CODING DOCUMENTATION

TRAINING

Revised May 31, 2019

 Table of Contents
⚫ Overview of Emergency Department Coding 21-23

⚫ Coding for Emergency Department Services 24-26

⚫ Coding Principles 27-29

⚫ Level of Specificity in Coding 30

⚫ Use of Other (NEC) and unspecified (NOS) Codes 31

⚫ “Z” Codes 32-33

⚫ External Cause Codes 34

⚫ Summary of Diagnosis Coding Philosophy 35-36

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 Table of Contents
⚫ ICD-10 Coding – How to Find Codes in the ICD-10 Book 37-49

⚫ Poisoning 50, 53

⚫ Adverse Reaction 51, 54

⚫ Poisoning/Adverse Reaction 52

⚫ Unspecified Drug Reaction 55

⚫ Diabetes Mellitus 56-58

⚫ Hypertension 59

⚫ ICD-10 Coding of Burns 60-62

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 Table of Contents
⚫ Classification of Charts – Sickness/Injury 63

⚫ Classification of Charts – 72 Hour Rule 64

⚫ MDM – Components 65

⚫ MDM- Risk 66-83

⚫ MDM – Presenting Problem Minimal Risk 68

⚫ MDM – Presenting Problem Low Risk 69

⚫ MDM – Presenting Problem Moderate Risk 70

⚫ MDM – Presenting Problem High Risk 71

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 Table of Contents
⚫ MDM – Diagnostic Procedures Minimal Risk 72

⚫ MDM – Diagnostic Procedures Low Risk 73

⚫ MDM- Diagnostic Procedures Moderate Risk 74

⚫ MDM – Diagnostic Procedures High Risk 75

⚫ MDM- Management Options Minimal Risk 76

⚫ MDM – Management Options Low Risk 77

⚫ MDM – Management Options Moderate Risk 78

⚫ MDM – Management Options High Risk 79

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 Table of Contents
⚫ MDM – Determining Risk 80-81

⚫ MDM – Risk Table 82-83

⚫ MDM – Number of Diagnoses or Treatment Options – Additional Workup 84-85

⚫ MDM – Number of Diagnoses or Treatment Options – Points Table 86

⚫ Amount and/or Complexity Data to be Reviewed 87

⚫ Common Types of Data 88-90

⚫ Amount and/or Complexity Data to be Reviewed – Point Assignment 91-92

⚫ Assigning E/M Services Code – Flow Chart 93-103, 106-107

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 Table of Contents
⚫ Assigning E/M Services Code – Urgency Table 104-105

⚫ Coding for Emergency Services – E/M Levels Table 108

⚫ MDM –E/M Levels –RTI Sickness and Injury Codes 109

⚫ MDM –Summary Table 110-112

⚫ History Summary Table 113

⚫ Elements of History – Chief Complaint 114

⚫ HPI Elements 115

⚫ Example of History of Present Illness Documentation 116

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 Table of Contents
⚫ Requirements for History of Present Illness 117

⚫ Levels of HPI 118

⚫ Review of Systems 119

⚫ Body Systems Recognized by CPT-4 for ROS 120

⚫ Types of ROS 121-123

⚫ Examples of Signs and Systems That May be Addressed in the ROS 124-126

⚫ HPI and ROS Elements 127

⚫ Past, Family and Social History (PFSH) 128-134

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 Table of Contents
⚫ Levels of PFSH for CPT coding 135

⚫ Reminders – Review of Systems/Past, Family and/or Social History 136

⚫ Differentiating Body Area from Organ System 137

⚫ Elements of Physical Examination 138-139

⚫ Types of Physical Exam 140

⚫ Physical Exam – Minimum Requirements for Organ System Exam 141-146

⚫ Physical Exam – Minimum Requirements for Body Area Exam 147

⚫ Physical Exam Summary Table 148

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 Table of Contents
⚫ E/M Policy when 1 BA/OS Documented in PE 149-150

⚫ Assigning the Caveat 151-153

⚫ Scenarios For Assigning A Caveat 154-155

⚫ Caveat vs. Unobtainable History 156-158

⚫ The Critical Care Equation 159

⚫ Critical Care Time 160, 169-172

⚫ Factor # 1 – Organ system acutely impaired 161-164

⚫ Factor # 2 – Life threatening deterioration 165-166

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 Table of Contents
⚫ Factor # 3 – Prevention of further deterioration 167-168

⚫ Billing Critical Care Services 169

⚫ Split Shared Critical Care 174

⚫ CCT Downcodes 166, 175, 183

⚫ CCT Denied – Process and Screen Prints 173, 176-178

⚫ CCT Reduced – Screen Prints 179-182

⚫ DOA Patients 184

⚫ Cardiac Arrest Patients 185

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 Table of Contents
⚫ New User Login Instructions 187-188

⚫ What is a Non-Billable? 189-191

⚫ Suspended Charts – Types 192

⚫ Missing Provider Documentation 193

⚫ Red Screen Survival Guide 194-195

⚫ Procedure Descriptions – Fee Schedule 197-239

⚫ Documentation Requirements for Tobacco Use Cessation 240-241

⚫ Introduction to CPT – Terms and Definitions 242-250

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 Table of Contents
⚫ Surgical Procedures 251

⚫ Surgical Package 252

⚫ Levels of Procedures 253

⚫ Integumentary Section 254

⚫ Incision and Drainage of Abscesses and Cysts 255

⚫ Foreign Body Removal – Skin 256

⚫ Foreign Body Removal – Eye 257

⚫ Debridement 258

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 Table of Contents
⚫ Nails – Debridement and Avulsion 259

⚫ Nails/Evacuation or Subungal Hematoma 260

⚫ Nail bed Laceration Repair 261

⚫ Nail Injury with Wedge Excision 262

⚫ Laceration/Wound Repair 263-269

⚫ Laceration/Wound Repair – Simple 264

⚫ Laceration/Wound Repair – Intermediate 265

⚫ Laceration/Wound Repair – Complex 266

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 Table of Contents
⚫ Laceration/Wound Repair –Reminders 267-268

⚫ Laceration Matrix 269

⚫ Billable Simple Suture Removals 270-273

⚫ Burn Treatment 274-276

⚫ Surgery – Musculoskeletal System 277-279

⚫ Billing E/M and Fracture Care Codes 280

⚫ Fracture Care Update – Requirements for Billing 281-282

⚫ Fracture Care Without Strap/Splint 283

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 Table of Contents
⚫ Splinting and Strapping 284-285

