form or the billing statement should
be supported by the documentation in the medical record

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Guidelines for Residents and Teaching Physicians

Both residents and teaching physicians may document physician services in the patient’s medical record.
The documentation must be dated and contain a legible signature or identity and may be:

• Dictated and transcribed

• Typed

• Hand-written

• Computer-generated Generally, the teaching physician

For a given encounter, the selection of the appropriate level of E/M must be present during all critical
services is determined according to the code of definitions in the or key portions of the procedure,
American Medical Association’s CPT® book and any applicable and immediately available to
documentation guidelines. furnish services during the entire
service in order for the service
When teaching physicians bill E/M services, they must personally
to be payable under the Medical
document at least the following:
Physician Fee Schedule.
• That he or she performed the service or was physically present
during the critical or key portions of the service furnished by the
resident; and

• His or her participation in the management of the patient.

On medical review, the combined entries into the medical record by the teaching physician and resident constitute
the documentation for the service and together must support the medical necessity of the service. Documentation by
the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and
participation of the teaching physician.

Advance Beneficiary Notice

An Advance Beneficiary Notice is a form that a physician must have a Medicare patient sign alerting the patient of the
following:

• That Medicare will probably deny payment for that specific service or item in the specific case.

• The reason the physician, provider, or supplier expects Medicare to deny payment.

• That the patient will be personally and fully responsible for payment if Medicare denies payment.

If there is a signed ABN on file the charge must be billed with a modifier GA. This will indicate to Medicare that a
waiver of liability statement is on file. A copy of the ABN is in the reference section of this manual.

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Medical Necessity
Medical necessity demonstrates that what was done to a patient is reasonable, necessary, and/or appropriate. This
is based on evidence-based clinical standards of care. To determine a carrier’s definition of medical necessity for a
service, refer to the carrier’s medical policy, usually available on the carrier’s website.

CMS maintains a listing of all Medicare carriers’ medical policies on the CMS website at
www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp.

Medicare refers to their medical policies as “Local Coverage Determinations” or LCDs. Upon reviewing an LCD – it
will specify the correct HCPCS code(s), ICD-9 codes that support medical necessity, documentation requirements
and utilization guidelines.

Below is a sample LCD for the administration of infliximab.

Contractor Name

Your State’s Medicare Carrier

Contractor Number

XXXXX

Contractor Type

MAC - Part B

LCD Information

LCD ID Number

LXXXXX

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LCD Information

LCD Title
Infliximab (Remicade)

AMA CPT® / ADA CDT Copyright Statement

CPT® codes, descriptions and other data only are copyright 2009 American Medical Association (or
such other date of publication of CPT®). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.
Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other
data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental
Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Your State

Oversight Region

Region XX

Original Determination Effective Date

For services performed on or after 02/01/2008

Original Determination Ending Date

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LCD Information

Revision Effective Date

For services performed on or after 08/01/2009

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Infliximab is a chimeric monoclonal antibody which binds specifically to tumor necrosis factor alpha. Its
clinical efficacy is in patients with moderate to severe Crohn’s disease who have failed to respond to prior
conventional therapies. FDA approval was given August 1998.

1. Treatment of moderately to severely active Crohn’s disease, for the reduction of the signs and
symptoms, in patients who have an inadequate response to conventional therapy (corticosteroids,
5-aminosalicylates, and/or mercaptopurine/azathioprine). The recommended dose is 5 mg/kg given as a
single intravenous infusion over at least two hours, following with additional doses at two and six weeks
after the first infusion. Maintenance regimen of 5 mg/kg of body weight should be given every 8 weeks
thereafter. For patients responding and then losing their response, consideration may be given to 10 mg
per kg of body weight. Patients not responding by week 14 are unlikely to respond with continued dosing
and treatment with Infliximab should be discontinued.

2. Treatment of patients with fistulizing Crohn’s disease for the reduction in the number of draining and
rectovaginal enterocutaneous fistula(s) and maintaining fistula closure. The recommended dose is an
initial 5 mg/kg as an intravenous infusion over at least two hours with additional doses of 5 mg/kg at two
and six weeks after the first infusion. Maintenance regimen of 5 mg/kg of body weight should be given
every 8 weeks thereafter. For patients responding and then losing their response, consideration may be
given to 10 mg per kg of body weight. Patients not responding by week 14 are unlikely to respond with
continued dosing and treatment with Infliximab should be discontinued.

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LCD Information

3. FDA approval was given November 10, 1999 for Infliximab to reduce signs and symptoms of rheumatoid
arthritis in adults in combination with methotrexate. The recommended dose is 3 mg/kg as an infusion over
at least two hours at two and six weeks after the initial infusion and then every eight weeks. For patients who
have an incomplete response, consideration may be given to 10 mg per kg of body weight or treating as
often as every four weeks.

4. Infliximab is indicated for reducing signs and symptoms in patients with active ankylosing spondylitis. The
recommended dose is 5 mg/kg as an IV infusion with similar doses at 2 and 6 weeks after the first infusion,
then every 6 weeks thereafter.

5. Infliximab is indicated for the treatment of psoriatic arthritis. The recommended dose is 5 mg/kg as a single
IV infusion over at least two hours, followed with additional doses at two and six weeks after the first infusion
then every 8 weeks thereafter. Infliximab can be used with or without methotrexate.

6. Infliximab is indicated for the treatment of psoriasis. The recommended dose is 5 mg/kg as a single IV
infusion over at least two hours, followed with additional doses at two and six weeks after the first infusion
then every 8 weeks thereafter.

7. Infliximab is indicated for the treatment of reactive arthritis. The recommended dose is 5 mg/kg as a single
IV infusion over at least two hours, followed with additional doses at two and six weeks after the first infusion
then every 8 weeks thereafter.

8. Infliximab is indicated for the treatment of inflammatory bowel disease arthritis. The recommended dose is
5 mg/kg as a single IV infusion over at least two hours, followed with additional doses at two and six weeks
after the first infusion then every 8 weeks thereafter.

9. Infliximab is indicated for reducing signs and symptoms, achieving clinical remission and mucosal healing,
and eliminating corticosteroid use in patients with moderately to severely active ulcerative colitis who have
had an inadequate response to conventional therapy. 5 mg/kg of body weight given as an induction regimen
at 0, 2, and 6 weeks followed by a maintenance regiment of 5 mg per kg of body weight given every 8 weeks
thereafter.

Trials are ongoing to determine the safety and efficacy of long term use or retreatment for relapse. Some
investigators also prescribe Imuran for patients receiving long-term therapy or retreatment with Infliximab to
decrease the possibility of antibody reactions to the monoclonal antibody.

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LCD Information

Infliximab use in pediatric patients with Crohn’s Disease did not have FDA approval prior to May 19,
2006. For moderately to severely active Crohn’s Disease is patients having an inadequate response to
conventional therapy 6 years of age or older, IV induction regiment of 5 mg/kg given at 0, 2, and 6 weeks
followed by a maintenance regiment of 5 mg/kg of body weight every 8 weeks.

The safety and efficacy has not been established for ankylosing spondylitis, psoriatic arthritis, ulcerative
colitis, or rheumatoid arthritis in pediatric patients. The safety and efficacy has not been established in
children less than 6 years of age.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this
service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete
absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be
assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used
to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy
services reported under other Revenue Codes are equally subject to this coverage determination. Complete
absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy
should be assumed to apply equally to all Revenue Codes.

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Coding Information

CPT®/HCPCS Codes

J1745 INJECTION INFLIXIMAB, 10 MG

ICD-9 Codes that Support Medical Necessity

555.0 REGIONAL ENTERITIS OF SMALL INTESTINE

555.1 REGIONAL ENTERITIS OF LARGE INTESTINE

555.2 REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE

555.9 REGIONAL ENTERITIS OF UNSPECIFIED SITE

556.0 ULCERATIVE (CHRONIC) ENTEROCOLITIS

556.1 ULCERATIVE (CHRONIC) ILEOCOLITIS

556.2 ULCERATIVE (CHRONIC) PROCTITIS

556.3 ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS

556.4 PSEUDOPOLYPOSIS OF COLON

556.5 LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS

556.6 UNIVERSAL ULCERATIVE (CHRONIC) COLITIS

556.8 OTHER ULCERATIVE COLITIS

556.9 ULCERATIVE COLITIS UNSPECIFIED

565.1* ANAL FISTULA

569.81* FISTULA OF INTESTINE EXCLUDING RECTUM AND ANUS

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Coding Information

696.0 PSORIATIC ARTHROPATHY

696.1 OTHER PSORIASIS AND SIMILAR DISORDERS

711.10 ARTHROPATHY SITE UNSPECIFIED ASSOCIATED WITH REITER’S DISEASE AND

NONSPECIFIC URETHRITIS

711.11 ARTHROPATHY INVOLVING SHOULDER REGION ASSOCIATED WITH REITER’S DISEASE

AND NONSPECIFIC URETHRITIS

711.12 ARTHROPATHY INVOLVING UPPER ARM ASSOCIATED WITH REITER’S DISEASE AND
NONSPECIFIC URETHRITIS

711.13 ARTHROPATHY INVOLVING FOREARM ASSOCIATED WITH REITER’S DISEASE AND

NONSPECIFIC URETHRITIS

711.14 ARTHROPATHY INVOLVING HAND ASSOCIATED WITH REITER’S DISEASE AND

NONSPECIFIC URETHRITIS

711.15 ARTHROPATHY INVOLVING PELVIC REGION AND THIGH ASSOCIATED WITH REITER’S
DISEASE AND NONSPECIFIC URETHRITIS

711.16 ARTHROPATHY INVOLVING LOWER LEG ASSOCIATED WITH REITER’S DISEASE AND
NONSPECIFIC URETHRITIS

711.17 ARTHROPATHY INVOLVING ANKLE AND FOOT ASSOCIATED WITH REITER’S DISEASE
AND NONSPECIFIC URETHRITIS

711.18 ARTHROPATHY INVOLVING OTHER SPECIFIED SITES ASSOCIATED WITH REITER’S

DISEASE AND NONSPECIFIC URETHRITIS

711.19 ARTHROPATHY INVOLVING MULTIPLE SITES ASSOCIATED WITH REITER’S DISEASE

AND NONSPECIFIC URETHRITIS

713.1 ARTHROPATHY ASSOCIATED WITH GASTROINTESTINAL CONDITIONS OTHER THAN

INFECTIONS

713.3 ARTHROPATHY ASSOCIATED WITH DERMATOLOGICAL DISORDERS

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Coding Information

713.7 OTHER GENERAL DISEASES WITH ARTICULAR INVOLVEMENT

714.0 RHEUMATOID ARTHRITIS

720.0 ANKYLOSING SPONDYLITIS

*ICD-9-CM codes 569.81 and 565.1 are secondary diagnoses and must be used with one of the codes
indicating Crohn’s disease.

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentation Requirements

*1. The medical record must contain duration, dosage, and response to methotrexate administration for
rheumatoid arthritis patients. *For patients that are unable to tolerate methotrexate, the notes should reflect
the use of other disease modifying anti-rheumatic drugs and be available for review. The presence and
location of fistulas must be recorded.

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Coding Information
The presence and location of fistulas must be recorded.
*2. The diagnosis of RA must be unequivocal. We recommend the use of American College of Rheumatology
criteria for establishing a diagnosis. ACR 20 or equivalent must be one of the criteria used for documenting
improvement. In patients with RA, improvement, as judged by ACR 20 criteria, or equivalent should
be noticeable at week 30 follow-up. If no improvement occurs, then Medicare will not cover continued
treatment. For continued treatment beyond 30 weeks, there must be documentation of demonstrable
improvement.

3. Diagnosis(es) correlating to the patient’s condition must be present on any claim submitted, and must be
coded to the highest level of specificity.

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision

WPS has consolidated the existing LCDs for MAC Jurisdiction 5 according to the instructions provided by
CMS so that they are the same throughout the jurisdiction. In the vast majority of cases, one least restrictive
LCD was selected as the jurisdictional LCD. In some cases, appropriate revisions, such as combining
sections of LCDs that only addressed a portion of a general topic into a single, more complete document,
were made to improve the clinical appropriateness of the LCD while keeping with the least restrictive
requirement.

In situations where one or more of the states in the jurisdiction does not have an LCD on a topic, then the
existing LCDs were reviewed and, based on the merits of the LCD, a decision was made to make the LCD
jurisdictional or to have no LCD on that topic with the approval of CMS.

Some revisions of the existing LCDs were necessary to remove references to the former contractor and to
update the Sources of Information and Basis for Decision. CPT®, HCPCS and ICD-9 codes will be updated
as necessary.

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 ACR Rheumatology Coding Manual

Coding Information

According to the J5 MAC contract, the J5 consolidated LCDs are posted on the web site for the 45 day
final notification period prior to the policy implementation date. The MAC contractor is not required to utilize
the formal notice and comment revision process specified in Chapter 13 of the Program Integrity Manual
(PIM) until the consolidation process is final. However, WPS welcomes provider input regarding the J5
consolidated LCDs. Based on the comments received; LCDs will be revised as necessary during the
transition from the existing to new contractor.

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although
the final decision rests with the contractor, this policy was developed in consideration of the active LCDs
maintained by the preceding Medicare contractors for Jurisdiction X.

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 ACR Rheumatology Coding Manual

Chapter Two

Documentation Guidelines
What are E/M Codes?
Evaluation and Management services refer to visits and consultations provided by a physician or health care
professional in the hospital or physician office setting. E/M codes are the most frequently used codes in Physician
practices and they are simply the documentation of patient visits. These are the codes that utilized when the
physician speaks with the patient and is determining a diagnosis. They are divided into wide-ranging categories
such as office visits, hospital visits, and consultations, and will always begin with “99…”.

To bill a patient visit conducted at a clinic, office, or hospital, the physician or health care professional must select an
E/M code that best represents the services provided. E/M codes are categorized first by place of service and then
level.

Also, there are three key components of every patient visit or consultation:

1. Patient history

2. Examination

3. Medical Decision Making

NOTE: Documentation guidelines for E/M services can be downloaded at www.cms.hhs.gov/MLNEDWebguides/25

EMDOC.asp.

Factors for Reporting E/M Services

Assigning an E/M code begins by determining the place of service, type of service and the patient’s status. Once a
coder can determine these factors, the appropriate level of E/M code can be assigned to a visit.

Step 1: Place of service

Generally, the place of service for rheumatologists will be in the office/outpatient or inpatient setting. It is very
important for all coders or billers in the rheumatology office identify where the physician services were rendered for
accurate and timely claim filing. The place of service is identified with a two digit number.

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Below is a list of the place of service, or POS, codes most commonly used by rheumatology practices:

Place of Place of Place of Service Description

Service Service Name
Codes

11 Office Location, other than hospital, skilled nursing facility, military treatment facility community
health center, state or local public health clinic, or intermediate care facility, where the
health professional routinely provides health examinations, diagnosis, and treatment of
illness or injury on an ambulatory basis.

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

22 Outpatient A portion of a hospital that provides diagnostic, therapeutic (both surgical and
Hospital nonsurgical), and rehabilitation services to sick or injured persons who do not require
hospitalization.

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

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

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

72 Rural health A certified facility located in a rural, medically underserved area that provides
clinic ambulatory primary medical care under the general direction of a physician.

Step 2: Type of service

There are three types of services; office visit (new or established), consultation, or inpatient hospital.

1. O
 ffice Visit: an office visit is a face-to-face encounter between the physician and a patient to allow for
management and care of a patient’s health.

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 onsultation: a consultation is an E/M service provided by a physician whose opinion or advice regarding
2. C
evaluation and management of a specific problem is requested by another physician or other appropriate
source. The verbal or written request for a consult must be documented in the patient’s medical record along
with the consultant’s opinion and any services that are ordered or performed. The consulting physician must also
communicate his/her opinion or advice to the requesting physician by written report. A sample of the request
form can be found on the ACR website www.rheumatology.org/practice/office/documentation/index.asp under
Consultations and Referrals.

NOTE: As of January 1, 2010 the Centers for Medicare & Medicaid Services eliminated both inpatient and
outpatient consultations codes. For coding outpatient services to CMS, rheumatology practices should use the
new patient E/M codes (99201 – 99205) to replace outpatient consult codes (99241 – 99245). For inpatient
services per CMS there is no simple one-to-one correspondence between the consultation codes and the
appropriate inpatient E/M codes. For inpatient consultation services, CMS has stated that physicians may bill the
initial hospital care service codes (99221 – 99223) and the initial nursing facility care codes (99304 – 99306),
where those codes appropriately describe the level of service provided. The general guideline is that physicians
should apply the most appropriate E/M code to bill Medicare for services that were previously billed using the
consultation codes.

3. Inpatient Services: Patients will sometimes need to be admitted to the hospital for additional care or work up.
When a patient is admitted to the hospital as an inpatient, in the course of an encounter in another site of service
(e.g., physician’s office setting, emergency room) all evaluation and management services provided by that
physician in conjunction with that admission are considered part of the initial hospital care and cannot be billed
separately.

Step 3: Patient Status

The status of a patient must be verified for correct coding and billing. There are four categories:

1. N
 ew: A new patient is someone 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 three years.

 stablished: An established patient is someone who has received any professional service from a physician in
2. E
group or same specialty within the past three years. (See Decision Tree on page 29.)

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1. N
 ew patients, consultations, inpatient and emergency room visits MUST have
all three key components (e.g., History, Examination and Medical Decision
Making) to meet an E/M level of service.

2. E
 stablished patients and subsequent inpatient visit MUST have two out of
three key components (e.g., History, Examination and Medical Decision
Making) to meet the appropriate level of E/M service.

3. O
 utpatient

An outpatient is a person who is seen in a physician practice who has not been formally admitted to a health care
facility.

4. Inpatient

An inpatient is a person who has been formally admitted to an inpatient facility and also receives services in a
hospital setting.

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DECISION TREE: NEW VS. ESTABLISHED PATIENTS

Levels of E/M Services

There are three to five levels of E/M services available to report for a patient encounter. The levels of E/M services
are not interchangeable among the different categories of services and are based on the documentation located
in the patient’s medical records. This includes the various amounts of skill, effort, time, responsibility, and medical
knowledge required for prevention or diagnosis and treatment to promote optimal health.

The levels of E/M services are based on seven components, six are used to define the levels of service and one is
a contributory factor. The first three are considered to be the key components, which are history, examination and

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medical decision making. The following three are the contributory factors, which include counseling, coordination of
care and nature of presenting problem.

Time is the next component. The use of time as a factor in E/M coding is there to assist physicians in selecting
the most appropriate level of service. When counseling and /or coordination of care dominates (more than 50%)
the physician/patient face-to-face time, then time may be considered the key or controlling factor to qualify for a
particular level of E/M services.

The Components

History

The patient’s history is the information that is supplied to the physician on the nature of the presenting problem.

History is comprised of four factors: chief complaint; history of present illness; the past, family and/or social history;
NOTE:
and All fouroffactors
the review of the history MUST be done to have a complete history – chief complaint, history of
systems.
present illness, review of systems, and past family social history.

Chief Complaint

All E/M codes must have a chief complaint documented in order for the visit to be considered medically necessary.
A chief complaint is a succinct statement describing the symptom, problem, condition, diagnosis or other factor that
is the reason for the encounter. This information will come from the patient.

The chief complaint can be documented

History of Present Illness
in the patient’s medical record when the
This is a chronological description of the development patient calls in to schedule an appointment.
of the patient’s present illness from the first sign and/or
symptom to the present.

The HPI includes the following descriptions:

• Location – Where is the problem?

• Duration – How long has the problem been there?

• Severity – How would you rate the pain on a scale of one to ten?

• Quality – Describe the quality of the pain (e.g., sharp, dull)?

• Context – Did the pain start gradually over time or is getting better?

• Modifying factors – What makes the pain better (e.g., ibuprofen, aspirin)?

• Associated signs and symptoms – Are there other signs associated with the main problem such as numbness?

• Timing – When do the symptoms occur?

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There are two types of HPIs –

• B
 rief which consists of one or two of the elements on page 30.

• E
 xtended which consists of four or more of the above elements (1995) or status of three chronic or inactive
conditions (1997).

NOTE: The HPI MUST be taken and documented in the patient’s medical record every visit by the physician only.

Review of Systems

An inventory of body systems obtained through questions from the physician or office staff seeking to identify signs
and/or symptoms the patient may be experiencing or has experienced. The ROS consists of the following systems:

• Constitutional (e.g., fever, weight loss)

• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
The ROS can be taken by the
• Respiratory
office staff, but the physician MUST
• Gastrointestinal
document that he/she has reviewed it.
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic

There are three levels of ROS:

• P
 roblem Pertinent which relates directly patient’s problem (one system).

• E
 xtended is a review of two to nine systems.

• Complete is a review of at least ten systems.

The patient’s positive responses and pertinent negatives for the system related to the problem should be documented.

Keep in mind when documenting the ROS - It is acceptable to document pertinent positive or negative
findings for specific areas and then say: “All other systems were reviewed and are negative.”

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Past, Family and/or Social History

This is a review of the patient’s past, family and/or social information that can assist the physician or health
professionals with the encounter. The PFSH is a review of three areas:

• Past history – patient’s past medical illness, operation, and injuries.

• Family history – patient’s family history including hereditary diseases.

• Social history – patient past and current activities.

NOTE: The PFSH only has to be documented once and can be referred back to if there is no change. No
documentation of the PFSH is a common reason for visits to be down coded.

Types of History

There are four levels of history based on the extent of the history that is dependent on clinical judgment and on
the nature of the presenting problem(s). There are four types of history that are recognized for E/M services:

• Problem-focused – brief HPI, no ROS and no PFSH.

• Expanded problem-focused – brief HPI, pertinent to problem ROS and no PFSH.

• Detailed – extended HPI, extended ROS (two to nine systems) and one area of the PFSH.

• C
 omprehensive – extended HPI, complete ROS (ten or more systems), and complete PFSH.

Chief complaint plus all of these elements

Type of History HPI ROS PFSH

Problem-focused Brief (1-3) N/A N/A

Expanded Problem- Brief (1-3) Problem Pertinent N/A

focused (1 system)

Detailed Extended (4+) Pertinent (2-9 systems) Pertinent (1 factor)

Comprehensive Extended (4+) Complete (10 systems) Complete

(based on ICD-9 code)

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Examination
As stated previously, the documentation of the examination can be either under the 1995 version or the 1997
version. The 1995 examination is very broad and somewhat vague when it comes to determining the level of the
expanded problem-focused level and a detailed level. The 1997 version is very specific and detailed and it is based
on bullet points.

Under both versions there are four levels of history:

• Problem-focused – a limited examination of the affected body area or organ system.

• E
 xpanded problem-focused – a limited examination of the affected body area or organ system and other
symptomatic or related organ system(s) (2 – 7 systems).

• Detailed – an extended examination of the affected body area(s) and other symptomatic or related organ
system(s) (2 – 7 systems).

• Comprehensive – a general multi-system examination or complete examination of a single organ system

(8 or more systems).

An examination may involve several organ systems or a single

organ system. The extent of the examination performed is based
upon clinical judgment, the patient’s history, and nature of the
presenting problem. A simple notation of “abnormal” is
The chart on page 34 depicts the body areas and organ systems not sufficient without further details
that are recognized according to the Current Procedural Terminology of the problem. But, it is sufficient
(CPT®) book. to have a simple documentation of
“negative” or “normal.”

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Using the 1995 Guidelines

BODY AREAS ORGAN SYSTEMS

• Head, including face • Constitutional (e.g., vital signs, general appearance)

• Neck • Eyes

• Chest, including breasts and axilla • Ears, Nose, Mouth and Throat

• Abdomen • Cardiovascular

• Genitalia, groin, buttocks • Respiratory

• Back • Gastrointestinal

• Each extremity • Genitourinary

• Musculoskeletal

• Skin

• Neurologic

• Hematologic/Lymphatic/Immunologic

• Psychiatric

Using the 1997 Guidelines

This version has two types of examination, the general multi-system and the single organ system. Listed below are
the examinations classified as either a general multi-system or a single organ system:

• Cardiovascular • Musculoskeletal

• Ears, Nose, Mouth, and Throat • Neurological

• Eyes • Psychiatric

• Genitourinary (Female) • Respiratory

• Genitourinary (Male) • Skin

• Hematologic, Lymphatic, Immunologic

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General Multi–System Examination

This involves the examination of one or more organ systems or body areas.

Level of Exam Perform and Document

Problem-focused One to five elements identified by a bullet.

Expanded Problem-focused At least six elements identified by a bullet.

Detailed At least two elements identified by a bullet from each of six areas/
systems OR at least twelve elements identified by a bullet in two or
more areas/systems.

Comprehensive Perform all elements identified by a bullet in at least nine organ

systems or body areas and document at least two elements identified
by a bullet from each of nine areas/systems.

Musculoskeletal Examination

This examination involves a more extensive examination of the specific organ system.

Level of Exam Perform and Document

Problem-focused One to five elements identified by a bullet.

Expanded Problem-focused At least six elements identified by a bullet.

Detailed At least twelve elements identified by a bullet.

Comprehensive Perform all elements identified by a bullet; document every element

in each box with a shaded border and a least one element in each box
with an unshaded border.

Complexity of Medical Decision Making

Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option.
There are four levels to medical decision making: straightforward, low complexity, moderate complexity, and high
complexity.

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The MDM is determined by considering the following factors:

1. the number of possible diagnoses and/or the number of management options that must be considered;

2. the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be
obtained, reviewed and analyzed; and

3. the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the
patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

The chart below depicts the elements for each level of medical decision making. NOTE that to qualify for a given
type of medical decision making, two of the three elements must either be met or exceeded.

TYPE OF DECISION NUMBER OF AMOUNT AND/OR RISK OF SIGNIFICANT

MAKING DIAGNOSES OR COMPLEXITY OF DATA COMPLICATIONS,
MANAGEMENT TO BE REVIEWED MORBIDITY, AND/OR
OPTIONS MORTALITY

Straightforward Minimal Minimal or None Minimal

Low Complexity Limited Limited Low

Moderate Complexity Multiple Moderate Moderate

High Complexity Extensive Extensive High

Time

Time can be the controlling factor to qualify for a particular level of E/M visit. This can occur when counseling and/
or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face in the
office or outpatient setting, floor/unit time in the hospital or nursing facility).

For example, if 25 minutes was spent face-to-face with an established patient in the office and more than half of that
time was spent counseling the patient or coordinating his or her care, CPT® code 99214 should be selected.

NOTE: Counseling or coordination of care must be documented separately from the information recorded in the
medical decision making and should be identified independently.

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 ACR Rheumatology Coding Manual

Chapter Three

Evaluation and Management

Office or Other Outpatient Services

New Patient

E/M codes are divided into two categories, new or established patient for office visits. 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 three 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 three years.

99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires
the following three key components:

1. A problem-focused history

• Chief complaint
If a physician is on call or covering
• Brief history of present illness or problem for another physician, the patient’s
encounter will be classified as it
2. A problem-focused examination
would have been by the physician
• A limited exam of affected body area or organ system who is not available.

3. Straightforward medical decision making

• Minimal number of diagnoses/management options

• Minimal (or no) amount/complexity of data obtained, reviewed and analyzed

• Minimal risk of complications/morbidity/mortality

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.

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 ACR Rheumatology Coding Manual

Example: A 45-year-old, who is self-referred, comes complaining of pain in her left big toe. The rheumatologist
examination is unremarkable except for bony enlargement consistent with a bunion in her first metatarsophalangeal
joint. Local treatment is prescribed.

99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires
the following three key components:

1. An expanded problem-focused history

• Chief complaint

• Brief history of present illness

• Problem pertinent system review

2. An expanded problem-focused examination

• A limited exam of affected body area or organ system and other symptomatic/related organ system(s)

3. Straightforward medical decision making

• Minimal number of diagnoses/management options

• Minimal (or none) amount/complexity of data obtained, reviewed and analyzed

• Minimal risk of complications/morbidity/mortality

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.

Example: A 20-year-old male comes in for an initial visit. He is complaining of pain in his right elbow. The pain has
been there for two weeks. A brief history, review of system, and exam is performed. The patient is given an elbow
splint and non-steroidal anti-inflammatory medication prescribed, along with education as to cause and prognosis
of “tendinitis.”

99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires
the following three key components:

1. A detailed history

• Chief complaint

• Extended history of present illness

• P
 roblem pertinent system review extended to include a review of a limited number of additional systems

• Pertinent past, family and/or social history directly related to the patient’s problems

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All
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 ACR Rheumatology Coding Manual

2. A detailed examination

• Extended exam of affected body area(s) and other symptomatic/related organ system(s)

3. Medical decision making of low complexity

• Limited number of diagnoses/management options

• Limited amount/complexity of data obtained, reviewed and analyzed

• Low risk of complications/morbidity/mortality

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.

Example: This is an initial office visit for obese 52-year-old man and he has a complaint of gouty arthritis. There was
a detailed history, review of system, and examination performed. A treatment plan was discussed, medication was
prescribed and appropriate laboratory testing order.

99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires
the following three key components:

1. A comprehensive history

• Chief complaint

• Extended history of present illness

• R
 eview of systems which is directly related to the problem(s) identified in the history of present illness plus a
review of all additional body systems

• Complete past, family and/or social history

2. A comprehensive examination

• A general multi-system exam, or

• A complete exam of a single organ system

3. Medical decision making of moderate complexity

• Multiple number of diagnoses/management options

• Moderate amount/complexity of data obtained, reviewed and analyzed

• Moderate risk of complications/morbidity/mortality

39
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 ACR Rheumatology Coding Manual

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.

Example: Initial office visit for 32 year-old female, self-referred for complaint of pain, numbness and color changes
in fingers when exposed to cold. Patient reports that her right distal index and 4th right fingers and left distal index
finger will turn white and then blue when exposed to cold temperatures with pain and numbness in the digits. These
symptoms have been occurring for the past year, but have increased in frequency in past two months. Patient
reports that fingers return to normal color and pain and numbness resolve after rewarming hands. Patient reports
that she has developed a “sore” on her distal left index finger. Patient reports fingers sometimes feel stiff when cold.
Patient denies any other musculoskeletal pain or stiffness and denies any joint swelling. Patient denies fatigue,
weight loss, recurrent fevers, rashes, chest pain, dyspnea, cough, palpitations, hypertension, unusual bruising,
menorrhagia, dysuria or frequency, abdominal pain, vomiting, diarrhea, constipation, dysphagia, hematochezia,
headaches, memory difficulties, insomnia, depression, or weakness. She has no known allergies.

Past Family Social Medical History: Her family is significant for rheumatoid arthritis in mother. No other comorbidities.
No surgeries or hospitalizations. The patient lives alone and does not drink or smoke.

On examination, patient was alert and oriented. Vital signs normal. Height 5’7”, weight 140 lbs, BMI 21.9. HEENT
exam is normal. No lymphadenopathy. Lungs clear. Heart RRR, no murmurs or friction rubs. Good peripheral pulses.
Her abdomen is soft, nontender, no mass or HSM. There was no CVA tenderness on percussion. Skin no rashes.
Demonstrated mild cyanosis in distal digits of right index & 4th fingers and left index finger. There was shallow ulcer
on distal fingertip of left index finger. Musculoskeletal exam: Her gait is normal. Good muscle strength in upper &
lower extremities, both proximally and distally. All joints are unremarkable with FROM and no evidence of synovitis.

99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires
the following three key components:

1. A comprehensive history

• Chief complaint

• Extended history of present illness

• R
 eview of systems which is directly related to the problem(s) identified in the history of present illness plus a
review of all additional body systems

• Complete past, family and/or social history

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2. A comprehensive examination

• A general multi-system exam or a complete exam of a single organ system

3. Medical decision making of high complexity

• Extensive number of diagnoses/management options

• Extensive amount/complexity of data obtained, reviewed and analyzed

• High risk of complications/morbidity/mortality

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.

Example: This is an initial visit for a 28-year-old woman with systemic lupus erythematosus, fever and a history of
seizures and thrombocytopenia. She has severe painful and swollen joints. She has been taking over the counter
medication to get some mild relief. A comprehensive history, review of system and examination was preformed.
Her medical decision making is of high complexity; based on laboratory and X-rays ordered.

Established Patient

99211 Office or other outpatient visit for the evaluation and management of an established patient that
may not require the presence of a physician. Usually the presenting problem(s) are minimal.
Typically, five minutes are spent performing or supervising these services.

Example: A patient returns to the office three days later to have PPD test evaluated and for instructions on
self-administration of TNF-alpha inhibitor. The RN evaluates the PPD test and informs the rheumatologist that it
is negative. The rheumatologist instructs RN to proceed with teaching patient self-administration of TNF-alpha
inhibitor and provides RN with prescription for TNF-alpha inhibitor to give to patient. RN instructs patient on self-
administration of TNF-alpha inhibitor and patient is scheduled to return to office next week to give self TNF-alpha
inhibitor injection under supervision of RN. The patient will return for routine E/M follow-up visit in one month.
The physician does not personally see patient during this visit, but is present in the office suite.

BILL THIS CODE if a patient comes in for a blood pressure check or TB results.

DO NOT BILL 99211 for teaching a patient how to give themselves an injection or for doing a preauthorization.

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99212 Office or other outpatient visit for the evaluation and management of an established patient which
requires at least two of the following three key components:

1. A problem-focused history

• Chief complaint

• Brief history of present illness

2. A problem-focused examination

• A limited exam of affected body area or organ system

3. Straightforward medical decision making

• Minimal number of diagnoses/management options

• Minimal (or no) amount/complexity of data obtained, reviewed and analyzed

• Minimal risk of complications/morbidity/mortality

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.

Example: This is a follow-up visit for a 35-year-old male seen before for pain and loss of motion in his right shoulder.
He returns for follow-up after a course of medication, an intraarticular injection and physical therapy. Review of test
results and a physical examination reveal that the patient is now better. The patient is told to return only if a new
problem occurs.

99213 Office or other outpatient visit for the evaluation and management of an established patient which
requires at least two of the following three key components:

1. An expanded problem-focused history

• Chief complaint
• Brief history of present illness
• Problem pertinent system review

2. An expanded problem-focused examination

• A limited exam of affected body area or organ system and other symptomatic or related organ systems
3. Medical decision making of low complexity
• Limited number of diagnoses/management options
• Limited amount/complexity of data obtained, reviewed and analyzed
• Low risk of complications/morbidity/mortality

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Counseling and 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 15 minutes face-to-face with the patient and/or family.

Example: A 68-year-old woman comes in for a follow-up office visit; she has polymyalgia rheumatica maintained
on chronic low-dose corticosteroids. The history reveals no increase in the shoulder or hip pain. There has been
some mild weight gain and bruising while on the medication. A limited examination was performed. The patient was
instructed on long-term prognosis of PMR and steroid side effects. Laboratory tests were ordered.

99214 Office or other outpatient visit for the evaluation and management of an established patient which
requires at least two of the following three key components:

1. A detailed history

• Chief complaint

• Extended history of present illness

• P
 roblem pertinent system review extended to include a review of a limited number of additional systems

• P
 ertinent past, family, and/or social history directly related to the patient’s problems

2. A detailed examination

• Extended exam of affected body area(s) and other symptomatic/related organ system(s)

3. Medical decision making of moderate complexity

• Multiple number of diagnoses/management options

• Moderate amount/complexity of data reviewed

• Moderate risk of complications/morbidity/mortality

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 25 minutes face-to-face with the patient and/or family.