⚫ CPT Surgical Procedures With Global Period 0-10 days 286

⚫ E/M Level of Service And Procedures 287-288

⚫ Moderate Sedation 290-298

⚫ Two Families 292-293
⚫ Description of Each Family of Sedation Codes 294-295
Documentation Required to Bill the Moderate Sedation Codes 296
Intra-service Time 297
Moderate Sedation Reminders 298

⚫ Endotracheal Intubation 299

⚫ Using Modifiers to Illustrate Special Circumstances 300-308

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 Table of Contents
⚫ Commonly Used Modifiers in the Emergency Department 309-310

⚫ General Guidelines for Billing Interpretations 311-314

⚫ Coding for EKG Interpretations 315-316

⚫ Coding for Interpretation of X-rays 317

⚫ Documenting Emergency Medicine Interpretations 318-324

⚫ Suggestions for the dictated or handwritten charts – x-rays 319, 321
⚫ Suggestions for the dictated or handwritten charts – EKG’s 320-322
⚫ Suggestions for the templated charts – x-rays and EKG’s 323
⚫ Pulse Oximetries 324

⚫ Portable Diagnostic Ultrasound Studies 325-326

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 Table of Contents
⚫ Physician Directed Care 327-328

⚫ Advanced Care Planning 329

⚫ Suicide Risk Assessment 330

⚫ MLP in Triage 332

⚫ Transfer of Care Policy 333

⚫ Enhanced Clinician Assignment 334-362

⚫ CMS Clarifies Teaching Physician Rules 363-366

⚫ Unacceptable Documentation – Teaching Physician 367

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 Table of Contents
⚫ Procedures – Teaching Physicians 367

⚫ Procedures – Teaching Physicians 368

⚫ Minor Surgical Procedures – Teaching Physicians 369

⚫ X-ray Interp – Teaching Physicians 370

⚫ Critical Care – Teaching Physicians 371

⚫ Resident and Teaching Physicain Reminders 372

⚫ E/M Service Documentation Provided by Students 373

⚫ The Use of Scribes and Medical Students 374-375

⚫ Observation Services 376-384

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ICD-10 & MDM

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 OVERVIEW OF
EMERGENCY DEPARTMENT CODING
ED Coding poses one of the • Volume of patients
biggest challenges in coding and • Evolving reimbursement
reimbursement. Staff must policies among Medicare
balance the critical needs of and private payers
patients against the • Constant updates &
documentation necessary for addition to CPT and ICD-
coding and reimbursement. 10 codes

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 OVERVIEW OF
EMERGENCY DEPARTMENT CODING

Undercoded procedures, missed codes and incomplete documentation

cost ER’s and MD’s millions of dollars in earned but uncollected
revenue each year.

⚫ Physician is responsible for correct documentation or procedures and

services
⚫ Anything not documented cannot be billed.
⚫ Anything communicated inaccurately most likely will lead to
inaccurate billing

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 We code in venues:
⚫ Diagnosis coding the translation of diagnoses (symptoms) into numerical
codes that identify symptoms, conditions, or complaints that caused the patient to
come to the ER. These codes establish medical necessity by indicating the severity
and urgent nature of the condition or complaint. “Paints a picture of the patient’s
condition.”
⚫ Procedural coding Physician’s Current Procedural Terminology 4th Edition
A systematic listing and coding of procedures & services performed by physicians in
a medical setting.

• Ancillary Procedures---specific treatment and diagnostic

• Evaluation & Management---determining the extent of physician skill

required in collecting a history, performing a physical exam and the amount
of medical decision making necessary to formulate a diagnosis and treatment
plan for each patient.
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CODING FOR EMERGENCY DEPARTMENT
SERVICES
Seven components are listed in the descriptions for E/M Levels:
KEY COMPONENTS
⚫ History
⚫ Physical Examination
⚫ Medical Decision Making

All of the key components must meet or exceed the level of E/M code selected

CONTRIBUTORY COMPONENTS
⚫ Time
⚫ Counseling
⚫ Coordination of care
⚫ Nature of presenting problem

Note: Emergency department E/M codes are the only codes that do not include physician attendance time
requirements for each level as these services are provided on a variable intensity basis.
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Coding for Emergency Department Services

E/M services include:

⚫ History
⚫ Physical Examinations
⚫ Evaluations
⚫ Treatments
⚫ Conferences with or concerning patient
⚫ Preventative Health Supervision

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Coding for Emergency Department Services
The following components are encompassed in E/M codes as required for
prevention or diagnosis, treatment of illness/injury and promotion of
optimal health:

⚫ Skill
⚫ Effort
⚫ Time
⚫ Responsibility
⚫ Medical Knowledge

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 CODING PRINCIPLES

The International Classification of Diseases, Clinical Modification (ICD-

10), presents a systematic listing of codes that describe medical conditions.
These codes justify to payers the treatment physicians perform for patients.
The codes should reflect the urgent nature of a condition. Failure to show
the urgent nature of the presenting problem could result in claim delay or
denial.

In the ED the patient’s condition must be verified in the medical record as

the primary symptoms rather than as an actual condition. For example, if a
patient presents with chest pain, the primary diagnostic code should
correspond to the chest pain rather than to heart disease. Heart disease itself
would not support the medical necessity of emergency services.

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 CODING PRINCIPLES

The Healthcare Financing Administration (HCFA) defines an emergency

situation as “the sudden onset of a medical condition manifesting itself
by acute symptoms of sufficient severity (including severe pain) that
absence of immediate medical attention could result in: placing the
patient’s health in serious jeopardy, serious impairment of bodily
functions, serious dysfunction of any body organ or part.”

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 CODING PRINCIPLES

To establish the urgent nature of services, clearly describe conditions that

justify services provided. The following coding principles help insure that the
diagnostic codes selected properly demonstrate medical necessity:

⚫ Designate emergency situations by identifying acute conditions such as coma, LOC,

hemorrhage.
⚫ Assign codes to the highest level of specificity, use of 4th and 5th digits, when
available, is mandatory.
⚫ Distinguish between acute and chronic where applicable.
⚫ Do not code rule out, probable or differential diagnoses
⚫ Code only the conditions related to the presenting problem and influence the current
services being reported.

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LEVEL OF SPECIFICITY IN CODING

Diagnostic codes are to be used at their highest

level of specificity.

⚫ Assign three digit codes only if there are no four-digit

codes within that category.
⚫ Assign four-digit codes only if there is no fifth-digit sub-
classification for that category.
⚫ Assign the fifth-digit sub-classification code for those
categories where it exists.

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Use of Other (NEC) and Unspecified
(NOS) Codes

Codes labeled as NEC (not elsewhere

classified) or NOS (not otherwise specified) are
used only when neither the diagnoses nor
review of the documentation provides adequate
information to permit assignment of a more
specific code.

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 Z00-Z99 Codes
There are three main reasons for using Z codes:

⚫ A person who is not currently sick or whose diagnosis is not yet established comes
to the ED for a specific purpose.

⚫ A patient has a problem or illness that is already established and it is either a current
condition or a resolving problem. The patient comes to the ED for a specific
treatment that is planned and expected. For example, uncomplicated suture removal
or prescription refill.

⚫ A circumstance or problem may be present that influences the person’s health status
but it is not in itself a current illness or injury.

The omission of a second code may lead to requests from carriers for
more information prior to payment of the claim. For emergency
services, “Z” codes should not be coded as the primary code. We
should first code a current or chronic symptom followed by the “Z” code.

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 Codes from the Z00-Z99 series,
Observation and evaluation for suspected conditions

Codes from the Z00-Z99 series are assigned as principal diagnoses for encounters
when there is some evidence to suggest the existence of an abnormal condition or
following an accident or other incident that ordinarily results in a health problem
and no supporting evidence for the suspected condition is found and no treatment is
currently required. The fact that the patient may be scheduled for continuing
observation does not prohibit the use of these codes.

Code all documented conditions that coexist at the time of the encounter/visit, and
that require or affect patient care treatment or management. Do not code conditions
previously treated that no longer exist.

For patients receiving ancillary diagnostic or therapeutic services only during the
encounter/visit, the appropriate Z code for the service is sequenced first and if
documented the diagnosis or problem for which the services are being performed is
sequenced second. Individual payer policy will determine if the use of these codes
is appropriate.

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 External Cause Codes V00-Y99
Occurrence codes or external cause codes are the second set of supplemental
codes. These codes are never listed as the primary diagnosis or listed alone.
External cause codes are intended to be used in addition to the codes that
indicate the nature of the condition that may be stated as due to external
causes. Use these codes to establish medical necessity, identify medications,
causes of injury and poisoning. External cause codes can be useful because
they provide a complete description of the emergency situation.

Some payers may not recognize external cause codes and others may utilize
the information to decide payment responsibility (ie. private pay to worker’s
compensation). Therefore individual payer consideration will need to be
evaluated.

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Summary of Diagnosis Coding Philosophy

Signs and symptoms should be coded when no definite cause or diagnosis has been
made. If the cause (or diagnosis) is identified, that diagnosis code should be
assigned as the primary code. When the sign or symptom represents an important
problem in medical care, even when the diagnosis is known,
(to make the
payor aware of the urgency for care). If the discharge diagnosis does not reflect the
patient's condition upon presentation to the emergency department, the payer may
feel that the need for emergency care was not justified. In order for emergency
services to be paid appropriately, it may sometimes be necessary to code the signs or
symptoms that were made known upon presentation to the ED - in addition to the
final (primary) diagnosis.

Contrary to the coding practices used by hospitals and medical record departments
for coding the diagnosis of hospital inpatients, EmCare does not code diagnoses
documented as "probable", "suspected". "rule out" (section 12.4 of rule). Rather, we
code the condition(s) to the highest degree of certainty for the encounter (i.e.
symptoms).

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Summary of Diagnosis Coding Philosophy
When the symptom or sign represents an important problem in medical care, even
though the cause is known (i.e. a chronic condition), the symptom or sign should be
coded in addition to the known cause to make the payor aware of the urgent need for
care. Many payors consider conditions such as asthma, diabetes, tobacco or alcohol
abuse as chronic conditions. The acute exacerbation of these conditions must be
relayed to the payor through descriptive ICD - 10 coding. For example, acute
shortness of breath is the necessary emergency that brings the asthmatic to the ED.

Additional Coding Tips:

⚫ Report ALL final diagnoses recorded by the physician.
⚫ Use signs/symptoms ONLY if they add to the demonstration of the severity of the case.
For example, it is not necessary to use "pain" with injuries/strains.
⚫ Make certain to use the code to the highest level of certainty. For example, if the auto
accident is described as a collision, use the V series; do not automatically default to V499.
Do not always default to W19 for falls, there may be a better code to select.

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 ICD-10 CODING
HOW TO LOOK FOR ICD-10 CODES IN THE BOOK

⚫ Look up the main term in the alphabetic index. Always consult the alpha index
before turning to the tabular list.
⚫ Follow cross references like: “see”, “see also” and “see category” to the correct
code when the dx is not located under the first term referenced.
⚫ Review sub-terms or modifying words and refer to indented terms under the
main term. The supplemental words can describe severity, location, or
symptoms.
⚫ Choose a tentative code and look it up in the tabular listing (numeric index) and
follow instructional notes when applicable.
⚫ NEC-not elsewhere classified. Use when you don’t have enough information to
code to a more specific subcategory or when ICD-10 doesn’t provide a code
specific for the patient’s condition.
⚫ NOS-not otherwise specified. The equivalent of “unspecified”.: NEC is more
specific than NOS.

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 ICD-10 CODING
HOW TO LOOK FOR ICD-10 CODES IN THE BOOK

⚫ Order of specificity: chapter, subchapter, category, subcategory, sub-

classification. For example in tabular list:
⚫ Chapter 12….diseases of the skin and subcutaneous tissue (L00-L99) ( )
⚫ Infections of skin and subcutaneous tissue (L00-L99) )
⚫ Finger L08.9 ( )
⚫ Cellulitis and abscess, unspecified L03.90 ( )
⚫ Remember to add the additional digit when required. There will be a plus sign
to the left of the subcategory telling you to an additional digit.
⚫ Remember also to assign codes to the highest level of specificity
⚫ Assign 3-digit codes only if there are no 4th digit codes within that code category
⚫ Assign 4-digit codes only if there is no 5th digit sub-classification for that category, and
⚫ Assign 5-digit sub-classification for those categories where it exists

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 ICD10
ICD-10 CODE LOCATION PROTOCOL

⚫ Use Cheat Sheets to try to locate ICD-10 starter sequence.

• Use Illness Sheet for illnesses;
• Use Injury Sheet for injuries;
• Use External Cause Sheet for external causes.
• Exception: for poisoning, go directly to Table of Drugs and Chemicals in ICD-10
book.
⚫ If starter sequence is found, use Build-a-Code in Embillz.
⚫ If starter sequence is not found, use Key Word Lookup (F6 browse) in Embillz.
⚫ If you are unable to find code using Key Word Lookup, use ICD-10 book.