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Example: A 38-year-old female returns for a routine follow-up office visit for rheumatoid arthritis. Patient is on
celecoxib, methotrexate, folic acid and lansoprazole. The patient reports moderate pain, swelling and stiffness in her
wrists and most finger joints every day, which is interfering with activities such as opening jars, buttoning clothing,
using a computer keyboard, etc. The patient reports generalized morning joint stiffness lasting from 1 to 3 hours
on most days of the week and easy fatigue. The patient has history of GERD, but denies dyspepsia or abdominal
complaints. The patient denies fevers, headaches, chest pain, dyspnea, cough, oral ulcers, Raynaud’s phenomenon,
rashes, hematochezia, insomnia or depression. The patient is a secretary in a law firm, is married and has two
young children, ages 3 and 5 years.

On examination, patient is alert and oriented with normal vital signs, height 5’6”, weight 135 lbs, BMI 21.8 HEENT
exam normal. No lymphadenopathy. Lungs clear. The heart has RRR, no murmurs, friction rubs. The abdomen is
soft, nontender, no mass or HSM. Her skin is good color and turgor, no rashes. Musculoskeletal exam: Gait slightly
stiff. Patient had warmth, swelling, irritability and decreased range of motion in bilateral wrists; swelling, irritability,
bony proliferation and decreased range of motion in bilateral 2nd through 3rd MCP joints and bilateral 2nd through
4th PIP joints and is beginning to develop swan neck deformities. Patient had synovial thickening and bony proliferation
in bilateral knees and large effusions in bilateral ankles with warmth and slight decreased dorsiflexion and plantar
flexion. All other joints are unremarkable with FROM and no evidence of active synovitis.

Diagnosis: Rheumatoid arthritis with active disease.

Plan: Review of labs done 6 weeks prior showed mild anemia and elevated ESR and CRP. Other labs were normal.
Therapeutic options were discussed with patient and decision was made to add TNF-alpha inhibitor. Actions, side
effects and administration of TNF-alpha inhibitors were reviewed with patient. Laboratory studies were ordered along
with a chest x-ray. PPD test was placed on patient’s right forearm. Patient was continued on celecoxib, methotrexate,
folic acid and lansoprazole. Patient was given prescription for occupational therapy evaluation and treatment to
include finger splints. Patient scheduled to return to office in 3 days to have PPD read and for patient education
visit with RN to learn self-administration of TNF-alpha injections.

99215 Office or other outpatient visit for the evaluation and management of an established patient which
requires at least two of the following three key components:

1. A comprehensive history

• Chief complaint

• Extended history of present illness

• R
 eview of systems which is directly related to the problem(s) identified in the history of present illness plus a
review of all additional body systems

• Complete past, family, and/or social history

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2. A comprehensive examination

• A general multi-system exam or a complete exam of a single organ system

3. Medical decision making of high complexity

• Extensive number of diagnoses/management options

• Extensive amount/complexity of data obtained, reviewed and analyzed

• High risk of complications/morbidity/mortality

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 40 minutes face-to-face with the patient and/or family.

Example: 30-year-old female patient comes in for a follow-up visit for undifferentiated connective tissue disease.
She has a fever, rash and increasing joint difficulties. A comprehensive examination was consistent with a diagnosis
of systemic lupus erythematosus. Tests were ordered to confirm the diagnosis.

Consultations and Special Services

The AMA CPT® manual defines a consultation 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. There are two subcategories of consultations: office (outpatient) and inpatient.

The difference between consultations and new patient visits is often a source of confusion. The difference in
reimbursement is sometimes dramatic, so it is important for rheumatologists to understand the distinction.

A consultant may initiate diagnostic and/or therapeutic services at the initial consultation without losing consultant
status. If the rheumatologist consultant subsequently assumes responsibility for management of a portion or all of
the patient’s condition, the established patient office visit codes (99211-99215) must be used for follow-up visits.
NOTE that Medicare carriers interpret national policies in different ways, particularly related to the initiation of
therapeutic services. If you have questions, contact the carrier.

If an additional request for opinion or advice regarding the same or a new problem is received from the attending
physician and documented in the medical record, the office consultation codes (99241-99245) may be reported
again by the rheumatologist consultant. Any specifically identifiable procedure (e.g., identified with a specific CPT®
code) performed on or subsequent to the date of the initial consultation should be reported separately.

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A “consultation” initiated by a non-physician (patient, patient’s family, third party payor, etc.) for a second or third
opinion is reported using new patient office visit codes (99201-99205), as appropriate. If the confirmatory consultation
is required by a third party payor, then the modifier “-32” or 09932 (mandated services), should be added to the
appropriate confirmatory consultation code.

The Centers for Medicare and Medicaid Services released the claims processing transmittal regarding the consultation
services payment policy for physicians to bill for both inpatient and outpatient on January 1, 2010 because of the
elimination of all consultation codes for inpatient and office/outpatient visits. Physicians should code patient visit with
the E/M code that represents where the visit occurred and identify the complexity of the visit performed.

Outpatient Services
Bill the appropriate new or established outpatient visit codes in the office and other outpatient settings using CPT®
codes 99201-99205 or 99211-99215.

Inpatient Services
For inpatient services, physicians and other non-physician practitioners who perform the initial evaluation and
management may bill the initial hospital care codes (99221 – 99223) or nursing facility care codes (99304-99306).
As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a
single day.

So as to define the admitting physician, CMS has created the “AI” modifier which is to be used by the admitting
or attending physician who oversees the patient’s care, as distinct from other physicians who may be furnishing
specialty care. The “AI” modifier is defined as “Principal Physician of Record.”

The admitting or attending physician must append modifier “-AI” in addition to the initial visit code. All other
physicians who perform an initial evaluation on this patient should only bill the E/M code for the complexity level
performed.

NOTE: The primary purpose of this modifier is to identify the principal physician of record on the initial hospital and
nursing home visit codes.

CMS indicated that it is not necessary to reject claims that include the “-AI” modifier on codes other than the initial
hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes).

Follow-up visits in the facility setting should be billed as subsequent hospital care visits and subsequent nursing
facility care visits as is the current policy. In all cases, physicians should bill the available code that most appropriately
describes the level of the services provided.

The transmittal can be reviewed at www.cms.hhs.gov/transmittals.

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Office or Other Outpatient Consultations

New or Established Patient
The following CPT® codes are used to report consultations provided in the physician’s office or in an outpatient
or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home,
custodial care or an emergency department. Each example for the codes implies that the rheumatology consultant
communicates (orally or in written form) with the requesting physician about the patient work-up, differential
diagnosis and potential treatment options.

To find consultation and referral forms to help

your office document requests for consultations,
visit www.rheumatology.org/practice and click on
Office Support. Consultation codes are now one of the highest overpay-
ments. A referral is not the same as a request for a
99241  Office Consultation for a new or
consultation. Make sure that a request for a referral is a
established patient, which requires the
request for the physician’s medical opinion or advice.
following three key components:

1. A problem-focused history

2. A problem-focused examination

3. 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 15 minutes face-to-face with patient and/or family.

Example: Initial Office Consultation for a 27-year-old office worker with a painful “catching” index finger. Brief history
taken and limited examination completed. Treatment options for trigger finger discussed. NSAIDs prescribed.

99242 Office consultation for a new or established patient, which requires the following three key components:

1. An expanded problem-focused history

2. An expanded problem-focused examination

3. Straightforward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with nature of the
problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians
typically spend 30 minutes face-to-face with the patient and/or family.

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Example: Office consultation with a 66-year-old female with wrist and hand pain and finger numbness secondary to
suspected carpal tunnel syndrome. History and examination completed. Laboratory tests were ordered. Medication
and splint prescribed.

99243 Office consultation for a new or established patient, which requires the following three key components:

1. A detailed history

2. A detailed examination

3. 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 40 minutes face-to-face with the patient and/or family.

Example: A 58-year-old female comes in for an office consultation; she has progressive pain and swelling in both
knees. A detailed history and examination was completed. Radiographs and laboratory tests were ordered. The
patient was given information regarding osteoarthritis. Medications prescribed with appropriate warnings regarding
toxicity.

99244 Office consultation for a new or established patient, which requires the following three key components:

1. A comprehensive history

2. A comprehensive examination

3. 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 60 minutes face-to-face with patient and/or family.

Example: A 44-year-old female patient comes in for an initial consultation. She presents with diabetes mellitus,
hypertension, diffuse psoriasis and arthritis unresponsive to anti-inflammatory medications. A comprehensive history
is taken. A comprehensive physical exam is performed. Radiographs and laboratory tests are ordered. A treatment
for psoriatic arthritis, drug toxicity and prognosis is discussed with the patient.

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99245 Office consultation for a new or established patient, which requires the following three key components:

1. A comprehensive history

2. A comprehensive examination

3. 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 80 minutes face-to-face with the patient and/or family.

Example: A 12-year-old female sent by primary care provider for an initial office visit, he requested a pediatric
rheumatology consultation. Patient was found to have 3+ proteinuria and anemia (Hgb 8.9) on routine physical
exam. Repeat U/A on first morning urine specimen had 3+ proteinuria and 1+ blood. ANA was 1:2560. Patient is
accompanied to rheumatology office by her mother, who reports that the child has been more fatigued for the past
six months and has had recurring fevers to 101.4o approximately 1-3 times per week for the past two weeks. Parent
reports that the child was noted to have lost five lbs. from her previous well-child exam. The patient has had periorbital
edema in the mornings for the past month, which the parent had attributed to “allergies”. The patient reports that her
socks often leave indentations above her ankles when she removes them at night. The patient reports generalized
musculoskeletal pain on most days, which she rated at a 6 on a Faces Scale of 0-10. She especially has pain and
stiffness in her hands and sometimes her rings are “too tight”, especially in the mornings. The patient has had an
intermittent raised red rash across her cheeks for the past three months, more prominent after being outdoors in
sunlight. The parent reports that the child’s hair has been thinning, but denied patchy alopecia. The child reports
new onset daily frontal and parietal headaches for the past two weeks, which do not wake her from sleep. She rates
headaches at 10 on Faces Scale 0-10. The patient denied nausea or photophobia. The parent reports that the child
seems to be more forgetful recently and her teachers have reported that she has not been completing her school
assignments. The patient reports she has sometimes has difficulty remembering her school assignments. Parent
denies patient has exhibited any other behavior changes. The child denies oral or nasal ulcers, visual disturbances,
swollen or tender lymph nodes, Raynaud’s phenomenon, chest pain, dyspnea, cough, epistaxis, unusual bruising,
dysuria, insomnia, tremors, seizures, hallucinations, abdominal pain, vomiting, diarrhea, constipation or hematochezia.
The patient is premenarche. The patient is not on any prescribed medications, but takes Tylenol for headaches or
musculoskeletal pain with occasional relief. She has no known allergies.

Past Medical History: Born at term to a G1P1 mother by NSVD. No prenatal or postnatal complications. Her growth
and development is normal. No surgeries or hospitalizations. No comorbidities. Immunizations are UTD. She had
chickenpox at three years of age.

Family Medical History: Significant for rheumatoid arthritis in paternal grandmother, hypothyroidism and migraine
headaches in mother, and type II diabetes mellitus in maternal grandfather. No family history of childhood arthritis,
lupus, cancer, IBD, psoriasis, or blood disorders.

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Social History: Lives with parents and nine year-old brother. Pets: one dog. Father is engineer and mother is social
worker, who works part-time. No smoking or firearms in home. Patient is in 7th grade and was doing well in school
until the past 6 weeks.

On examination, patient was alert and oriented to time, place & person. Short term and long term memory is grossly
intact. BP 129/87, HR 100, RR 20, temp 36.80C. Height is 154.9 cm, weight 44.5 kg, BMI 18.5 HEENT exam
remarkable for mild periorbital edema and a small ulcer on hard palate. Fundoscopic exam is normal. Her skin is
slightly pale with erythematosus maculopapular malar rash. She has mildly enlarged nontender cervical and inguinal
nodes. Lungs clear. Heart RRR, no murmurs or friction rubs. Her abdomen is soft, nontender, no mass or HSM.
Breasts and pubic hair early Tanner stage II. Musculoskeletal exam: Gait steady. Good muscle strength in upper &
lower extremities, proximally & distally. The spine shows normal curvature, FROM. Patient had mild swelling and
irritability in right wrist and right 2nd and 3rd PIP joints. All other joints are unremarkable with FROM and no evidence
of active synovitis. DTRs are normal.

Diagnoses:

1. Proteinuria, anemia, fatigue, rash & positive ANA

2. Mild hypertension

3. Headaches & memory difficulties

4. Probable SLE with lupus nephritis

5. R/O CNS vasculitis

6. R/O other autoimmune connective tissue disease

Plan: A lengthy discussion was had with the parent and patient regarding clinical findings, differential diagnoses,
further diagnostic workup and potential therapies. Laboratory studies ordered for lupus evaluation. MRI/MRA of brain
ordered to evaluate for CNS vasculitis. Nephrology consult requested. Her nephrologist contacted and arrangements
made for patient to be evaluated by nephrologist later the same day. Advised parent that renal biopsy will probably
be needed. Advised patient to adhere to low sodium diet and copy of diet given and reviewed with patient and
parent. Advised that patient must limit sun exposure to the extent possible & use sunscreen with SPF >45 when
she must be outdoors in sunlight. Parent to call clinic after patient sees nephrologist to review initial lab results,
determine medication therapy and follow up appointment. Report on clinical findings, impression and plan dictated to
patient’s primary care provider.

This encounter was an outpatient consultation as there was a formal consultation request from the patient’s primary
care provides as there was a formal consultation request from the patient’s primary care provider for rheumatology
evaluation and opinion regarding patient’s symptoms and the NP/PA provided a written report of his/her findings and
plan to the patient’s primary care provider.

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This was a high-complexity consultation as it included:

Services for Inpatient Visits

Hospital visits can be separated into two broad groups: (1) visits for which the physician is the primary attending and
(2) visits for which the physician is the consultant. Pages 47-51 contain a detailed explanation of office consultations.
In this section, it is important to understand that consultations are regarded differently in the hospital than in the
office.

Visits for which the rheumatologist is the primary attending will be addressed first. The relevant CPT® codes are
divided into initial observation care, initial hospital care and subsequent hospital care with three levels of services.

Initial Observation Care

New or Established Patient
Initial observation care codes (99218-99220) are used to report the first encounter by the supervising physician with
the patient when designated as “observation status.” This refers to the initiation of observation status, supervision of
the care plan for observation and performance of periodic assessment. It is not necessary that the hospital have a
designated area in which observation services are performed.

If such an area does exist in a hospital (as a separate unit in the hospital, or in the emergency department, etc.),
these codes are to be used if the patient is placed there. If the hospital does not have a designated “observation
area” then you are to code to the location of the service (i.e., emergency room, ambulatory surgery center).

Only the supervising physician admitting the patient to “observation status” may use these codes. If a consultation
is requested by this admitting physician, the consulting physician would use outpatient consultation codes (99241-
99245).

If a patient is seen in “observation status” and admitted to the

hospital the same day, an initial hospital care code (99221-
99223), which includes the work of the combined E/M services,
should be used.
If a patient sees their rheumatologist
If a patient is seen in “observation status” today and admitted to
the hospital tomorrow, an initial observation care code (99218- in the emergency room and later
99220) should be used to bill for today’s services, and an initial admitted the patient to observation
hospital care code (99221-99223) should be used for tomorrow’s status on the same date of service,
services. the emergency room visit from the
morning would have to be combined
Initial observation care codes may not be used for post-operative
with the observation code done later
recovery if the procedure is considered part of a global surgical
package. Also note that these codes apply to all E/M services that day.
that are provided on the same day of patient admission to
“observation status.”

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An initial history and physical should be performed on each patient admitted to “observation status.” This is true even
if the admitting physician also performed a history and physical in the hospital emergency department. Physicians
should note the date and time of the history and physical to make it clear to auditors that the physical was performed
after the patient was admitted to “observation status.”

99218 Initial observation care, per day, for the evaluation and management of a patient which requires the
following three key components:

1. A detailed or comprehensive history

2. A detailed or comprehensive examination

3. Medical decision making that is straightforward or 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 problem(s) requiring admission to “observation status” are of low severity.

99219 Initial observation care, per day, for the evaluation and management of a patient which requires the
following three key components:

1. A comprehensive history

2. A comprehensive examination

3. 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 problem(s) requiring admission to “observation status” are of moderate severity.

99220 Initial observation care, per day, for the evaluation and management of a patient which requires the
following three key components:

1. A comprehensive history

2. A comprehensive examination

3. 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 problem(s) requiring admission to “observation status” are of high severity.

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Observation Care Discharge Services

CPT® code 99217 is to be used to report all services provided to a patient on discharge from “observation status” if
the discharge is on a day other than the initial date of “observation status.” Discharge of a patient from “observation
status” includes final examination of the patient, discussion of the hospital stay, instructions for continuing care and
preparation of discharge records.

Initial Hospital Care

New or Established Patient
Most third-party payors will not reimburse for more than one medical visit by the same provider per day. If a patient
is seen in the office and admitted to the hospital the same day, a single code must be assigned to the E/M services
provided if they were for the same diagnosis. In such cases, billing the code for the initial hospital care should
reflect the work of these combined services because, in general, initial hospital codes will provide the appropriate
reimbursement for the services rendered since these codes assume time spent in reviewing radiographs and give
credit for physician “floor time.”

If the diagnosis is different for the E/M services provided on the same day, then two codes, one reflecting office
service and the other reflecting admission service, are appropriate. Selection of the CPT® and ICD-9-CM codes and
subsequent documentation should indicate why the second visit was appropriate.

NOTE: For Medicare billing purposes, if an admission and office

visit are performed on the same day, bill only the admission. As
of January 1, 2010, inpatient physicians and other non-physician
practitioners who perform an initial evaluation and management
may bill the initial hospital care codes (99221 – 99223). As a result There are two types of inpatient
of this change, multiple billings of initial hospital codes could occur hospital codes: initial and
even in a single day. So as to define the admitting physician, CMS subsequent.
has created the “AI” modifier which is to be used by the admitting
or attending physician who oversees the patient’s care, as distinct
from other physicians who may be furnishing specialty care. The “AI”
modifier is defined as “Principal Physician of Record.”

For all of carriers, if two hospital visits are billed on the same day, only one will be reimbursed unless the second one
is for an emergency situation (e.g., the patient is admitted with a stable condition that becomes unstable later in the
day). Carriers will consider payment for the second visit on a post-payment basis.

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When the patient is admitted to the hospital as an inpatient, in the course of an encounter in another site of service
(e.g., hospital emergency department, observation status in a hospital, physician’s office, nursing facility), all evalu-
ation and management services provided by that physician in conjunction with that admission are considered part
of the initial hospital care when performed on the same date as the admission. The inpatient care level of service
reported by the admitting physician should include the services related to the admission that he/she provided in the
other sites of service as well as in the inpatient setting.

Evaluation and management services on the same date provided in sites other than the hospital that are related to
the admission should not be reported separately.

99221 Initial hospital care, per day, for the evaluation and management of a patient which requires the
following three key components:

1. A detailed or comprehensive history

2. A detailed or comprehensive examination

3. Medical decision making that is straightforward or 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 problem(s) requiring admission are of low
severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.

Example: A rheumatologist is called to the hospital see a 60-year-old male patient with rheumatoid arthritis two
days following an uncomplicated total knee replacement. The patient is expected to be discharged the following
day but the knee is still slightly swollen. The patient reports having some discomfort in the operative knee when
pressure is placed on it. He states the pain is tolerable with some oral hydrocodone/acetaminophen and denies
any other complaints. He shows signs of weight loss since his last visit with the rheumatologist. His nonsteroidal
anti-inflammatory drugs and methotrexate were discontinued one week preoperatively. Currently, he is on aspirin for
thrombosis prophylaxis and an intermittent pneumatic compression device, ordered by the orthopedic surgeon. The
orthopedic surgeon has ordered a visiting nurse and physical therapy after discharge.

At the time of the examination, patient is alert and oriented. His vital signs are normal. Lungs are clear. His heart
is regular rate and rhythm, no murmurs or friction rubs. He has good peripheral pulses. His abdomen is soft,
nontender, no masses or hepatosplenomegaly. The surgical dressing on his right knee is dry and intact with a knee
immobilizer and intermittent pneumatic compression device in place. The patient has slight decreased extension in
right elbow, bony proliferation and mild boutonniere’s deformities in fingers.

He was instructed to schedule a follow-up office visit in three weeks with his rheumatologist, and will restart NSAID
and methotrexate once cleared by the orthopedic surgeon.

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99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires the
following three key components:

1. A comprehensive history

2. A comprehensive examination

3. Medical decision making of moderate severity

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 problem(s) requiring admission are of moderate
severity. Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit.

Example: This is a hospital admission of a 19-year-old female with fever, rash and acute monoarthritis. A
comprehensive history and examination is performed. Appropriate cultures, radiographs and laboratory are ordered.
A joint aspiration is done. Antibiotics are instituted for presumed gonoococcal arthritis. The patient is educated as to
etiology of the illness.

99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires the
following three key components:

1. A comprehensive history

2. A comprehensive examination

3. 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 problem(s) requiring admission are of high
severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.

Example: This is a 66-year-old female patient admitted to the hospital for multisystem disease and a positive ANCA.
The patient has a history of diabetes, hypertension, pulmonary hypertension, spenectomy and chronic renal insufficiency.
She was admitted to the hospital because of left foot pain and swelling. She reports that three weeks prior to
admission, she hit her foot on a wheelchair in a store, and then she developed a blister with swelling, erythema, and
pain. Additionally, she has had some left ear pain for five days with subsequent bleeding out of the left ear with some
hearing loss. She has mucosal bleeding from the mouth and eyes.

She states that she has lost 30 pounds since October. She also is complaining of chills, low-grade fever, short-
ness of breath and a cough. The patient was started on Coumadin because of pulmonary emboli. She has been
off Coumadin since her admission. She was noted to have acute renal failure at the time of admission, but her
creatinine level has improved although it is not normal. She has skin lesions on her right hand on both legs, but does
not know how long they have been there. She has nasal bleeding. She denies any numbness or tingling. She denies
any changes in color of her fingers. She denies any nausea, vomiting, constipation, or diarrhea. She denies any
change in urination or dysuria.

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Past medical history: Type two diabetes, insulin dependent, systemic hypertension, pulmonary hypertension, depression,
atrial fibrillation, hyperlipidemia, chronic renal insufficiency, and pulmonary embolus.

Social history: She lives with her daughter. Denies tobacco or alcohol use.

Family history: No known autoimmune disease but history of CVA, breast cancer, and hypertension.

Examination:
General: An ill- appearing female in no acute distress.

Vital signs: She is afebrile. Patient on nasal cannula O2 with good oxygen saturation and normotensive.

HEENT: Pupils equal, round, and reactive to light and accommodation. Extra ocular movements are intact. She does
have severely dry mucous membranes. She has some dried blood surrounding her eyes and some sclera hemorrhage.
She does have some dried blood in the mouth and at the nares. She has evidence of a bleeding ulcer at the right ear.

Neck: Supple. No lymphadenopathy. No thyromegaly.

Heart: Regular rate and rhythm. No murmurs, rubs or gallops.

Lungs: She does have some diffuse decreased breath sounds. Exam is anterolateral and unable to appreciate rales,
rhonchi, or rubs.

Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly.

Extremities: No cyanosis, clubbing or edema.

Skin: She does have evidence of a punch biopsy on the palm of the left hand. She has some small, punctuate,
erythematosus lesions on the palm of her left hand. She has an approximately 2cm bullous lesion on the right thigh
and hemorrhagic, bullous appearing lesion measuring approximately 3cm on the anterior left tibia. The left foot has an
extensive dressing that is in place and was not removed to evidence of active bleeding.

Musculoskeletal: No synovitis. There is full range of motion of all joints.

Neurologic: She is not oriented to year does not know the president. She does know her name and that she is in the
hospital. No evidence of abnormal reflexes. Difficult to get a good strength exam due to her poor cooperation, but
appears to move all extremities, and does not have apparent sensory deficit but does not fully cooperate with the
sensory exam.

Laboratory data: Extensive data are reviewed off the portal, including lab data over the last three months and all
imaging studies for the last three months.

Assessment: Pulmonary infiltrate, pulmonary hypertension, Ethmoid sinusitis, frontal sinusitis, maxillary sinusitis,
bullous skin lesions, oropharyngeal hemorrhage, acute renal failure on baseline renal insufficiency, positive C-ANCA/
positive T-ANCA significant titers, Coumadin toxicity, diabetes, hypertension, atrial fibrillation, and depression.

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Recommendations: I have discussed the patient’s situation in detail with hematology and Renal. I will hold a
conference with the family to discuss patient’s condition.

Certainly, this is most consistent with Wegener’s granulomatosis. Other possibility would be microscopic polyangiitis.
At this point, I think she is at high risk for any type of biopsy. Renal biopsy will be low yield. Open lung biopsy will put
her at significant risk for a bad outcome. I do not believe that we will obtain significant information from a skin biopsy
to change her prognosis or treatment course. I would recommend that we do another CT scan of her chest to get a
more detailed assessment of the pulmonary lesions. I would recommend high dose steroids. The patient is at high
risk from steroid and Cytoxan use because of her high risk of infection and high risk from bone marrow suppression.
Also, may consider discussing with Pulmonary whether they can do a BAL to rule out infection before starting
cytotoxic agents. We will discuss in detail with the family and continue to discuss with the other consultants. Her
prognosis is poor without treatment. Also her prognosis is poor from treatment due to the potential for complications.

Time invested in this visit was greater than 120 minutes.

Subsequent Hospital Care

Coding for subsequent hospital care should reflect the level and intensity of service required for the individual
patient on a particular day. Codes for daily care may vary depending on the possible development of new problems
or worsening of existing problems. These codes are meant to be used for all care provided on a given day. If the
rheumatologist visits or sees a hospital inpatient more than once a day, all such encounters and all care rendered
for the patient on that day should be combined in one level of service code. For payment purposes, Medicare will
combine both the office and admission services into a single hospital visit. The only time it will not is if the later
visit is for emergency purposes – then it will only pay on a post payment basis. The exceptions are a return visit for
complications constituting critical care or for a second distinct problem which requires a different ICD-9-CM code.
In the former case, both a hospital care code (for non-critical care) and a critical care code should be used with
supporting documentation to show that both services were necessary.

All levels of subsequent hospital care include reviewing the medical record and reviewing the results of diagnostic
studies and changes in the patient’s status (e.g., change in history, physical condition and response to management)
since the last assessment by the physician.

99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires
at least two of the following three key components:

1. A problem-focused interval history

2. A problem-focused examination

3. Medical decision making that is straightforward or of low complexity

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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 patient is stable, recovering or improving.
Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

Example: Follow-up hospital visit for a 55-year-old female with rheumatoid arthritis, three days following an
uncomplicated joint replacement. The patient’s general medical care is being managed by her internist. A brief
examination and chart review was completed.

99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires
at least two of the following three key components:

1. An expanded problem-focused interval history

2. An expanded problem-focused examination

3. 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 patient is responding inadequately to therapy
or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s
hospital floor or unit.

Example: The rheumatologist sees a 58-year male with Wegener’s granulomatosis, hospitalized for acute hemoptysis
and progressive dyspnea, in the morning of the patient’s third hospital day. The rheumatologist performs and
documents an expanded problem-focused history, detailed examination and moderate complexity medical decision
making. The rheumatologist in the same practice as the PA, sees the patient later that day, reviews the patient’s
laboratory results drawn that morning, auscultates the patient’s heart and lungs findings and documents her findings.

99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires
at least two of the following three key components:

1. A detailed interval history

2. A detailed examination

3. 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 patient is unstable or has developed a significant
complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s
hospital floor or unit.

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Example: This is a follow-up hospital visit for a 55-year-old female with rheumatoid arthritis, and three days of
postoperative leg pain and swelling from total hip replacement. The patient’s general medical care is being managed
by the rheumatologist. She denies chest pain, shortness of breath or a flare of rheumatoid arthritis. An expanded
problem-focused examination is performed. Anticoagulant therapy is instituted for presumed deep venous thrombosis.
A venous study is ordered. The rheumatologist discussed the plan with the orthopedic surgeon.

Hospital Discharge Services

The hospital discharge day management codes are to be used to report the total duration of time spent by a physician
for final hospital discharge of a patient. The codes include, as appropriate, final examination of the patient, discussion
of the hospital stay, even if the time spent by the physician on that date is not continuous. Instructions for continuing
care are give to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms is
completed. The patient does not have to be seen, but services have to be provided on the date billed.

99238 Hospital discharge day management, 30 minutes or less.

99239 Hospital discharge day management, more than 30 minutes.

To report services for a patient who is admitted as an inpatient and discharged on the same day, use only the codes
for observation or inpatient care services, including admission and discharge services (99234-99236). To report
concurrent care services provided by a physician(s) other than the attending physician, use subsequent hospital
care codes (99231-99233).

Hospital Consultations
New or Established Patient
Different codes are used for inpatient and outpatient consultations. The Harvard Resource-based Relative Value
Scale study show that inpatient work and overhead were quite different from outpatient work and overhead for
consultations. Consequently, different descriptors are used for inpatient consultations.

The following codes are used to report physician consultations provided to hospital inpatients, residents of nursing
facilities or patients in a partial hospital setting. Only one initial consultation should be reported by a consultant per
admission. There are no longer codes for follow-up in-patient consultations. Subsequent services during the same
admission should be reported as Subsequent Hospital Care.

NOTE: Reminder as of January 1, 2010 Medicare eliminated inpatient consultations codes. For inpatient physicians
and other non-physician practitioners who perform an initial evaluation and management may bill the initial hospital
care codes (99221-99223) or nursing facility care codes (99304-99306). As a result of this change, multiple billings
of initial hospital and nursing home visit codes could occur even in a single day.

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99251 Initial inpatient consultation for a new or established patient, which requires the following three
key components:

1. A problem-focused history

2. A problem-focused examination

3. 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 20 minutes at the bedside and on the patient’s hospital floor or unit.

Example: Hospital consultation for a 65-year-old female osteoarthritis patient admitted for kidney stones. Medication
is adjusted accordingly.

99252 Initial inpatient consultation for a new or established patient, which requires the following three
key components:

1 An expanded problem-focused history

2. An expanded problem-focused examination

3. 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 severity.
Physicians typically spend 40 minutes at the bedside and on the patient’s hospital floor or unit.

Example: This is a hospital consultation for a 72-year-old male patient recovering from angioplasty who develops
an acute bursitis of the left shoulder. The rheumatologist had seen the patient four years previously for an episode
of pseudo gout in the right knee. The patient is on antihypertensive and lipid lowering drugs. He is afebrile and
otherwise has made an uneventful recovery.

99253 Initial inpatient consultation for a new or established patient which requires the following three
key components:

1. A detailed history

2. A detailed examination

3. 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 55 minutes at the bedside and on the patient’s hospital floor or unit.

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Example: This is a hospital consultation for an obese female hospitalized for an endoscopic removal of her gallbladder.
She is making an apparently uneventful recovery from a moderately difficult procedure. On the third day (which was
going to be her discharge day), she develops a right Podagra and pain in multiple joints. In addition to a bright red
first toe, she has warmth and an effusion in her left knee. The rheumatologist is consulted. The family is present
and is anxious about this complication; they remind the rheumatologist that the patient’s brother was seen by the
rheumatologist for gout. Records reviewed, x-rays ordered and knee aspirated, and the fluid was sent to the laboratory.
Gout crystals found, and therapy was initiated. The rheumatologist informs the family that the patient will be seen the
next day for review.

99254 Initial inpatient consultation for a new or established patient which requires the following three
key components:

1. A comprehensive history

2. A comprehensive examination

3. 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 80 minutes at the bedside and on the patient’s hospital floor or unit.

Example: This is a hospital consultation for a 68-year-old woman, who was admitted for a six-month history of
severe polyarthritis. The arthritis is unresponsive to initial therapy. The patient’s family is present. A comprehensive
history and musculoskeletal examination is performed. A review of laboratory studies, chart and x-rays were
completed with patient and family. The results were consistent with rheumatoid arthritis. Treatment options, drug
toxicity, and long-term prognosis discussed with the patient and family. The addition of “second-line” anti-rheumatic
therapy instituted and a physical therapy consultation was arranged.

99255 Initial inpatient consultation for a new or established patient which requires the following three
key components:

1. A comprehensive history

2. A comprehensive examination

3. 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 110 minutes at the bedside and on the patient’s hospital floor or unit.

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Example: A 22-year-old steroid-dependent woman is seen for an initial hospital consultation; she presents with
systemic lupus erythematosus, arthritis and glomerulonephritis. The patient is re-evaluated for loss of consciousness
and chest pain. A comprehensive examination is performed. A review of x-rays, cardiac echo cardiogram, laboratory
studies and chart was completed. The case was discussed with the patient and her nephrologist and cardiologist.
Appropriate diagnostic studies were ordered. Steroid dosage was adjusted along with institution of anticoagulation.

Critical Care Services

As defined by the AMA CPT® manual, critical care includes the care of critically ill or unstable, critically injured,
patients who require the constant attention of the physician. (NOTE: Medicare’s definition is critically ill and un-
stable.) The critical care unit is an area where the time required to provide the services is an important determinant
of which code to use. CPT® code 99291 is used to report the first hour of critical care on a given day. It should be
used only once per day even if the time spent by the physician is not continuous on that day. Critical care of less
than 30 minutes should be reported with the appropriate E/M service code. CPT® code 99292 is used to report each
additional 30 minutes beyond the first hour. There are no subsequent follow up critical care codes. Services for a
patient who is not critically ill but happens to be in a critical care unit are reported using subsequent hospital care
codes (99231-99233) or hospital consultation codes (99251-99255). For further guidelines, please refer to the AMA
CPT® manual.

Prolonged Services
There are two types of prolonged service rheumatologists may bill for when care is beyond the normal time frame
during either an inpatient or outpatient visit. These services must be billed along with an E/M visit. They are known
as add on codes.

With Direct (Face-to-Face) Patient Contact

+ 99354 P
 rolonged physician service in the office or other outpatient setting requiring direct
(face-to-face) patient contact beyond the usual service; first hour (List separately in
addition to code for office other outpatient Evaluation and Management service)

+ 99355 e
 ach additional 30 minutes (List separately in addition to code for prolonged physician service)

+ 99356 P
 rolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service;
first hour (List separately in addition to code for inpatient Evaluation and Management service)

+ 99357 e
 ach additional 30 minutes (List separately in addition to code for prolonged physician service)

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Without Direct (Face-to-Face) Patient Contact

+ 99358 P
 rolonged evaluation and management service before and/or after direct (face-to-face) patient care
(e.g. review of extensive records and tests, communication with other professionals and/or the patient/
family); first hour (List separately in addition to code(s) for other physician service(s) and/or inpatient or
outpatient Evaluation and Management service)

+ 99359 e
 ach additional 30 minutes (List separately in addition to code for prolonged physician service)

Telephone Services
There are two types of codes for telephone services: non-face-to-face physician and non-face-to-face nonphysician.
These codes are used to report care done by a qualified health professional for an established patient or guardian of
an established patient.