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 Diagnosis Coding Rules Summary
⚫ Definitive diagnosis
Relevant to current visit – yes
Not relevant to current visit – yes
⚫ Signs and symptoms
Routinely associated with documented diagnosis – no
Not routinely associated with documented diagnosis – yes
No diagnosis documented – yes
⚫ Past medical history – no
⚫ Rule-outs – no
⚫ Cause of injury – yes
⚫ No diagnoses, signs or symptoms (health status) – yes

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Injury Cheat Sheet

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Injury Cheat Sheet

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ICD10 Illness Cheat Sheet

43
ICD10 Illness Cheat Sheet

44
ICD10 Illness Cheat Sheet

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ICD10 Illness Cheat Sheet

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ICD10 Illness Cheat Sheet

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ICD10 External Causes

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ICD10 External Causes

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POISONING
A condition due to incorrect use of a medication
⚫ wrong medication given or taken

⚫ wrong dosage given or taken

⚫ medication given or taken by wrong person

⚫ alcohol poisoning

⚫ overdose

⚫ Error in dosage or administration of prescription

Rx→ poisoning

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ADVERSE REACTION
A condition due to a drug used exactly as prescribed
Diagnosis may read: toxic effect toxicity

⚫ allergic reaction
⚫ cumulative effect of drug (toxicity)

⚫ idiosyncratic reaction

⚫ paradoxical reaction

⚫ synergetic reaction

⚫ interaction between prescribed

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 POISONING/ADVERSE REACTION

DRUG INTERACTIONS

Poisoning Adverse effect

1) other prescription Rx X

2) nonprescription Rx taken X
on patient’s own initiative
3) nonprescription Rx taken X
as prescribed
4) alcohol X

Two (2) or more prescription Rx → assign E code for each drug involved
Code T50.9* when related to unknown drug adverse reaction followed by symptoms and use
an injury E/M level.
Code T78 when allergic reaction to unknown source and follow it with symptoms use an
injury E/M level.

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POISONING

1st →Poisoning ID# (column 1)

2nd →Manifestation

3rd →E Code (circumstance) (table)

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ADVERSE REACTIONS
(Rx still being taken)

1st →Manifestation or Symptoms

2nd →Therapeutic use column (T Code)

(Mandatory)

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UNSPECIFIED DRUG REACTION

T50.*→Adverse reaction to Rx properly

administered when nature of reaction is not
specified

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 DIABETES MELLITUS
E00-E90
Other Terminology: Bronze Diabetes, Diabetes
Insipidus---if diagnosis is “Diabetes” take to mean
Diabetes Mellitus
2 Classification Axes
--identifies presence of any associated
complications
--indicates both the type of diabetes and of out
of control classify as “out of control” only if stated by MD---
not determined by elevated glucose

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 DIABETES MELLITUS

TYPES
--Insulin Dependent (IDDM)---must be stated in record
Ketone prone, Juvenile Onset or Juvenile Type---body fails to
produce Insulin at all or production is greatly reduced---requires
Insulin to sustain life.
--Non-insulin Dependent---adult onset---ketosis resistant
Insulin is produced but is insufficient or the body is unable to
utilize adequately. Usually does not required Insulin---oral
hypoglycemics, diet and exercise usually will control---if not
effective, Insulin may be required to control persistent hyper-
glycemia---may be described as “Insulin requiring” but aren’t
Insulin dependent

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 DIABETES MELLITUS

COMPLICATIONS
Both types may lead to a variety of complications

⚫ Ketoacidosis (E10 (Type 1) or E11 (Type 2)) glycosuria, ketonuria,

hyperglycemia, ketonemia acidosis (low arterial blood PH) and low
plasma bicarbonate
⚫ If the type of diabetes is not documented, default to E11 (Type 2).
⚫ Do not assume that a patient on insulin must have Type 1 diabetes. The
default for diabetes without further specification defaults to Type 2. Add
the code for long term use of insulin (Z79.4)
⚫ Dual coding required---code for diabetes assigned first with code for
assoc. manifestation indicating the complication
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 HYPERTENSION I10-I16
Classified by:
Type: Primary or Secondary
Nature: Benign, Malignant, Accelerated or Unspecified
⚫ Benign (I10) may be called Essential, Hypertensive Vascular Disease or
Systolic
⚫ Malignant/Accelerated (I10) a severe disorder with progressive vascular
damage. Code only if documented by the MD as malignant or accelerated.
⚫ Unspecified (I10) rarely documented as a new finding. Usually a part of
the patient’s PMH. Most common documentation of hypertension.
Never code hypertension based on an elevated blood pressure reading.
When the MD documents an elevated blood pressure in the diagnostic
impressions and there is no history of hypertension, use code (R03.0)
if he treats the problem or recommends follow up with PMD.

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 ICD-10 CODING OF BURNS
⚫ Burns are classified by the depth of the burn (first degree through fourth
degree) and the type of burn. The muscles, nerves, bones, blood
vessels, respiratory system function, temperature regulation, joint
function, fluid/electrolyte imbalance, physical appearance, and
psychological functioning are all affected by a major burn injury.
⚫ When assigning your ICD-10 code for burns you should first determine
the site of the burn and then the degree of the burn. Then use category
T31 to indicate the total percentage of body surface (TBSA). (ex: 2nd
degree burn of the wrist with 2% TBSA would be ICD T23279A &
T310)
⚫ The emergency room physician/MLP should indicate the degree of the
burn. This could be listed in the diagnosis, the exam section, or on or
near a picture of the area or in the nurse’s notes.

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 Burns
Categories T20-T32
Classified by Depth of Burn
1st degree---limited to outer layer of the epidermis--erythema and tenderness
2nd degree---partial thickness injury to dermis---may be superficial or deep
3rd degree--- barrier is lost---presence of necrotic tissue creates fluid volume loss
If the ERMD only documents the appearance of the burn, you should use the following: redness or
erythema => first degree; blistering or full thickness burn => second degree.

Category (T20-T26) indicates anatomical site of burn

4th character (sub category) indicates depth or degree of burn
5th character (sub classification) indicates more specific anatomical site

Category (T30-T32) multiple burns, various sites---use only when specific location of
burn is not documented

Category (T27-T28) burns of internal organs

4th character indicates specific site

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ICD-10 CODING OF BURNS
Category (T31) indicates extent of BSA involved---determined by MD using
“The rule of 9’s”
4th character indicates total % BSA involved---all level of burns
5th character indicated % BSA involved with 3rd degree
Use this category when documented by MD---usually doesn’t document
under 20% BSA

Coding Rules:
1. Always coded as injury
2. Code most severe burn to site
3. Multiple burns same site: code only most severe per site
4. Multiple burns different site: code most severe for each site

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CLASSIFICATION OF CHARTS

⚫ INJURY-TRAUMA OR DAMAGE TO SOME PART OF THE

BODY
(EXAMPLES: ABRASIONS, CONTUSIONS, FRACTURES…ETC.)