Below is a list of both types of telephone services codes:

Non-Face-to-Face Physician Services

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 seven 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

99442 11 – 20 minutes of medical discussion

99443 21 – 30 minutes of medical discussion

Non-Face-to-Face Nonphysician Services

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 seven 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

98967 11 – 20 minutes of medical discussion

98968 21 – 30 minutes of medical discussion

Medicare and many private carriers will not reimburse for either prolonged services or telephone services. When
billing to CMS, an Advance Beneficiary Notice must be signed and dated prior to the service. It is recommended that
your practice verify with each carrier its policy on these charges.

NOTE: It is acceptable to bill these charges directly to the patient. Just make sure you notify patients both in writing
and on signage that is prominently displayed in the office.

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Chapter Four

Rheumatology Technical Procedures

Minor Surgical Procedures
In addition to the major global surgeries in the Surgery section of the AMA CPT®manual, there are a number
of minor surgeries. These minor surgeries involve a readily identifiable surgical procedure but include variable
preoperative and postoperative services (e.g., injection of a tendon sheath and manipulation of a joint under
anesthesia). Because of the indefinite preoperative and postoperative services, they are not traditionally paid using
a global surgery policy.

20526 Injection, therapeutic (e.g., local anesthetic corticosteroid),

carpal tunnel

20550 Injection(s); single tendon sheath, or ligament, aponeurosis

(e.g., plantar “fascia”) Trigger point injections are coded
20551 single tendon origin/insertion based on the number of muscles,
not the number of injections. You
20552 Injection(s); single or multiple trigger point(s), one or two
may not bill for both 20552 and
muscle(s)
20553. For example, if a patient
20553 s ingle or multiple trigger point(s), three or more muscle(s)
comes in for trigger point injec-
20600 Arthrocentesis, aspiration and/or injection; small joint or bursa tions in six different muscles, you
(e.g., fingers, toes) bill code 20553 only.
20605 intermediate joint or bursa (e.g., temporomandibular,
acromioclavicular, wrist, elbow or ankle, olecranon bursa)

20610 major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa)

NOTE: When billing two joints of the same size and it is not bilateral, you may want to use modifier -59 to ensure
that the carrier realizes you are performing two separate joints. In some cases, there have been denials of the
second code because it was thought the practices were billing for the aspiration and the injection. This is not
allowed; the joint injection is for both aspiration and/or injection.

(If imaging guidance is performed, see 76942, 77002, 77012, or 77021. See page 71.)

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64490 Injection(s) diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating
that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

+64491 second level (List separately in addition to code for primary procedure)

+64492 third and any additional level(s) (List separately in addition to code for primary procedure)

– (Do not report 64492 more than once per day) –

– (Use 64491, 64492 in conjunction with 64490) –

64493 Injection(s), diagnostic therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating
that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

+64494 s econd level (List separately in addition to code for primary procedure)

+64495 third and any additional level(s) (List separately in addition to code for primary)

– (Do not report 64495 more than once per day) –

– (Use 64494, 64495 in conjunction with 64493) –

• Image guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of 64490-64495.
Imaging guidance and localization are required for the performance of paravertebral facet joint injection described
by codes 64490-64495. If imaging is not used; report 20550-20553. If ultrasound guidance is used, report 64999.

• For bilateral procedures, use modifier 50.

• For injection of the T12-L1 joint, or nerves innervating that joint, use 64493.

Drug Administration
Following are the most common drug administration codes used in rheumatology practices for the injection and infusion
of medications. The codes are broken down by categories: hydration, therapeutic, prophylactic and diagnostic.

When coding from the drug administration group it is important to know the guidelines. It is significant to know that only
one “initial” code from this group can be billed. The term “initial” refers to the first code within the family of codes during
a patient’s encounter. When multiple drugs or other agents are administered, the additional sequential codes should be
used.

NOTE: It may be appropriate in some instances for the initial code to be a chemotherapy code and the additional
sequential code to be a non-chemotherapy code.

A number of these codes are based on time. Two types of these codes in this group are infusions and IV pushes.
Accurate documentation of the time is very important. The time begins when the medicine is started in the line and it
should be stopped when the medicine is finished.

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The first hour of an infusion must be at least 16 minutes in order to be

considered for the initial hour of an infusion. If it is 15 minutes or less it
should be coded as an IV push. Each additional hour must be at least
31 minutes into that additional hour. Anything less than the 31 minutes Time does not start when the IV
will not count toward an additional hour of infusion. is put into the patient nor does it
Example 1: The infusion time of a chemotherapy drug was 91 minutes begin when the saline is infused
it would be coded as 96413 and 96415. – only when the actual medicine
is infused. This is a common
Example 2: The infusion time of a chemotherapy drug was 90 minutes
it would be coded as 96413 only. documentation error.

The billing of local anesthesia, IV start, access to indwelling IV,

subcutaneous catheter or port, flushing at the conclusion of the infusion, or the standard tubing, syringes, and
supplies is not allowed – all of these items are built into the code.

NOTE: CPT® code 99211 cannot be billed with any drug administration code. This code has been built into the
Relative Value unit for these codes.

96360 Intravenous infusion, hydration; initial, up to 1 hour (Do not report 90760 if performed as a concurrent
infusion service)

96361 Each additional hour, up to 8 hours (List separately in addition to code for primary procedure)

NOTE: Codes 96360 and 96361 should not be billed for the infusion of saline if it is used to administer the drug.
Either code should only be billed if the saline is used to flush out the drug in a patient’s system. In that case you
would bill the 96360 or the 96361 with a modifier 59 to indicate that the hydration was not used to facilitate the drug.

96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

96366 e
 ach additional hour, up to 8 hours (List separately in addition to code for primary procedure)

96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

96374 intravenous push, single or initial substance/drug

96375 e
 ach additional sequential intravenous push a new substance/drug (List separately in addition to code for
primary procedure)

NOTE: Chemotherapy administration codes 96401, 96413 and 96415 apply to a parenteral administration of
non-radionuclide Antineoplastic drugs; and also to anti-neoplastic agents provided for the treatment of noncancer
diagnosis (e.g., cyclophosphamide for auto-immune conditions) or to substance such as certain monoclonal antibody
agents, and other biologic response modifiers.

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96401 C
 hemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic

96413 C
 hemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/
drug

96415 e
 ach additional hour, 1 to 8 hours (List separately in addition to code for primary procedure)

Modifiers
There are two types of modifiers: functional/pricing modifiers and informational modifiers. Functional/pricing
modifiers do exactly what they state — control the money. Without the correct modifier, the charge could be rejected
or lumped in with another charge. Informational modifiers provide information to the carrier such as body area (e.g.,
LT for left or RT for right). It could also provide information as to whether or not the patient is aware of his or her
liability (e.g., GA to notify CMS that there is a signed Advance Beneficiary Notice on file).

Functional/Pricing Modifier
• M
 odifier 25 - Significant, separately identifiable evaluation and management service by the same physician on the
same day of the procedure or other service.

• Modifier 50 - Bilateral procedure

NOTE: Carrier will often tell you that a separate diagnosis is needed for this modifier. This is incorrect per the
2010 CPT®; “As such, different diagnoses are not required for reporting of the E/M service on the same date.” It is
recommended that the documentation for the E/M visit should be totally separate from the document for the procedure
done that same day.

• M
 odifier 26 - Professional component

NOTE: This modifier should only be used if the rheumatologist is reading and writing a report of his findings of
the X-ray. If the physician is reading and performing the X-ray no modifier is needed. You would just bill the X-ray
procedure with no modifier to show that it was done as a global procedure.

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• Modifier LT – Left side

• Modifier RT – Right side

NOTE: Modifier 50 will reimbursed at 150 percent, not at 100 percent and 100 percent for the two procedures.
You should verify with your carrier on how they want this modifier used. You may be asked to:

• B
 ill it as one line with both procedure charge amount on it with the 50 modifier and one in the unit field.

• B
 ill the procedures on two lines with the 50 modifier on the second procedure with one in the unit field for
each procedure.

• B
 ill it with modifiers on two lines, with the modifier LT on first procedure and RT on the second procedure with
one in the unit field for each procedure.

• Modifier 51 - Multiple procedures

• Modifier 59 - Distinct procedural service

NOTE: This modifier should be used when you are trying to demonstrate that two separate and different sites or
sessions.

Example: If you two large joints are being injected, such as a shoulder and a knee, you would place a modifier
59 on the second 20610 to show that there was two different joints injected and the practice is not billing for the
injection and aspiration of the same joint.

• Modifier 76 - Repeat procedure or service by same physician

• Modifier 90 - Reference (outside) laboratory

• Modifier 91 - Repeat clinical diagnostic laboratory test

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Chapter Five

Radiologic Examination
Several codes are available for each radiologic examination depending on the number of views obtained. To ensure
proper reimbursement, the correct code reflecting the total number of procedures performed should be chosen.
Specific codes for radiologic tests (single and multiple views) can be found in the AMA CPT® manual. Physician
should report these codes when a radiologic procedure is performed and/or read.

A word of caution is offered here regarding patients covered by Medicare. If radiologic studies are personally
performed by the physician or by the physician’s employees under appropriate supervision and that physician
provides the interpretation, the radiologic studies may be billed routinely as a global service (both technical and
professional component).

However, if a radiologic study is obtained that the physician did not actually perform or supervise, then billing and
reimbursement fall under the “purchased service” provision. The purchased service may be billed directly to the
Medicare carrier by the provider of the technical component, or the physician can bill for it. If the physician bills for it,
he or she must check “Yes” in Block 20 of the claim to indicate the technical component was purchased and indicate
the actual amount paid for the service. In addition, a “Yes” requires completion of Block 32 with the name, address
and Medicare billing number of the provider providing the purchased service. A “No” in Block 20 tells the Medicare
carrier that there are no purchased services on the claim.

Certain procedures, including many radiographs and bone density scans, are a combination of professional and
technical services. Use of the modifier “-26” with these codes indicates that only the professional service (interpreting
the data) was provided. The modifier “-26” is used by rheumatologists who provide a written interpretation on a
radiograph or bone density scan from an outside diagnostic center. Rheumatologists who only review a radiograph
from an outside diagnostic center and do not provide written interpretation would not use modifier “-26” as this work
is considered part of the E/M service.

If a rheumatologist performs or supervises a radiograph in the office and provides written interpretation, then the
usual radiologic procedure code, such as CPT® 73100, is used. If another physician requests a report on a film done
elsewhere, then CPT® 76140 (consultation on radiographic examination made elsewhere, written report) is used.
A written report is required. This code is not applicable when the physician requesting the report is from the same
institution or practice.

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Magnetic Resonance Imaging

Upper Extremities
73221 M
 agnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s)

73222 with contrast material(s)

73223 without contrast material(s), followed by contrast material(s) and further sequences

Lower Extremities
73721 M
 agnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material(s)

73722 with contrast material(s)

73723 without contrast material(s), followed by contrast material(s) and further

There are several CPT® codes for bone densitometry. Dual energy X-ray absorptiometry has separate codes for
axial, peripheral scans, and vertebral fracture assessment.

77080 Dual-energy
 X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips,
pelvis, spine)

77081 appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

77082 vertebral fracture assessment

NOTE: CMS has very strict guidelines for DXAs. You can find any carriers’ local coverage determination at
www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp.

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Radiologic Guidance
There are three types of radiologic guidance that rheumatologists would use along with some minor surgical
procedures: ultrasound, fluoroscopic, computed tomography and magnetic resonance.

76942 U
 ltrasound guidance for needle placement (e.g., biopsy, aspiration, injection, localization device),
imaging supervision and interpretation

NOTE: There has been a significant rise in the usage of code 76492. Because of this, the Office of the Inspector
General has placed this code on the OIG watch list. Your practice should be prepared to show documentation of
medical necessity for this code.

77033 F
 luoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or
therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet
joint, paravertebral facet joint nerve, or sacroiliac joint), including neurolytic agent destruction

77012 C
 omputed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization
device), radiological supervision and interpretation

Ultrasound

76800 Ultrasound, spinal canal and contents

76880 Ultrasound, extremity, nonvascular, real time with image documentation

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Chapter Six

Pathology and Laboratory

Laboratory codes have nuances that may promote confusion. Most codes for specific analyte/method and specimen
source/analyte combinations have been eliminated. The rheumatologist must be certain that the correct code is
applied to ensure proper reimbursement. Offices that process laboratory tests should follow the guidelines listed
below:

1. If you do the testing in your own laboratory, bill for the test using the appropriate laboratory code number, in
addition to the office visit.

2. If you collect the specimen and send it to an outside laboratory, bill for the office visit and a handling fee (CPT®
codes 99000-99002) or add the modifier “-90” (or the five digit modifier 09990) with the code for the test
performed. This alerts third-party payors that an outside laboratory performed the tests and supports the billing
by both the rheumatologist and the laboratory.

NOTE: Medicare does pay for 36415 (venipuncture) to draw the blood specimen, but does not pay for 99000-
99002. However private payor payments vary.

3. If the laboratory bills you for the tests, bill the patient using the appropriate code from the laboratory section. This
applies only to non-Medicare patients. Medicare patients who have laboratory tests performed by an outside
laboratory must be billed directly by the outside laboratory. It should be pointed out that, at least in a few states,
Medicaid and other third-party payors stipulate the same requirements.

4. If you are unable to locate a specific code for a test in the AMA CPT® manual, try to find it based on the method
of performing the test.

5 The allowable laboratory tests reimbursed for particular diagnoses are carefully monitored. You should consult
your Medicare carrier’s bulletin to identify the laboratory tests that will be reimbursed only if it corresponds with
the medically necessary diagnosis list.

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Blood Counts
Not only are there codes for manual and automated performances of complete blood counts, there are also codes
for each component. Refer to the index in the AMA CPT® manual for the appropriate list of codes. The most
frequently used codes done in rheumatology offices are listed below:

85014 hematocrit (HCT)

85018 hemoglobin (Hgb)

85025 c omplete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC
count

85027 complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)

85032 manual cell count (erythrocyte, leukocyte, or platelet)

85049 platelet, automated

85651 Sedimentation rate, erythrocyte; non-automated

Urinalyses
Urinalyses can be listed as a complete routine (with pH, specific gravity, protein, reducing substance and
microscopy) or by constituent subsets (complete microscopy) or qualitative chemical analysis with any number of
constituents.

81000 U
 rinalysis, by dip stick or tablet regent for bilrubin, glucose, hemoglobin, keton, leukocytes, nitrite, pH,
protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy

81001 automated, with microscopy

81002 non-automated, without microscopy

81003 automated, without microscopy

81005 Urinalysis; qualitative or semiquantitative, except immunoassays

Cultures
Body fluids cultures may be described using CPT® codes 87040-87999, depending on the site or origin and the type
of culture obtained. Urine cultures are usually performed in a quantitative manner with colony counts.

87086 Culture, bacterial; quantitative colony count, urine

87088 with isolation and presumptive identification of each isolate, urine

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Immunology
The branch of biomedicine that is concerned with the structure and function of the immune system, innate
and acquired immunity, and laboratory techniques involving the interaction of antigens with antibodies.

86255 Fluorescent noninfectious agent antibody; screen, each antibody

86256 titer, each antibody

86430 Rheumatoid factor, qualitative

86431 quantitative

86480 Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response

86580 tuberculosis, intradermal (skin test)

NOTE: There have been some denials of the PPD test done before a patient starts biologics. Medicare does
not pay for screening, it has been reported that carriers will accept V01.01 – contact with or exposure to
communicable disease.

Tissue Typing
Tissue typing can be coded as a single antigen, e.g., HLA B27, or multiple antigens. A separate code is utilized for
HLA DR/DQ typing, with codes for single antigen and for multiple antigens.

86812 HLA typing; A, B, or C (e.g., A10, B7, B27), single antigen

86813 A, B, or C, multiple antigens

86816 DR/DQ, single antigen

86817 DR/DQ, multiple antigens

Synovial Fluid Examination

Synovial fluid examinations should be coded as follows:

85810 Viscosity

89050 C
 ell count, miscellaneous body fluids (e.g., cerebrospinal
fluid, joint fluid), except blood;
Gross examination
89051 with differential count
• Viscosity
89060 C
 rystal identification by light microscopy with or without
polarizing lens analysis, tissue or any body fluid (except urine) • Color

82947 Glucose; quantitative, blood (except reagent strip) • Clarity

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Drug Monitoring
Medicare carefully monitors follow-up testing. Listing disease-specific diagnosis codes will not be sufficient to prove
medical necessity for drug monitoring. You must also list the ICD-9-CM codes that support medical necessity for
high-risk medications. These include:

V58.65 Glucocorticoids

V58.69 Long-term (current) use of other (high-risk) medications.

V67.51 Following completed treatment with high-risk medications

CLIA
The Clinical Laboratory Improvement Amendments were passed by Congress in 1988 to improve the quality of
testing in all laboratories nationwide. These health assessment tests examine diagnoses, prevention and treatment
of the human body. The basis of the complexity of CLIA tests are categorized into three levels, waived tests, moderate
and high complexity.

Waived Tests
Waived tests include any test listed in the regulation (process of categorizing and re-categorizing of tests), any test
in which the manufacturer instructions allow inspections and random compliance checks, and tests cleared by the
FDA for home usage. When billing for waived tests approved on or after January 23, 1996, laboratories must use
QW modifier. It is not mandatory for tests approved before January 23, 1996.

The specified tests that are listed in the FDA regulation as waived are:

1. Dipstick or tablet reagent urinalysis (non-automated) for the following:

– Bilirubin

– Glucose

– Hemoglobin

– Ketone

– Leukocytes

– Nitrite

– pH

– Protein

– Specific gravity

– Urobilinogen

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2. Fecal occult blood

3. Erythrocyte sedimentation rate -- non-automated

4. Hemoglobin-copper sulfate -- non-automated

5. Blood glucose by glucose monitoring devices cleared by the FDA specifically for home use

6. Spun microhematocrit

7. ( Added 1/19/93) Hemoglobin by single analyte instruments with self-contained or component features
to perform specimen/reagent interaction, providing direct measurement and readout

Moderate and High Complexity Tests

Moderate and high complexity tests must meet requirements for proficiency testing, patient test management, quality
assurance/control and personnel. Waived tests are exempted from these requirements.

Proficiency testing evaluates the laboratory’s performance mandated by CLIA. Moderate and high complexity tests
are required to enroll in an approved proficiency testing program for specialties in which certification is sought.
Regulations create rules for PT providers that include sample problem solving, distribution, preparation, result
reporting and records.

Patient test management must maintain and establish a system to ensure identification and reliability of specimens
during the testing process and correct handling of the results. Requirements for the submission and handling,
specimen referral, test applications, test records and reports are stipulated by the regulations.

Quality assurance/control ensures that every laboratory must create quality control procedures that oversee and
assess every test technique to guarantee precise and dependable results. Each laboratory must ascertain written
policies and procedures for a QA program intended to oversee and assess the complete testing process.

Personnel requirements tie into the complexity of testing. The condition differs for personnel who execute moderate
and high complexity testing and are identified individually. Qualifications for a precise mixture of positions and define
accountability for people who fill the position.

All laboratories must have one of the below certifications from CLIA to perform clinical testing on specimens:

a) Certificate of Waiver is issued to a laboratory to perform waived tests only.

b) C
 ertificate of Provider-Performed Microscopy Procedures is issued to a laboratory in which a mid-level
practitioner, physician or dentist can perform microscopy procedures. Waived tests may also be performed.

c) C
 ertificate of Registration is issued to a laboratory that performs moderate and/or high complexity testing
until it is determined by a survey to be in compliance with CLIA regulations.

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d) C
 ertificate of Compliance is issued to a laboratory after an inspection determines that it is compliant with CLIA
requirements.

e) C
 ertificate of Accreditation is issued to a laboratory based on the accreditation of an organization approved
by CMS.

How to Apply for a CLIA Certificate of Waiver

Obtaining a Certificate of Waiver is usually a straightforward process. An application (Form CMS-116) can
be obtained on the CMS website at www.cms.gov/clia/cliaapp.asp or from your state health department. The
application requests the following information that you must complete:

I. General Information – provide information about your organization, including street address, name of director,
and federal tax identification number. Don’t fill out the CLIA identification number if this is an initial application.

II. Type of Certificate Requested – request a Certificate of Waiver.

III. Type of Laboratory – indicate the facility or setting in which you will perform the rapid test, e.g., community
clinic, health fair, mobile laboratory (van). If none of the categories apply to your setting, check “other.”

IV. Hours of Laboratory Testing – indicate the times you plan to do testing.

V.  ultiple Sites – indicate if you will be doing testing at more than one site. If you will have multiple sites, provide
M
the number of sites and complete the remainder of this section. In general, a mobile van is considered a multiple
site if it is not in a fixed location and moves from site to site for testing. If that is the case, the name and address
of the testing site for that van would be the same as the organization it operates under or the physical location
where the van is housed.

VI. Waived Testing – estimate the number of tests you will be performing annually.

VII. Non-Waived Tests – skip this section if you are performing a waived test only.

VIII. T
 ype of Control – check the type of organization for which you are making this application (private nonprofit,
for-profit, government).

IX. D
 irector Affiliation With Other Laboratories – provide the name and address of other laboratories (facilities)
that your director also directs. CLIA regulations allow a director to direct a maximum of five laboratories.

X. Individuals Involved in Laboratory Testing – indicate the total number of individuals involved in testing
— those who are directing, supervising, consulting or testing. Include counselors only if they will perform or
supervise testing.

XI. C
 onsent and Signature – carefully read the consent information at the bottom of page four before signing and
dating.

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Chapter Seven

Diagnostic Codes for Rheumatology

ICD-9 Clinical Modification – Diagnostic Codes
Abdomen, abdominal – see also condition Arthritis, arthritic (acute) (chronic) (subacute)

[0-7, 9] Abdominal pain 789.0_ 716.9_

meaning Osteoarthritis – see also Osteoarthrosis
NOTE: The following fifth-digit subclassification is
to be used for codes 789.0, 789.3, 789.4, 789.6
NOTE: Use the following fifth-digit subclassification
0 unspecified site with categories 711-712, 715-716:
1 right upper quadrant
0 site unspecified
2 left upper quadrant
1 shoulder region
3 right lower quadrant
2 upper arm
4 left lower quadrant
3 forearm
5 periumbilic
4 hand
6 epigastric
5 pelvic region and thigh
7 generalized
6 lower leg
9 other specific site
7 ankle and foot
– multiple sites
8 other specified sites
9 multiple sites

Albuminuria, albuminuric (acute) (chronic)

(subacute) 791.0

Anemia 285.9 crystal (-induced) – see Arthritis, due to crystals

Angiitis 447.6 due to or associated with

hypersensitivity 446.20 bacterial disease NEC 040.89 [711.4]

Angina (attack) (cardiac) (chest) (effort) (heart) crystals (see also Gout)
(pectoris) (syndrome) 413.9 dicalcium phosphate 275.49 [712.1]

Arteritis 447.6 pyrophosphate 275.49 [712.2]

giant cell 446.5 specified NEC 275.49 [712.8]
necrosing or necrotizing 446.0 dermatological disorder NEC 709.9 [713.3]
temporal 446.5
gastrointestinal condition NEC 569.9 [713.1]

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Reiter’s disease 099.3 [711.1] Arthropathy – see also Arthritis 716.9_

sarcoidosis 135 [713.7]
viral disease NEC 079.99 [711.5] NOTE: Use the following fifth-digit subclassification
with categories 711-712, 716:
gonococcal 098.50
gouty 274.00 0 site unspecified
1 shoulder region
acute 274.01
2 upper arm
hypertrophic (see also Osteoarthrosis) 715.9_
3 forearm
spine 721.90 4 hand
with myelopathy 721.91 5 pelvic region and thigh
idiopathic, blennorrheal 099.3
inflammatory NEC 714.9
juvenile rheumatoid (chronic) (polyarticular)
Behçet’s 136.1 [711.2]
714.30
crystal (-induced) – see Arthritis, due to crystals
acute 714.31
gouty 274.00
monoarticular 714.33
postrheumatic, chronic (Jaccoud’s) 714.4
pauciarticular 714.32
Arteriosclerosis, arteriosclerotic (artery) (deformans)
lumbar (see also Spondylosis, lumbar) 721.3 (diffuse) (disease) (endarteritis) (general) (obliterans)
postrheumatic, chronic (Jaccoud’s) 714.4 (obliterative) (occlusive) (senile) (with calcification) 440.9
psoriatic 696.0 coronary (artery) 414.00
primary progressive 714.0 Atherosclerosis – see Arteriosclerosis
spine 720.9 Autoimmune
rheumatic 714.0 disease NEC 279.49
acute or subacute – see Fever, rheumatic Backache (postural) 724.5
chronic 714.0 Baker’s
spine 720.9 cyst (knee) 727.51
rheumatoid (nodular) 714.0 Behçet’s syndrome 136.1
with Bronchitis (diffuse) (hypostatic) (infectious)
splenoadenomegaly and leukopenia (inflammatory) (simple) 490
714.1 acute or subacute 466.0
visceral or systemic involvement 714.2 chronic 491.9
juvenile (chronic) (polyarticular) Bursitis NEC 727.3
714.30 ankle 726.79
acute 714.31 elbow 726.33
monoarticular 714.33 finger 726.8
pauciarticular 714.32 foot 726.79
septic 711.0_ hand 726.4

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hip 726.5 Cyst (mucus) (retention) (serous) (simple)

knee 726.60 Baker’s (knee) 727.51
olecranon 726.33 Cystitis (bacillary) (colli) (diffuse) (exudative)
pes anserinus 726.61 (hemorrhagic) (purulent) (recurrent) (septic)
prepatellar 726.65 (suppurative) (ulcerative) 595.9
shoulder 726.10 acute 595.0
trochanteric area 726.5 Degeneration, degenerative
wrist 726.4 articular cartilage NEC (see also Disorder,
Capsulitis (joint) 726.90 cartilage, articular) 718.0_
adhesive (shoulder) 726.0 elbow 718.02
Carpal tunnel syndrome 354.0 knee 717.5
Cervicalgia 723.1 patella 717.7
Chest – see condition shoulder 718.01
Chondrocalcinosis (articular) (crystal deposition) spine (see also Spondylosis) 721.90
(dihydrate) – (see also Arthritis, due to, crystals) intervertebral disc 722.6
275.49 [712.3] with myelopathy 722.70
due to cervical, cervicothoracic 722.4
calcium pyrophosphate 275.49 [712.2] with myleopathy 722.71
dicalcium phosphate crystals 275.49 [712.1] lumbar, lumbrosacral 722.52
pyrophosphate crystals 275.49 [712.2] with myelopathy 722.73
Chondromalacia 733.92 thoracic, thoracolumbar 722.51
patella, patellae 717.7 with myelopathy 722.72
Colitis (acute) (catarrhal) (croupous) (ccystica de Quervain’s disease (tendon sheath) 727.04
superficialis) (exudative) (hemorrhagic) (noninfectious) syndrome 259.51
(phlegmonous) (presumed noninfectious) 558.9 Derangement
ulcerative (chronic) (idiopathic) (nonspecific) 556.9 ankle (internal) 718.97
Constipation 564.00 cartilage (articular) NEC (see also Disorder
Contusion (skin surface intact) 924.9 cartilage, articular) 718.0
with knee 717.9
ankle 924.21 recurrent 718.36
back 922.31 elbow (internal) 718.92
buttock 922.32 hip (joint) (internal) (old) 718.95
foot (with ankle) (excluding toe(s)) 924.20 current injury (see also Dislocation, hip) 835.00
hip 924.01 recurrent 718.35
with thigh 924.00 joint (internal) 718.90
knee 924.11 ankle 718.97
leg 924.5 elbow 718.92
lower (with knee) 924.10 foot 718.97
Cramp(s) hand 718.94
muscle (extremity) (general) 729.82 hip 718.95

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knee 717.9 Diarrhea, diarrheal (acute) (autumn) (bilious) (bloody)

multiple sites 718.99 (catarrhal) (choleraic) (chronic) (gravis) (green) (infantile)
pelvic region 718.95 (lienteric) (noninfectious) (presumed noninfectious)
recurrent 718.30 (putrefactive) (secondary) (sporadic) (summer)
ankle 718.37 (symptomatic) (thermic) 787.91
elbow 718.32 Disease, diseased – see also Syndrome
foot 718.37 autoimmune NEC 279.49
hand 718.34 cerebrovascular NEC 437.9
hip 718.35
connective tissue, diffuse (see also Disease,
knee 718.36
collagen) 710.9
multiple sites 718.39
de Quervain’s (tendon sheath) 727.04
pelvic region 718.35
Kawasaki 446.1
shoulder region 718.31
kidney (functional) (pelvis) (see also Disease,
specified site NEC 718.38
wrist 718.33 renal) 593.9
shoulder region 718.91 chronic 585.9
specified site NEC 718.98 Lyme 088.81
wrist 718.93 pulmonary – see also Disease, lung
k nee (cartilage) (internal) 717.9 obstructive diffuse (chronic) 496
Dermatomyositis (acute) (chronic) 710.3 Reiter’s 099.3
Diabetes, diabetic (brittle) (congenital) (familial)
Use additional code for associated:
(mellitus) (severe) (slight) (without complication) 250.0_
arthropathy (711.1)
renal (functional) (pelvis) (see also Disease,
kidney) 593.9

NOTE: Use the following fifth-digit subclassification end-stage 585.6

with category 250: Still’s (juvenile rheumatoid arthritis) 714.30
0 type II or unspecified type, not stated as Takayasu’s (pulseless) 446.7
uncontrolled Tietze’s 733.6
Fifth-digit 0 is for use for type II patients, Disorder – see also Disease
even if the patient requires insulin
bone NEC 733.90
1 type I [juvenile type], not stated as
specified NEC 733.99
uncontrolled
2 type II or unspecified type, uncontrolled bursa 727.9
Fifth-digit 2 is for use for type II patients, shoulder region 726.10
even if the patient requires insulin cartilage NEC 733.90
3 type I [juvenile type], uncontrolled ankle 718.07
elbow 718.02
foot 718.07
hand 718.04

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hip 718.05 Dystrophy, dystrophia 783.9

knee 717.9 sympathetic (posttraumatic) (reflex) 337.20
multiple sites 718.09 lower limb 337.22
pelvic region 718.05 specific site NEC 337.29
shoulder region 718.01 upper limb 337.21
specified Edema, edematous
site NEC 718.08 connective tissue 782.3
type NEC 733.99 joint (see also Effusion, joint) 719.0_
wrist 718.03 legs 782.3
immune mechanism (immunity) 279.9 lower extremities – see Edema, legs
single component (C11-C99) 279.8 Effect, adverse
specified type NEC 279.8 drugs and medicinal 995.20
metabolism NEC 277.9 Effusion
with joint 719.00
calcium 275.40 Enteritis
plasma protein 273.9 regional (of) 555.9
specified type NEC 273.8 Epicondylitis (elbow) (lateral) 726.32
Displacement, displaced medial 726.31
Erythema, erythematosus (generalized)
NOTE: For acquired displacement of bones, nodosum 695.2
cartilage, joints, tendons, due to injury, see also
Failure, failed
Dislocation.
heart (acute) (sudden) 428.9
Displacements at ages under one year should congestive (compensated) (decompensated)
be considered congenital, provided there is no (see also Failure, heart) 428.0
indication the condition was acquired after birth.
Fasciitis 729.4
plantar 728.71
intervertebral disc (with neuritis, radiculitis, Fatigue 780.79
sciatica, or other pain) 722.2 Fever 780.60
cervical, cervicodorsal, cervicothoracic 722.0 Fatigue 780.79
lumbar, lumbosacral 722.10 chronic, syndrome 780.71
with myleopathy 722.73 Fibrillation
thoracic, thoracolumbar 722.11 atrial (established) (paroxysmal) 427.31
Dizziness 780.4 Fibromyalgia 729.1
Dyspepsia (allergic) (congenital) (fermentative) Fibrositis (periarticular) (rheumatoid) 729.0
(flatulent) (functional) (gastric) (gastrointestinal) Findings, (abnormal), without diagnosis (examination)
(neurogenic) (occupational) (reflex) 536.8 (laboratory tests) 796.4
antibody titers, elevated 795.79
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antigen-antibody reaction 795.79 acute 535.0

C-reactive protein (CRP) 790.95 Gastroenteritis (acute) (catarrhal) (congestive)
crystals, urine 791.9 (hemorrhagic) (noninfectious) (see also Enteritis) 558.9
sedimentation rate, elevated 790.1 Giddiness 780.4

skin test, positive 795.79 Gout, gouty 274.9

Fracture (abduction) (adduction) (avulsion) arthritis 274.00

(compression) (crush) (dislocation) (oblique) (separation) acute 274.01
(closed) 829.0 arthropathy 274.00
acute 274.01
NOTE: For fracture of any of the following sites with chronic (without mention of tophus (tophi)) 274.02
fracture of other bones- see Fracture, multiple. with tophus (tophi) 274.03
“Closed” includes the following descriptions of tophi 274.03
fractures, with or without delayed healing, unless ear 274.81
they are specified as open or compound:
specified site NEC 274.82
comminuted linear Granulomatosis NEC 686.1
depressed simple
Wegener’s (necrotizing respiratory) 446.4
elevated slipped epiphysis
fissured spiral Headache 784.0
greenstick unspecified Hernia, hernial
esophageal hiatus (sliding) 553.3
Hypercholesterolemia
pure 272.0
pathologic (unknown) 733.10
Hypertension, hypertensive
ankle 733.16
unspecified 401.9
femur (neck) 733.14
Hypertrophy, hypertrophic
specified NEC 733.15
bone 733.99
fibula 733.16
prostate, benign 600.00
hip 733.14
Hyponatremia 276.1
humerus 733.11 Hypopotassemia 276.8
radius (distal) 733.12 Hypothyroidism (acquired) 244.9
specified site NEC 733.19 Infection, infected, infective
tibia 733.16 respiratory 519.8
ulna 733.12 upper (acute) (infectious) NEC 465.9
wrist 733.12 urinary (tract) NEC 599.0
Gastritis 535.5_ Insufficiency, insufficient

NOTE: Use the following fifth-digit subclassification for venous (peripheral) 459.81
category 535: Keratoconjunctivitis – (see also Keratitis ) 370.40
0 without mention of hemorrhage sicca (Sjögren’s syndrome) 710.2
1 with hemorrhage
not in Sjögren’s syndrome 370.33

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Kidney – see condition Nephritis, nephritic (albuminuric) (azotemic) (congenital)

Lupus 710.0 (degenerative) (diffuse) (disseminated) (epithelial)
discoid (local) 695.4 (familial) (focal) (granulomatous) (hemorrhagic)

erythematodes (discoid) (local) 695.4 (infantile) (nonsuppurative, excretory) (uremic) 583.9

erythematosus (discoid) (local) 695.4 lupus 710.0 [583.81]

disseminated 710.0 acute 710.0 [580.81]

systemic 710.0 chronic 710.0 [582.81]

nephritis 710.0 [583.81] Neuropathy, neuropathic- (see also Disorder, nerve)