⚫ SICKNESS/ILLNESS-UNHEALTHY CONDITION, AN
ABNORMAL PROCESS IN WHICH ASPECTS OF FUNCTION OF
A PERSON IS DIMINISHED OR IMPAIRED, COMPARED WITH
PERSON’S PREVIOUS CONDITION
(EXAMPLES: CHEST PAIN, NAUSEA, CHF, FEVER…ETC. )

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 CLASSIFICATION OF CHARTS

72 HOUR RULE
INJURY CHARTS ARE CODED AS INJURIES UP TO 72 HOURS AFTER THE
INJURY. AFTER 72 HOURS THE CHARTS ARE CODED AS SICKNESS
CHARTS.

CODE CHART AS AN INJURY STILL WITHIN 72 HOUR TIME FRAME

CODE CHART AS A SICKNESS, INJURY IS OLDER THAN 72 HOURS

EXCLUSIONS TO THE 72 HOUR RULE

⚫ MVA OR PMVA INSURANCE
⚫ WORKMAN’S COMPENSATION
⚫ NEWLY DIAGNOSED FRACTURES

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 MDM
Medical Decision Making is the complexity of establishing a diagnosis and /or
selecting management options measured by:

⚫ Amount and complexity of medical records, diagnostic tests, and/or other info
that must be obtained, reviewed, and analyzed (DATA)
⚫ The number of possible diagnosis and/or the number of management options
that must be considered (DIANOSIS/MANAGEMENT OPTIONS)
⚫ The risk of significant complications, morbidity, and/or mortality associated
with the patient’s presenting problem and the management options selected
(RISK)

To qualify for a given type of MDM, 2 of the 3 above components must meet
or exceed the MDM complexity selected.

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 MDM

RISK: risk is generally implied by:

⚫ Presenting Problem-the nature and severity of the presenting problem

⚫ Diagnostic Procedures-based on the risk to the patient during and immediately

following any procedure or treatment

⚫ Management Options Selected-the more complex the options, the higher the risk

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Medical Decision Making
RISK
The highest level or risk in any one category determines the overall level
of risk
There are levels of risk

⚫ 1. minimal

⚫ 2. low

⚫ 3. moderate

⚫ 4. high

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 MDM
Risk component, Presenting Problem category – Minimal risk

Risk
Level Presenting Problem(s)
• 1 self-limited or minor problem
Minimal risk

Examples:
Cold
Insect bite
Tinea corporis

NOTE: Determination of the level of “Presenting Problem(s)” may be made by using the chief complaint,
a diagnosis, a clinical impression, or a “rule out” under one of these areas. It may be based on the
potential severity of the presenting problem as perceived and documented by the physician.

68
 MDM
Risk component, Presenting Problem category – Low risk

Risk
Level
Presenting Problem(s)
• 2 or more self-limited or minor problems
• 1 stable chronic illness
Examples:
Well controlled hypertension
Non-insulin dependent diabetes
Low risk

Cataract
BPH
• Acute uncomplicated illness or injury
Examples:
Cystitis
Allergic rhinitis
Simple sprain

NOTE: Determination of the level of “Presenting Problem(s)” may be made by using the chief complaint,
a diagnosis, a clinical impression, or a “rule out” under one of these areas. It may be based on the
potential severity of the presenting problem as perceived and documented by the physician.

69
 MDM
Risk component, Presenting Problem category – Moderate risk

NOTE: Determination of the level of “Presenting Problem(s)” may be made by using the chief complaint,
a diagnosis, a clinical impression, or a “rule out” under one of these areas. It may be based on the
potential severity of the presenting problem as perceived and documented by the physician.

70
 MDM
Risk component, Presenting Problem category – High risk
Risk
Presenting Problem(s)
Level
• 1 or more chronic illness w/severe exacerbation, progression, Renal failure, acute
or side effects of treatment Severe abdominal pain w/guarding
• Acute or chronic illness or injury that may pose threat to life Appendicitis, acute
or bodily function Bowel bstruction/perforation/peritonitis
Examples: Ischemic bowel disease
Multiple trauma (fractures, internal injuries, etc.) GI bleed, acute or active
Myocardial infarction (MI) Diabetic ketoacidosis (DKA)
Chest pain with cardiac workup (EKG and cardiac enzymes) Ectopic pregnancy
Nontraumatic jaw, shoulder, neck or abdominal pain or Sickle cell crisis
dizziness or SOB or near-syncope w/cardiac workup Meningitis
Unstable angina Sepsis
Vent. tachycardia/supravent. tachycardia (SVT) Meth-resistant staph aureus (MRSA)
High risk

Heart block, 2° or 3° Shock (any type incl. hypovolemic, cardiogenic, neurogenic,

Pulmonary embolus (or d-dimer or VQ scan w/chest pain or neonatal)
SOB) Systolic BP<90 w/IV fluids (IV bolus or >60 ml/hr)
Respiratory distress, severe Heart rate>100 w/IV fluids (IV bolus or >60 ml/hr)
Arterial obstruction Orthostatic hypotension sx w/IV fluids (IV bolus or >60 ml/hr)
Abdominal aortic aneurysm (AAA) Cerebral vascular accident (CVA)
Hemorrhage Any sx with CT of the head (w/ or w/o contrast)
Deep vein thrombosis (DVT) (or extrem. Doppler or d-dimer Psych illness w/potential threat to self or other
w/limb pain, joint pain or limb swelling) Psych illness w/severe agitation or combative behavior
Compartment syndrome (except negative finding documented Hallucinations or delusions
only in PE) • Abrupt change in neurologic status
Progressive severe rheumatoid arthritis Examples:
Seizure, status epilepticus, syncopal episode, TIA, abrupt weakness
or sensory loss

NOTE: Determination of the level of “Presenting Problem(s)” may be made by using the chief complaint, a diagnosis, a clinical
impression, or a “rule out” under one of these areas. It may be based on the potential severity of the presenting problem as
perceived and documented by the physician.