355.9
acute 710.0 [580.81]
hereditary 356.9
chronic 710.0 [582.81]
peripheral 356.0
Malaise 780.79
Osteoathritis – (see also Osteoarthrosis) 715.9_
Melena 578.1
Osteoarthopathy (see also Osteoarthorosis) 715.9_
Metatarsalgia 726.70
chronic idiopathic hypertrophic 757.39
Monoarthritis 716.60
familial idiopathic 757.39
ankle 716.67
hypertrophic pulmonary 731.2
arm 716.62
secondary 731.2
lower (and wrist) 716.63
idiopathic hypertrophic 757.39
upper (and elbow) 716.62
primary hypertrophic 731.2
foot (and ankle) 716.67
pulmonary hypertrophic 731.2
forearm (and wrist) 716.63
secondary hypertrophic 731.2
hand 716.64
Osteoarthrosis (degenerative) (hypertrophic)
leg 716.66
(rheumatoid) 715.9_
lower 716.66
upper 716.65
pelvic region (hip) (thigh) 716.65 NOTE: Use the following fifth-digit subclassification
shoulder (region) 716.61 with categories 715:
specified site NEC 716.68 0 site unspecified
Myalgia (intercostals) 729.1 1 shoulder region
2 upper arm
Myositis 729.1
3 forearm
rheumatic 729.1 4 hand
rheumatoid 729.1 5 pelvic region and thigh
traumatic (old) 729.1 6 lower leg
7 ankle and foot
Nausea – (see also Vomiting) 787.02
8 other specified sites except spine
with vomiting 787.01 9 multiple sites

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generalized 715.0 [0,4,9] Berger’s (paresthesia of lower limb) 782.0

localized 715.3_ Parkinsonism (arteriosclerotic) (idiopathic) (primary)
idiopathic 715.1_ 332.0
primary 715.1_ Periarthritis (joint) 726.90
secondary 715.2_ shoulder 726.2
multiple sites, (not generalized) 715.89 wrist 726.4
polyarticular 715.09 Pharyngitis (acute) (catarrhal) (gangrenous) (infective)
spine (see also Spondylosis) 721.90 (malignant) (membranous) (phlegmonous) (pneumococcal)
temporomandibular joint 524.6 (pseudomembranous) (simple) (staphylococcal)
(subacute) (suppurative) (ulcerative) (viral) 462
Osteomyelitis (general) (infective) (localized) (neonatal)
(purulent) (pyogenic) (septic) (staphylococcal) Polyarteritis (nodosa) (renal) 446.0
(streptococcal) (suppurative) (with periostitis) 730.2_ Polyarthralgia 719.49
sicca 730.1_ psychogenic 306.0
Osteoporosis (generalized) 733.00 Polyarthritis, polyarthropathy NEC 716.59
Overload inflammatory 714.9
fluid 276.6 Polychondritis (atrophic) (chronic) (relapsing) 733.99
Pain(s) – (see also Painful) 780.96 Polymyalgia 725
abdominal 789.0 rheumatica 725
chest (central) 786.50 Polymyositis (acute) (chronic)
hand 729.5 (hemorrahagic)710.4
joint 719.40 with involvement of
ankle 719.47 lung 710.4 [517.8]
elbow 719.42 skin 710.3
foot 719.47 Proteinuria – (see also Albuminuria) 791.0
hand 719.44 Purpura
hip 719.45 Schönlein (-Henoch) (allergic) 287.0
knee 719.46 thrombocytopenic thrombotic 446.6
multiple sites 719.49 Radiculitis (pressure) (vertebrogenic) 729.2
pelvic region 719.45 cervical NEC 723.4
shoulder (region) 719.41 leg 724.4
specified site NEC 719.48 lumbar NEC 724.4
wrist 719.43 lumbosacral 724.2
limb 729.5 rheumatic 729.2
Palindromic, arthritis – (see also Rheumatism, thoracic (with visceral pain) 724.4
palindromic) 719.3_ Radiculopathy – (see also Radiculitis) 729.2
Palpitation (heart) 785.1 Raynaud’s
Paresthesia – (see also Disturbance, sensation) disease or syndrome (paroxysmal digital cyanosis)
782.0 443.0
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Retention, retained circumscribed 701.0

fluid 276.6 linear 701.0
Rheumatism, rheumatic (acute NEC) 729.0 localized (linear) 701.0
adherent pericardium 393 newborn 778.1
arthritis Sclerosis, sclerotic
acute or subacute – see Fever, rheumatic systemic (progressive) 710.1
chronic 714.0 Scoliosis (acquired) (postural) 737.30
spine 720.0 due to or associated with
articular (chronic) NEC (see also Arthritis) osteoporosis (see also Osteoporosis)
716.9_ 733.00[737.43]
acute or subacute – see Fever, rheumatic Spondylitis 720.9
back 724.9 ankylosing (chronic) 720.0
blennorrhagic 098.59 Spondylolisthesis (congenital) (lumbosacral) 756.12
carditis – see Disease, heart, rheumatic acquired 738.4
cerebral – see Fever, rheumatic degenerative 738.4
chorea (acute) – see Chorea, rheumatic traumatic 738.4
chronic NEC 729.0 Spondylolysis (congenital) 756.11
coronary arteritis 391.9 acquired 738.4
chronic 398.99 cervical 756.19
degeneration, myocardium (see also lumbosacral region 756.11
Degeneration, myocardium with Spondylopathy
rheumatic fever) 398.0 inflammatory 720.9
desert 114.0 Spondylosis 721.90
gonococcal 098.59 with
gout 274.00 myleopathy NEC 721.91
inflammatory (acute) (chronic) (subacute) see cervical, cervicodorsal 721.0
Fever, rheumatic with myleopathy 721.1
joint (chronic) NEC (see also Arthritis) inflammatory 720.9
716.9_ lumbar, lumbosacral 721.3
Rheumatoid – see also condition with myleopathy 721.42
lung 714.81 thoracic 721.2
Sarcoidosis 135 with myleopathy 721.41
Sciatica (inflectional) 724.3 tramautic 721.7
due to Sprain, strain (joint) (ligament) (muscle) (tendon) 848.9
displacement of intervertebral disc 722.10 ankle 845.00
Scleroderma, sclerodermia (acrosclerotic) (diffuse) and foot 845.00
(generalized) (progressive) (pulmonary) 710.1 elbow 841.9

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foot 845.10 Syndrome – see also Disease

hand 842.10 carpal tunnel 354.0
hip 843.9 de Quervain’s 259.51
and thigh 843.9 eosinophilia myalgia 710.5
knee 844.9 fatigue NEC 300.5
and leg 844.9 chronic 780.71
old 717.5 Felty’s (rheumatoid arthritis with
leg 844.9 splenomeagly and leukopenia) 714.1
and knee 844.9 Goodpasture’s (pneumorenal) 446.21
low back 846.9 irritable bowel 564.1
lumbosacral 846.0 nephrotic (see also Nephrosis) 581.9
chronic or old 724.6 diabetic 250.4_ [581.81]
Stenosis (cicatricial) – see also Stricture Raynaud’s (paroxysmal digital cyanosis) 443.0
spinal 724.00 restless leg (RLS) 333.94
cervical 723.0 sicca (keratoconjunctivitis) 710.2
lumbar region, without neurogenic claudication Sjögren (-Gougerot) (keratoconjunctivitis
724.02 sicca) 710.2
Lumbar region NOS with lung involvement 710.2 [517.8]
lumbar region, with neurogenic claudication thoracic outlet (compression) 353.0
724.03 System, systemic – see also condition disease,
specified region NEC 724.09 combined – see Degeneration, combined

thoracic, thoracolumbar 724.01 lupus erythematosus 710.0

Swelling 782.3 Takayasu (-Onishi) disease or syndrome (pulseless

ankle 719.07 disease) 446.7

arm 729.81 Tendinitis, tendonitis – (see also Tenosynovitis) 726.90

extremity (lower) (upper) 729.81 calcific 727.82

finger 729.81 shoulder 726.11

foot 729.81 pes anserinus 726.61

hand 729.81 trochanteric 726.5

joint (see also Effusion, joint) 719.0 Tenosynovitis (see also Synovitis) 727.00
leg 729.81 bicipital (calcifying) 726.12
limb 729.81 Thrombosis, thrombotic (marantic) (multiple)
muscle (limb) 729.81 (progressive) (vein) (vessel) 453.9

neck 784.2
pelvis 789.3_
toe 729.81

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Tietze’s disease or syndrome 733.6

Trigger finger (acquired) 727.03
congential 756.89
Ulcer, ulcerated, ulcerating, ulceration, ulcerative
707.9
peptic (site unspecified) 533.9

NOTE: Use the following fifth-digit subclassification with categories 531 – 534:

0 without mention of obstruction

1 with obstruction

Vasculitis 447.6
Weight
gain (abnormal) (excessive) 783.1
loss (cause unknown) 783.21

(a) ICD-9-CM codes must be listed in priority order. Narrative

descriptions of diagnoses will not suffice.

(b) ICD-9-CM codes must be recorded at the highest level of

specialty.

(c) Nonspecific codes may be appropriate for an initial visit for

a problem but greater specificity, if known should be coded.
Try to minimize use of .8 or .9 unless additional information
is not available.

(d) An underline (__) indicates the diagnosis requires a

fifth digit which should be identified to indicate site of
involvement.

(e) “And” indicates that an additional code is required for the

diagnosis.

(f) For diagnoses not listed, refer to ICD-9-CM, Ninth Revision,

Vols. 1 and 2.

(g) BOLD and Italic represents new and revised ICD-9-CM

codes.

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HCPCS Codes for Rheumatology

A list has been compiled of the most common ICD-9 and HCPCS codes. Please take the time to review this list it can
be a quick reference guide to assist in coding claims correctly. All new CPT®/HCPCS are effective. Please be certain
you are using the most updated information. All deleted codes should be discontinued.

J0129 Injection, abatacept, 10mg - *96413

J0718 Injection, certolizumab pegol, 1 mg - *96372

J1020 Depomedral, injection, methylprednisolone acetate, 20mg - *96372, 96373

J1030 Depomedral, injection, methylprednisolone acetate, 40mg- *96372, 96373

J1040 Depomedral, injection, methylprednisolone acetate, 80mg - *96372, 96373

J1200 Diphenhydramine (Benadryl), injection, up to 50mg - *96372, 96373

J1740 ibandronate sodium (IV Boniva), 1mg - *96374, 96375

J1745 Infliximab (Remicade), injection, 10mg - *96413, 96415

J3488 Injection, zoledronic acid (Reclast), 1mg - *96365

J2430 Pamidronate disodium (Aredia), 30mg - *96365, 96366

J2920 Methylprednisolone (Solu-Medral) - *96374, 96375

J2930 Methylprednisolone (Solu-Medral) -*96374, 96375

J7030 Normal saline solution infuse, 1000cc - *96360, 96361

J7040 Normal saline solution infuse, 500mL - *96360, 96361

J7042 5% dextrose/normal saline, 500mL - *96360, 96361

J7050 Normal saline solution infuse, 250cc - *96360, 96361

J7051 Sterile saline/water, 5cc - *96360, 96361

J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose - *20610

J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose - *20610

J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose - *20610

J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, per dose - *20610

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J9070 Cyclophosphamide, 100mg - *96413, 96415

J9080 Cyclophosphamide, 200mg - *96413, 96415

J9090 Cyclophosphamide, 500mg - *96413, 96415

J9091 Cyclophosphamide, 1g -*96413, 96415

J9092 Cyclophosphamide, 2g - *96413, 96415

J9093 Cyclophosphamide, lyophilized, 100mg -*96413, 96415

J9094 Cyclophosphamide, lyophilized, 200mg - *96413, 96415

J9250 Methotrexate sodium injection, 5mg - *96041

J9260 Methotrexate sodium injection, 50mg - *96401

J9310 Injection, rituximab (RituXan), 100mt - *96413

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Chapter Eight

Resource-Based Relative Value Scale

In 1992, the Resource-Based Relative Value Scale was put into place. This system is a way to compare the relative
work of a large number of medical episodes to one another. The RBRVS is the payment scale used by Medicare.
And by using the formula below, a physician can determine how much Medicare will reimburse for a physician
services.

The American Medical Associates created the Relative Value Update Committee. The RUC is compiled of 26 voting
specialties that are in charge of processing the value of 7,000+ CPT® codes, along with assigning value to new
codes. This is done by assigning a relative value unit on each code.

The Medicare payment schedule’s impact on a physician’s Medicare payments is primarily a function of three key
factors:

• The resource-based relative value scale

– This is where physicians can find their states RVU – they are in three parts:
1. Work
2. Physician expense
3. Malpractice expense
– M
 embers can find their states RVU on our website at www.rheumatology.org/practice.

• The geographic practice cost indexes – they are in three parts:

1. Work
2. Physician expense
3. Malpractice expense
– Members can find their states GPCI at www.rheumatology.org/practice.

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• The monetary conversion factor - the formula for calculating Medicare payments is:
Non-Facility Pricing Amount =
[(Work RVU x Work GPCI) + (Transitioned Non-Facility PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x Conversion
Factor

Facility Pricing Amount =

[(Work RVU x Work GPCI) + (Facility PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x Conversion Factor

Conversion Factor for 2010 = $36.0846

Example: 99214 for Alabama for non-facility

1.50 x 0.982 = 1.473

1.15 x 0.853 = 0.98095
0.08 x 0.496 = 0.03968

1.473 + 0.98095 + 0.03968 = 2.49363 x $36.0846 = $89.98

Average Sales Price

The Average Sales Price is the manufacturer’s reporting of the country’s average sale prices on drugs. The ASP
data is reported quarterly. Medicare ASP fee schedule is the average sale price plus six percent. A list of drugs
most commonly used by rheumatologists is available at www.rheumatology.org/practice.

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Chapter Nine

Physician Quality Reporting Initiative

The 2006 Tax Relief and Health Care ACR (P.L. 109-432) requires the founding of a physician quality reporting
system. This program includes an incentive payment for eligible professional who suitably report data on quality
measures for covered professional services performed on Medicare indemnity beneficiaries.

Starting January 1 of every year physicians can start reporting PQRI measures. There are a total of 175 PQRI
measures, 20 measures of which affect rheumatology practices. The incentive bonus pay for successfully reporting
will be two percent of the allowable Medicare Part B Fee for Service with no cap.

As stated before there are a total of 20 PQRI measures that affect rheumatology:

• 24 – (OP): Communication with the Physician Managing Ongoing Care Post Fracture

• 39 – (OP): Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older

• 40 – (OP): Osteoporosis: Management Following Fracture

• 41 – (OP): Pharmacologic Therapy

• 1
 08 – Rheumatoid Arthritis (RA): Disease Modifying Anti-rheumatic Drug Therapy in Rheumatoid Arthritis

• 109 – Osteoarthritis (OA): Function and Pain Assessment

• 124 – Health Information Technology (HIT): Adoption/Use of Electronic Health Information (EHR)

• 131 – Pain Assessment Prior to Initiation of Patient Therapy and Follow-up

• 1
 42 – Osteoarthritis (OA): Assessment for Use of Anti-inflammatory or Analgesic Over-the Counter (OTC)
Medications

• 148 – Back Pain: Initial Visit

• 149 – Back Pain: Physical Exam

• 150 – Back Pain: Advice for Normal Activities

• 151 – Back Pain: Advice Against Bed Rest

• 154 – Falls: Risk Assessment

• 155 – Falls: Plan of Care

• 176 – Rheumatoid Arthritis (RA): Tuberculosis Screening

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• 177 – Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

• 178 – Rheumatoid Arthritis (RA): Functional Status Assessment

• 179 – Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

• 180 - Rheumatoid Arthritis (RA): Glucocorticoid Management

Currently there are two options of reporting PQRI: registry or claims-based. The registry-based reporting registration
can be found at www.rheumatology.org/practice. Claims-based reporting can be either individual measures or for
measures groups.

Individual Measures Reporting Options

Registry-Based – Rheumatology Clinical Registry: (Options for Mid-Year PQRI Start)

• S
 uccessfully report three or more measures for a minimum of 80 percent of applicable Medicare Part B FFS
patients between January 1 - December 31

- or -

• S
 uccessfully report three or more measures for a minimum of 80 percent of applicable Medicare Part B FFS
patients between July 1 - December 31

Claims-Based: (January 1 Start Date)

• S
 uccessfully report three or more measures for a minimum of 80 percent of applicable Medicare Part B FFS
patients between July 1 - December 31

Measures Group Reporting Options (Including RA)

The Measures Group-based measure that would affect rheumatologists is the Rheumatoid Arthritis Measure Group
and the Back Pain Measure Group. The RA Measure Group includes six measures:

• 108 – Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy

• 176 – Tuberculosis Screening

• 177 – Periodic Assessment of Disease Activity

• 178 – Functional Status Assessment

• 179 – Assessment and Classification of Disease Prognosis

• 180 – Glucocorticoid Management

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The Back Pain Measure Group is the only measure group that has measures that cannot be reported as individual
measures. The Back Pain Measure Group contains four measures:

• 148 – Back Pain: Initial Visit

• 149 – Back Pain: Physical Exam

• 150 - Back Pain: Advice for Normal Activities

• 151 – Back Pain: Advice Against Bed Rest

Registry-Based – Rheumatology Clinical Registry: (Options for Mid-Year PQRI Start)

• S
 uccessfully report on a minimum of 30 patients in the group between January 1 - December 31 (Medicare and
non-Medicare patients allowed; must have at least two Medicare patients)

OR choose one of the following two options:

• S
 uccessfully report on a minimum of 80 percent of patients in the group with a minimum of 30 patients
January 1 - December 31 (Medicare patients only)

- or -

• S
 uccessfully report on a minimum of 80 percent of patients in the group with a minimum of 15 patients
between July 1 - December 31 (Medicare patients only)

NOTE: For reporting options that include a minimum 80 percent requirement, this means that providers must
report successfully for at least 80 percent of their patients to which the measure applies in the given time period.
Providers who choose to report on only 80 percent of their patient population for a certain measure must,
therefore, report with complete accuracy. Because this would allow no room for error without losing the entire
incentive payment, CMS recommends that providers report on more than 80 percent of their patient population
for each measure, whenever possible, even up to 100 percent.