71
 MDM
Risk component, Diagnostic Procedures category – Minimal risk

Risk Diagnostic Procedure(s)

Level Ordered
• Labs w/venipuncture
•
Minimal

X-ray
•
risk

EKG/EEG
• Urinalysis
• Ultrasound
• KOH prep

72
 MDM
Risk component, Diagnostic Procedures category – Low risk

Risk
Level
Diagnostic Procedure(s) Ordered
• Physiologic tests not under stress
Examples:
Pulmonary function tests
Low risk

• Non-cardiovascular imaging studies

w/contrast
Examples:
Barium enema
• Superficial needle biopsies
• Clinical lab tests requiring arterial puncture
• Skin biopsies

73
 MDM
Risk component, Diagnostic Procedures category – Moderate risk

Risk
Level
Diagnostic Procedure(s) Ordered
• Physiologic tests under stress
Examples:
Cardiac stress test
Fetal contraction stress test
• Diagnostic endoscopies w/no identified risk factors
• Deep needle or incisional biopsy
• Cardiovascular imaging studies w/contrast w/no
Moderate risk

identified risk factors

Examples:
Arteriogram
Cardiac catheterization
• Obtain fluid from body cavity
Examples:
Thoracentesis
Arthrocentesis
Culdocentesis
Lumbar puncture
• IVP
• CT w/contrast (except head)

74
 MDM
Risk component, Diagnostic Procedures category – High risk

Risk
Level
Diagnostic Procedure(s) Ordered
• Cardiovascular imaging studies w/contrast
w/identified risk factors
• Diagnostic endoscopies w/risk factors
High risk

• Cardiac electrophysiological tests

• Discography

75
 MDM
Risk component, Management Options category – Minimal risk

Risk Management Options

Level Selected
• Rest
Minimal

• Gargles
risk

• Elastic bandage
• Superficial dressing

76
 MDM
Risk component, Management Options category – Low risk

Risk
Level
Management Options Selected
• Over-the-counter drugs
• Minor surgery w/no identified risk
Low risk

factors or comorbidities
Examples:
Incision and drainage (I&D)
• IV fluids without additives
• Physical therapy
• Occupational therapy

77
 MDM
Risk component, Management Options category – Moderate risk

Risk
Level
Management Options Selected
• Minor surgery w/identified risk factors or
comorbidities
Moderate risk

• Non-emergency major surgery (open,

endoscopic or percutaneous) w/no
identified risk factors or comorbidities
• Prescription drug management
• IV fluids w/additives
• Closed treatment of fracture or dislocation
without manipulation

78
 MDM
Risk component, Management Options category – High risk
Risk
Level
Management Options Selected
• Non-emergency major surgery (open, endoscopic or
percutaneous) w/identified risk factors or comorbidities
• Emergency major surgery (open, percutaneous or endoscopic)
• Parenteral controlled substances (IV, IM, SQ or intranasal)
Examples (see drug chart for more info):
Ativan Dilaudid Phenobarbital
Codeine Fentanyl Valium
Demerol Morphine Versed
• Drug therapy requiring intensive monitoring for toxicity
Examples (see drug chart for more info):
Adenocard Heparin Phenobarbital
Adrenalin Isuprel Potassium Cl
Aminophylline Lidocaine Tegretol
Calan/Isoptin Lopressor TPA
High risk

Dilantin Nipride Tridil

Dobutrex Normadyne
• Titrated drips
Examples (see drug chart for more info):
Bretyllium Heparin Nipride
Cardizem Insulin Pronestyl
Dopamine Intropin Tridil
• Endotracheal intubation
• Ventilator management
• Initiation of ACLS or BLS
• Pericardiocentesis
• Chest tube
• CVP line
• Decision to DNR or de-escalate care due to poor prognosis
• Blood transfusion
• Admission to ICU/CCU or telemetry/stepdown unit
• Involuntary psych admission
• Use of mechanical or chemical restraints

79
 MDM

Risk of complications and/or morbidity or mortality

component

Level of risk is determined by the highest level of any

one category (presenting problem, diagnostic
procedure, management options). If one “high risk”
item is found in any category, the level of risk is high.

80
 MDM

Determining level of medical decision making

To qualify for high complexity medical decision making, “risk of
complications and/or morbidity or mortality” must be one of the two
key elements meeting the stated requirements for high complexity.

NOTE: Determination of the level of “presenting problem(s)” (one

determinant of “risk of complications and/or morbidity or mortality”)
may be made by using the chief complaint, a diagnosis, a clinical
impression, or a “rule out” under one of these areas. It may be based on
the potential severity of the presenting problem as perceived and
documented by the physician.

81
82
83
 MDM

Number of diagnoses or treatment options component

NOTES:
All ED patients are new to the examiner.

“Additional workup planned” is defined to include the following:

⚫ Specialist consult or order for specialist consult
⚫ Diagnostic test or procedure or order for diagnostic test
or procedure (i.e. labs/UA, x-rays, MRI, CT-scans,
ultrasounds, EKG, monitor or any other ancillary testing,
NOT including pulse ox)
⚫ Admission to hospital except for medical clearance or
medical screening
⚫ Transfer except return to nursing home

84
Confidential – Property of RTI v10.10.05
 Ancillary Tests That Qualify As
Additional Workup
Some ancillary tests that would count as additional workup:
⚫ Rapid flu
⚫ Rapid strep
⚫ Urine dips (including pregnancy test)
⚫ Glucose finger stick
⚫ Biosite POC
Some ancillary tests that would NOT count as additional workup:
⚫ Guiac
⚫ Pulse ox

⚫ Fetal Heart Tones

85
MDM
Number of diagnoses or treatment options component

Points are assigned according to the following table:

Problem(s) status Number of points

Self-limited or minor (stable, improved or worsening) (max=2) 1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening 2
New problem (to examiner); no additional workup planned (max=1) 3

New problem (to examiner); additional workup planned 4

Number of diagnoses and treatment options level is determined by the following table:
Dx/tx options level Total points
Minimal (related to straightforward MDM) 1
Limited (low complexity MDM) 2
Multiple (moderate complexity MDM) 3
Extensive (high complexity MDM) 4 or more

86
Amount and/or Complexity of Data to be Reviewed

⚫ The amount and or complexity of medical records,

diagnostic tests, and/or other information that must be
obtained, reviewed and analyzed.

87
 Common Types of DATA

Nursing History and Vital Signs

⚫ A notation to indicate that the physician reviewed and
agreed with the nursing assessment or identification of
conflicting information
Previous Medical Records
⚫ A brief discussion that (a) previous records were
requested and/or (b) previous records were reviewed and
pertinent information briefly outlined in the current
record.