Claims-based: (January 1 start date)

• S
 uccessfully report on a minimum of 30 consecutive patients in the group between January 1 - December 31
(Medicare patients only)

- or -

• S
 uccessfully report on a minimum of 80 percent of patients in the group with a minimum 30 patients between
January 1 - December 31 (Medicare patients only)

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Claims-based: (July 1 start date)

• S
 uccessfully report on a minimum of 80 percent of patients in the group with a minimum 15 patients between
July 1 - December 31 (Medicare patients only)

NOTE: The following option is still available for mid-year start: Successfully report on a minimum of 30
consecutive patients in the group whose visits took place at any time in the calendar year (Medicare patients
only).

Exclusions
Exclusion modifiers may be appended to a CPT® II code (on a claim) OR within a registry to indicate that an
action specified in the measure was not provided due to medical, patient, or system reason(s) documented in the
medical record. These modifiers serve as denominator exclusions for the purpose of measuring performance. Some
measures do not provide for performance exclusions.

Reasons for appending a performance measure exclusion modifier fall into one of four categories:

1P exclusion modifier due to medical reasons

Examples include: not indicated (absence of organ/limb, already received/performed); contraindicated

(patient allergic history, potential adverse drug interaction)

2P exclusion modifier due to patient reasons

Examples include: patient declined; economic, social, or religious reasons

3P exclusion modifier due to system reasons

Examples include: resources to perform the services not available; insurance or coverage/payer-related
limitations; other reasons attributable to health care delivery system

8P reporting modifier - action not performed, reason not otherwise specified

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Chapter Ten

Sample Letters
The ACR has written many letters over the years to aid practices with insurance appeals and denials. The letters can
be located on the ACR website at www.rheumatology.org/practice.

List of sample letters include:

– Medical necessity for infliximab

– Modifier- 25 denial
– MRI letter
– Frequent documentation requests
– Frequent medical records request
– Denial of biologics
– E/M level 4 letter
– Lab Panels
– Infusion denials
– VFA
– Peer-review for rituximab
– Infliximab used for AS
– Restriction of performing DEXA
– Anti-CCP
– Bundling drugs in with procedure
– Denial of ibandronate
– Allowable for infliximab after failed treatment
– Denial of TB test

Sample Forms
Over the years our members have used forms for their practice that aid them in performing their day-to-day duties in
their office. Some of our members have been gracious enough to share forms for your use. The forms are available
online at www.rheumatology.org/pratice.

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 Appendix A
Sample Advance Notice to Beneficiary (General and Laboratory Use)

(A) Notifier(s):
(B) Patient Name: (C) Identification Number:

ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)

NOTE: If Medicare doesn’t pay for (D)_____________ below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have
good reason to think you need. We expect Medicare may not pay for the (D)_____________ below.
(D) (E) Reason Medicare May Not Pay: (F) Estimated
Cost:

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
• Choose an option below about whether to receive the (D)_____________listed above.
Note: If you choose Option 1 or 2, we may help you to use any other
insurance that you might have, but Medicare cannot require us to do this.
(G) OPTIONS: Check only one box. We cannot choose a box for you.

❏ OPTION 1. I want the (D)__________ listed above. You may ask to be paid now, but I
also want Medicare billed for an official decision on payment, which is sent to me on a Medicare
Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for
payment, but I can appeal to Medicare by following the directions on the MSN If Medicare
does pay, you will refund any payments I made to you, less co-pays or deductibles.
❏ OPTION 2. I want the (D)__________ listed above, but do not bill Medicare. You may
ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
❏ OPTION 3. I don’t want the (D)__________listed above. I understand with this choice
I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
(H) Additional Information:

This notice gives our opinion, not an official Medicare decision If you have other questions
on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You also receive a copy.
(I) Signature: (J) Date:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to
average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131 (03/08) Form Approved OMB No. 0938-0566

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 ACR Rheumatology Coding Manual

Appendix B
Medicare Part B Carriers
ALABAMA CALIFORNIA

Cahaba Government Benefits Administrators (GBA) Palmetto GBA

PO Box 13384 PO Box 1476 Medical Review Part B

Birmingham, AL 35205-3384 Augusta, GA 30903-1476
Phone: 205-220-1214 Phone: 310-476-5760
Fax: 205-220-1218 Fax: 803-462-3918
www.cahabagba.com www.palmettogba.com

ALASKA COLORADO

Noridian Administrative Services, LLC Trailblazer Health Enterprises, Inc.

7525 NE Ambassador Place, Ste B 8330 LBJ Freeway, Exec Center III

Portland, OR 97220 Dallas, TX 75243-1213

Phone: 503-944-8810 Phone: 469-372-6074
Fax: 503-944-8814 Fax: 469-372-2649
www.noridianmedicare.com www.trailblazerhealth.com

ARIZONA CONNECTICUT

Noridian Administrative Services, LLC National Government Services, Inc.

8920 N 23rd Ave, Ste #1 P.O. Box 4767

Phoenix, AZ 85021 Syracuse, NY 13221-4767
Phone: 602-749-2506 Phone: 914-801-3567
Fax: 602-749-2550 Fax: 914-801-3600
www.noridianmedicare.com www.ngsmedicare.com

ARKANSAS DELAWARE

Pinnacle Business Solutions, Inc. Highmark Medicare Services

515 West Pershing Blvd 120 Fifth Avenue, Ste P5101

North Little Rock, AR 72114 Pittsburgh, PA 15222-3099
Phone: 501-210-0703 Phone: 412-544-1931
Fax: 501-210-0756 Fax: 412-544-1971
www.pinnaclemedicare.com www.highmarkmedicareservices.com

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DISTRICT OF COLUMBIA IDAHO

Highmark Medicare Services CIGNA Government Services

120 Fifth Avenue, Ste P5101 Two Vantage Way RTG 576
Pittsburgh, PA 15222-3099 Nashville, TN 37228
Phone: 412-544-1931 Phone: 615-782-4565
Fax: 412-544-1971 Fax: 615-782-4480
www.highmarkmedicareservices.com www.cignagovernmentservices.com

FLORIDA ILLINOIS

First Coast Service Options, Inc. Wisconsin Physician Services Corp

532 Riverside Avenue 20T 111 East Wacker Drive, Ste. 950
Jacksonville, FL 32202 Chicago, IL 60601
Phone: 904-791-8211 Phone: 312-228-6254
Fax: 904-361-0327 Fax: 312-228-6280
www.medicare.fcso.com www.wpsic.com

GEORGIA INDIANA

Cahaba Government Benefits Administrators (GBA) National Government Services

P.O. Box 13384 8115 Knue Road, INA102-AF10

Birmingham, AL 35205-3384 Indianapolis, IN 46250
Phone: 205-220-1214 Phone: 317-841-4607
Fax: 205-220-1218 Fax: 317-841-4600
www.cahabagba.com www.ngsmedicare.com

HAWAII IOWA

Palmetto GBA Wisconsin Physician Services

PO Box 1476 Medical Review Part B 111 East Wacker Drive, Ste. 950
Augusta, GA 30903-1476 Chicago, IL 60601
Phone: 310-476-5760 Phone: 312-228-6254
Fax: 803-462-3918 Fax: 312-228-6280
www.palmettogba.com www.wpsic.com

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KANSAS MARYLAND

Wisconsin Physician Services Highmark Medicare Services

111 East Wacker Drive, Ste. 950 120 Fifth Avenue, Ste P5101
Chicago, IL 60601 Pittsburgh, PA 15222-3099
Phone: 312-228-6254 Phone: 412-544-1931
Fax: 312-228-6280 Fax: 412-544-1971
www.wpsic.com www.highmarkmedicareservices.com

KENTUCKY MASSACHUSETTS

National Government Services, Inc National Heritage Insurance Company

8115 Knue Road, INA102-AF10 75 Sgt. William B. Terry Drive

Indianapolis, IN 46250 Hingham, MA 02043
Phone: 317-841-4607 Phone: 781-741-3122
Fax: 317-841-4600 Fax: 781-741-3211
www.ngsmedicare.com www.medicarenhic.com

LOUISIANA MICHIGAN

Pinnacle Business Solutions, Inc. Wisconsin Physician Services

515 West Pershing Blvd 111 East Wacker Drive, Ste 950
North Little Rock, AR 72114 Chicago, IL 60601
Phone: 501-210-0703 Phone: 312-228-6254
Fax: 501-210-0756 Fax: 312-228-6280
www.pinnaclemedicare.com www.wpsic.com

MINNESOTA
MAINE
Wisconsin Physician Services
National Heritage Insurance Company
111 East Wacker Drive, Ste 950
75 Sgt. William B. Terry Drive
Chicago, IL 60601
Hingham, MA 02043
Phone: 312-228-6254
Phone: 781-741-3122
Fax: 312-228-6280
Fax: 781-741-3211
www.wpsic.com
www.medicarenhic.com

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MISSISSIPPI NEVADA

Cahaba Government Benefits Administrators (GBA) Palmetto GBA

PO Box 13384 PO Box 1476 Medical Review Part B

Birmingham, AL 35205-3384 Augusta, GA 30903-1476
Phone: 205-220-1214 Phone: 310-476-5760
Fax: 205-220-1218 Fax: 803-462-3918
www.cahabagba.com www.palmettogba.com

MISSOURI NEW HAMPSHIRE

Wisconsin Physician Services Highmark Medicare Services

111 East Wacker Drive, Ste. 950 120 Fifth Avenue, Ste. P5101
Chicago, IL 60601 Pittsburgh, PA 15222-3099
Phone: 312-228-6254 Phone: 412-544-1931
Fax: 312-228-6280 Fax: 412-544-1971
www.wpsic.com www.highmarkmedicareservices.com

MONTANTA NEW JERSEY

Noridian Administrative Services, LLC National Government Services

8920 N 23rd Ave, Ste #1 120 Fifth Avenue, Ste. P5101

Phoenix, AZ 85021 Pittsburgh, PA 15222-3099
Phone: 602-749-2506 Phone: 412-544-1931
Fax: 602-749-2550 Fax: 412-544-1971
www.noridianmedicare.com www.highmarkmedicareservices.com

NEBRASKA NEW MEXICO

Wisconsin Physician Services TrailBlazer Health Enterprises, LLC

111 East Wacker Drive, Ste. 950 8330 LBJ Freeway, Exec Center III
Chicago, IL 60601 Dallas, TX 75243-1213
Phone: 312-228-6254 Phone: 469-372-6074
Fax: 312-228-6280 Fax: 469-372-2649
www.wpsic.com www.trailblazerhealth.com

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NEW YORK OKLAHOMA

National Government Services, Inc. Trailblazer Health Enterprises, LLC

P.O. Box 4767 8330 LBJ Freeway, Exec Center III

Syracuse, NY 13221-4767 Dallas, TX 75243-1213
Phone: 914-801-3567 Phone: 469-372-6074
Fax: 914-801-3600 Fax: 469-372-2649
www.ngsmedicare.com www.trailblazerhealth.com

NORTH CAROLINA OREGON

CIGNA Government Services Noridian Administrative Services, LLC

4135 Mendenhall Oaks Parkway 7525 NE Ambassador Place, Ste. B

High Point, NC 27256 Portland, OR 97220
Phone: 336-821-4511 Phone: 503-944-8810
Fax: 336-821-4591 Fax: 503-944-8814
www.cignagovernmentservices.com www.noridianmedicare.com

NORTH DAKOTA PENNSYLVANIA

Noridian Administrative Services, LLC Highmark Medicare Services

8920 N 23rd Ave, Ste. #1 120 Fifth Avenue, Ste. P5101

Phoenix, AZ 85021 Pittsburgh, PA 15222-3099
Phone: 602-749-2506 Phone: 412-544-1931
Fax: 602-749-2550 Fax: 412-544-1971
www.noridianmedicare.com www.highmarkmedicareservices.com

OHIO PUERTO RICO

Palmetto GBA First Coast Service Options, Inc.

4249 Easton Way, Ste. 400 532 Riverside Avenue 20T

Columbus, OH 43219 Jacksonville, FL 32202
Phone: 614-473-6424 Phone: 904-791-8211
Fax: 614-473-6204 Fax: 904-361-0327
www.palmettogba.com www.medicare.fcso.com

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RHODE ISLAND TEXAS

National Heritage Insurance Company Trailblazer Health Enterprises, Inc.

75 Sgt. William B. Terry Drive 8330 LBJ Freeway, Exec Center III
Hingham, MA 02043 Dallas, TX 75243-1213
Phone: 781-741-3122 Phone: 469-372-6074
Fax: 781-741-3211 Fax: 469-372-2649
www.medicarenhic.com www.trailblazerhealth.com

SOUTH CAROLINA UTAH

Palmetto GBA Noridian Administrative Services, LLC

P.O. Box 100190, AG-300 8920 N 23rd Ave, Ste. #1

Columbia, SC 29202-3190 Phoenix, AZ 85021
Phone: 803-763-5059 Phone: 602-749-2506
Fax: 803-935-0199 Fax: 602-749-2550
www.palmettogba.com www.noridianmedicare.com

SOUTH DAKOTA VERMONT

Noridian Administrative Services, LLC National Heritage Insurance Company

8920 N 23rd Ave, Ste. #1 75 Sgt. William B. Terry Drive

Phoenix, AZ 85021 Hingham, MA 02043
Phone: 602-749-2506 Phone: 781-741-3122
Fax: 602-749-2550 Fax: 781-741-3211
www.noridianmedicare.com www.medicarenhic.com

TENNESSEE VIRGIN ISLANDS

Cahaba Government Benefits Administrators (GBA) First Coast Service Options, Inc.

P.O. Box 13384 532 Riverside Avenue 20T

Birmingham, AL 35205-3384 Jacksonville, FL 32202
Phone: 205-220-1214 Phone: 904-791-8211
Fax: 205-220-1218 Fax: 904-361-0327
www.cahabagba.com www.medicare.fcso.com

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VIRGINIA WISCONSIN

TrailBlazer Health Enterprises, LLC Wisconsin Physician Services

8330 LBJ Freeway, Executive Center III 111 East Wacker Drive, Ste. 950
Dallas, TX 75243-1213 Chicago, IL 60601
Phone: 469-372-0992 Phone: 312-228-6254
Fax: 469-372-2649 Fax: 312-228-6280
www.trailblazerhealth.com www.wpsic.com

WASHINGTON WYOMING

Noridian Administrative Services, LLC Noridian Administrative Services, LLC

7525 NE Ambassador Place, Ste. B 8920 N 23rd Ave, Ste. #1

Portland, OR 97220 Phoenix, AZ 85021
Phone: 503-944-8810 Phone: 602-749-2506
Fax: 503-944-8814 Fax: 602-749-2550
www.noridianmedicare.com www.noridianmedicare.com

WEST VIRGINIA

Palmetto GBA

4249 Easter Way

Columbus, OH 43219
www.palmettogba.com

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 ACR Rheumatology Coding Manual

Appendix C

Centers for Medicare and Medicaid Services Regional Offices

If you have difficulties with the Medicare carrier which seems unresolvable through direct communication with the
carrier and/or through interaction between the Committee on Rheumatologic Care or a medical society liaison,
you may want to report your concerns to the appropriate regional office of the Centers for Medicare and Medicaid
Services. The addresses of the 10 CMS regional offices across the country are listed below.

Region I – Boston
(Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont)

Associate Regional Administrator

CMS
Program Operations
John F. Kennedy Federal Building
Room 2325
Boston, MA 02203
617-565-1282

Region II – New York

(New Jersey, New York, Puerto Rico, US Virgin Islands)

Association Regional Administrator

CMS
Program Operations
Jacob K. Javits Federal Building
26 Federal Plaza, 38th Floor
New York, NY 10278
212-616-2519

Region III – Philadelphia

(Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia)

Associate Regional Administrator

CMS
Public Ledger Building, Suite 216
150 S. Independence Mall West
Philadelphia, PA 19106
215-861-4097

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Region IV – Atlanta
(Alabama, North Carolina, South Carolina, Florida, Georgia, Kentucky, Mississippi, Tennessee)

Associate Regional Administrator

CMS
Program Operations
Atlanta Federal Center
61 Forsyth Street, SW, Suite 4T20
Atlanta, GA 30303
404-562-7379

Region V – Chicago
(Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin)

Associate Regional Administrator

CMS
Program Operations
233 North Michigan Avenue, Suite 600
Chicago, IL 60601
312-886-3642

Region VI – Dallas
(Arkansas, Louisiana, New Mexico, Oklahoma, Texas)

Associate Regional Administrator

CMS
Program Operations
1301 Young Street, Suite 714
Dallas, TX 75202
214-767-6444

Region VII – Kansas City

(Iowa, Kansas, Missouri, Nebraska)

Associate Regional Administrator

CMS
Program Operations
Richard Bolling Federal Building
601 East 12th Street, Room 235
Kansas City, MO 64106
816-426-6538

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Region VIII – Denver

(Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming)

Associate Regional Administrator

CMS
Federal Office Building
Colorado State Bank Building
1600 Broadway, Suite 700
Denver, CO 80202
303-844-6538

Region IX – San Francisco

(American Samoa, Arizona, California, Guam, Hawaii, Nevada, Common Wealth of the Northern Mariana Islands)

Associate Regional Administrator

CMS
Program Operations
75 Hawthorne Street, Suite 408
San Francisco, CA 94105
415-744-3501

Region X – Seattle
(Alaska, Idaho, Oregon, Washington)

Associate Regional Administrator

CMS
Program Operations
2201 Sixth Avenue, MS-40
Seattle, WA 98121
206-615-2315

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