88
 Common Types of DATA
Additional History
⚫ Documentation of the decision to obtain additional
information and the elaboration of the relevant findings
of the information obtained from the family, caretaker or
other source to supplement patient information
Laboratory Tests
⚫ A brief identification of the diagnostic tests ordered,
reviewed or interpreted. A brief notation of the result of
the test should also be documented.

89
 Common Types of DATA

Evaluation of Interpretive Reports

⚫ A brief assessment of interpretative reports and their affect
on patient diagnosis and/or treatment. When performed, a
notation of discussions with interpreting physicians.
Number and Type of Studies Reviewed &
Analyzed
⚫ A listing of all studies ordered and a brief notation of the
level of review or interpretation.

90
 MDM
Amount and/or complexity of data reviewed component
Points are assigned according to the following table:
Data reviewed Number of points
Review and/or order clinical lab tests 1
Review and/or order radiology tests 1
Review and/or order medicine tests 1
Discussion of results w/performing physician 1
Decision to obtain old records and/or obtain hx from someone other than pt 1
Review and summarization of old records and/or obtaining hx from someone other than pt and/or 2
discussion of case w/another HC provider
Independent visualization of image, tracing or specimen itself (not simply review of report) 2

Amount and/or complexity of data reviewed in determined by the following table:

Data reviewed level Total points
Minimal (related to straightforward MDM) 1
Limited (low complexity MDM) 2
Multiple (moderate complexity MDM) 3
Extensive (high complexity MDM) 4 or more

91
 Figuring Data Points
Amount and/or complexity of data reviewed component

When the physician documents independent visualization of an

image, tracing or specimen that he or she ordered, count 1 point
for the order plus 2 points for the visualization (3 total). The
physician must indicate “interp by me”. If no “interp by me”
box is available, the physician will be credited with independent
visualization if the interpretation is documented as having
occurred during a period of time defined as “EDMD reading
time” for the particular test.

92
ASSIGNING E&M SERVICES CODE

1. Check for Critical Care

If Critical Care is checked or requested by MD, validate request, and code CCT if valid
Check for
Critical Care If Critical Care is NOT checked or requested, or requested but not supported,
check for documentation of H&P

Check for
Documentation
of History & Exam

93
ASSIGNING E&M SERVICES CODE

2. Determination of Billable Status

If Critical Care is checked or requested by MD, validate request, and code CCT if valid
Check for
Critical Care If Critical Care is NOT checked or requested, or requested but not supported,
check for documentation of H&P

Check for If either History and/or Physical Exam are NOT documented, and no caveat exists,
chart is Nonbillable or Sendback
STOP
Documentation
of History & Exam If History and Physical Exam are both documented, or caveat exists, go to determination of MDM

DETERMINATION OF MEDICAL DECISION MAKING (MDM)

94
 ASSIGNING E&M SERVICES CODE
3. Determination of Medical Decision Making (MDM)
If Critical Care is checked or requested by MD, validate request, and code CCT if valid
Check for
Critical Care If Critical Care is NOT checked or requested, or requested but not supported,
check for documentation of H&P

Check for If either History and/or Physical Exam are NOT documented, and no caveat exists,
chart is Nonbillable or Sendback
STOP
Documentation
of History & Exam If History and Physical Exam are both documented, or caveat exists, go to determination of MDM

DETERMINE RISK
DETERMINATION OF MEDICAL
DECISION MAKING (MDM)

RISK RISK RISK RISK

HIGH MODERATE LOW MINIMAL

a. Determine Level of Risk

95
 ASSIGNING E&M SERVICES CODE
3. Determination of Medical Decision Making (MDM)
If Critical Care is checked or requested by MD, validate request, and code CCT if valid
Check for
Critical Care If Critical Care is NOT checked or requested, or requested but not supported,
check for documentation of H&P

Check for If either History and/or Physical Exam are NOT documented, and no caveat exists,
chart is Nonbillable or Sendback
STOP
Documentation
of History & Exam If History and Physical Exam are both documented, or caveat exists, go to determination of MDM

RISK
HIGH
DETERMINE RISK
DETERMINATION OF MEDICAL
DECISION MAKING (MDM)
Determine
Dx/Mgmt Options
a. Determine Level of Risk
b. If Risk is High, Determine Dx/Mgmt
No
Add’l workup Options to Determine Level of MDM
add’l workup
done/planned
done/planned

NOTE: Dx/Mgmt Options is only considered

MDM MDM
High Moderate when Risk is High.

96
 ASSIGNING E&M SERVICES CODE
3. Determination of Medical Decision Making (MDM)
If Critical Care is checked or requested by MD, validate request, and code CCT if valid
Check for
If Critical Care is NOT checked or requested, or requested but not supported,
Critical Care check for documentation of H&P

If either History and/or Physical Exam are NOT documented, and no caveat exists,
Check for chart is Nonbillable or Sendback
STOP
Documentation
of History & Exam If History and Physical Exam are both documented, or caveat exists, go to determination of MDM

DETERMINE RISK
DETERMINATION OF MEDICAL
DECISION MAKING (MDM)

RISK
MODERATE

a. Determine Level of Risk

b. If Risk is Moderate, MDM is Moderate
MDM
Moderate

97
 ASSIGNING E&M SERVICES CODE
3. Determination of Medical Decision Making (MDM)
If Critical Care is checked or requested by MD, validate request, and code CCT if valid
Check for
Critical Care If Critical Care is NOT checked or requested, or requested but not supported,
check for documentation of H&P

Check for If either History and/or Physical Exam are NOT documented, and no caveat exists,
chart is Nonbillable or Sendback
STOP
Documentation
of History & Exam If History and Physical Exam are both documented, or caveat exists, go to determination of MDM

DETERMINE RISK
DETERMINATION OF MEDICAL
RISK DECISION MAKING (MDM)
LOW

Determine
Data Reviewed
a. Determine Level of Risk
Data
b. If Risk is Low, Determine Data
Limited/
Extensive/
Minimal/
Data Reviewed to Determine Moderate
None
Level of MDM MDM MDM
Moderate Low

98
ASSIGNING E&M SERVICES CODE
3. Determination of Medical Decision Making (MDM)

If Critical Care is checked or requested by MD, validate request, and code CCT if valid
Check for
Critical Care If Critical Care is NOT checked or requested, or requested but not supported,
check for documentation of H&P

Check for If either History and/or Physical Exam are NOT documented, and no caveat exists,
chart is Nonbillable or Sendback
STOP
Documentation
of History & Exam If History and Physical Exam are both documented, or caveat exists, go to determination of MDM

DETERMINATION OF MEDICAL
DETERMINE RISK
DECISION MAKING (MDM)
RISK
MINIMAL

Determine
Data Reviewed
a. Determine Level of Risk
b. If Risk is Minimal, Determine Data Data
Extensive/
Data
Data
Minimal/
Limited
Reviewed to Determine Level of MDM Moderate None

MDM MDM MDM

Moderate Low S’forward

99
 ASSIGNING E&M SERVICES CODE
3. Determination of Medical Decision Making (MDM)
If Critical Care is checked or requested by MD, validate request, and code CCT if valid
Check for
Critical Care If Critical Care is NOT checked or requested, or requested but not supported,
check for documentation of H&P
Check for If either History and/or Physical Exam are NOT documented, and no caveat exists, STOP
Documentation chart is Nonbillable or Sendback
of History & Exam
If History and Physical Exam are both documented, or caveat exists, go to determination of MDM

DETERMINE RISK DETERMINATION OF MEDICAL

DECISION MAKING (MDM)
RISK RISK RISK RISK
HIGH MODERATE LOW MINIMAL

Determine Determine Determine

Dx/Mgmt Options Data Reviewed Data Reviewed

No Data
Add’l workup Data Data Data
add’l workup Extensive/
Limited/
Extensive/
Data
Minimal/
done/planned Minimal/ Limited
done/planned Moderate Moderate None
None

MDM MDM MDM MDM MDM MDM MDM MDM

High Moderate Moderate Moderate Low Moderate Low S’forward

100
ASSIGNING E&M SERVICES CODE

4. Determination of E&M Level when MDM is Straightforward

- E&M level is 99281

MDM
STRAIGHTFORWARD

E&M is
99281

101
ASSIGNING E&M SERVICES CODE

4. Determination of E&M Level when MDM is Low - Check Payor, count H&P elements if
necessary to determine E&M level

MDM
LOW

Check
Payor

Payor is
Medicare/
Champus
Payor
is
Count H&P
Other
elements

E&M is
E&M is 99282
highest level
achieved by
both H&P
up to 99282

102
ASSIGNING E&M MDM
MODERATE

SERVICES CODE Check

Payor

Payor is Medicare/ Payor

Champus is Other
4. Determination of E&M Level
when MDM is Moderate - Look at Urgency of Look at Urgency of
Check Payor. Presenting Problem Presenting Problem

For Medicare/CHAMPUS,
Does NOT Does NOT
determine if urgent Requires
require
Requires
require
urgent urgent
evaluation is required by eval
urgent
eval
urgent
eval eval
MD, and then count H&P by MD
by MD
by MD
by MD
elements to determine E&M
level. Count Count
H&P H&P
E&M is E&M is
For non-Medicare/Champus elements elements
99284 99283
payors, E&M is 99284 if E&M is E&M is
urgent evaluation is highest level highest level
achieved by achieved by
required by MD, and 99283 both H&P both H&P
if not. up to 99284 up to 99283

103
ASSIGNING E&M SERVICES CODE
Differentiating 99283 and 99284 – Determining Urgency
1. Have signs and symptoms (documented by physician) worsened recently (within 48 hours)?
Words and phrases to look for:
“increased”
“worsened”
“progressed”
“dull ache to sharp pain”
“increased frequency” (except referring to urination)

* "Increasing", "worsening", & "progressing" show a continuum of time and therefore are indicative of urgency regardless of a
documented time frame.

2. Do current signs and symptoms (documented by physician) with recent onset (within 48 hours) indicate urgency?
Signs and symptoms to look for:
Shortness of breath
Wheezing
Numbness
Dizziness or vertigo
Active bleeding (except menstrual bleeding)
“Radiating” signs or symptoms, including pain

3. Was the patient given IM, IV or SQ medication for pain (not PO) or was the patient given serial prescription pain medication
(by any route of administration) in the ED?

4. Was the patient given IM medication (of any type) and any other medication (of any type or route of administration)?

5. Was the patient given IM medication (of any type) and any ancillary test, excluding pulse ox?

104
 ASSIGNING E&M SERVICES CODE
Differentiating 99283 and 99284 – Determining Urgency – cont’d

6. Was the patient given IV medication (of any type – not just pain meds) or IV fluids (bolus or continuous, not KVO) in the ED?

7. Was the patient given multiple or continuous nebulizer treatments in the ED?

8. Was an EKG or radiology study other than x-ray (including ultrasound, CT, MRI, IVP, etc.) performed on the patient during the
ED stay?

9. Was a psych consult ordered?

10. Did the patient have a temperature of 104°F (40°C) or higher (any age, taken by any method) during the ED
stay?

11. Was the patient brought to the ED with neck and/or spine immobilization?

12. Was the patient admitted to the hospital or to observation (including following an ED visit for psych clearance or detox
clearance)?

13. Was the patient sent to the ED from another provider’s treatment location?

14. Did the patient present with a dislocation or fracture with deformity?

15. Do you think this patient needed to be seen in the ED rather than waiting to see his or her MD in the office?
“YES” answer to any of these questions indicates that the case requires urgent
evaluation by the ED provider.

105
 ASSIGNING E&M SERVICES CODE
4. Determination of E&M Level when MDM is High - Check Payor, count H&P
MDM
elements if necessary to determine E&M level HIGH

Check
Payor

Payor is Payor
Medicare/ is
Champus Other

Count H&P
elements

E&M is
E&M is 99285
highest level
achieved by
both H&P

106
 ASSIGNING E&M SERVICES CODE

MDM
MDM MDM
MODERATE MDM
HIGH LOW
Check
S’F’WARD
Check Payor Check
Payor Payor
Payor is Medicare/ Payor
Champus is Other
Payor is Payor Payor is Payor
Medicare/ is Look at Urgency of
Look at Urgency of Medicare/ is
Champus Other Presenting Problem Champus Other
Presenting Problem

Does NOT
Count H&P Requires Does NOT
require Requires Count H&P
elements urgent require
urgent elements
eval urgent
by MD
eval urgent
by MD eval
eval
by MD
by MD
E&M is Count
E&M is Count
H&P
99285 H&P E&M is E&M is
highest level elements E&M is
elements E&M is 99282 99281
achieved by E&M is highest level
both H&P 99284 achieved by
E&M is E&M is 99283
highest level highest level both H&P
achieved by achieved by up to 99282
both H&P both H&P
up to 99284 up to 99283

107
 CODING FOR EMERGENCY
DEPARTMENT SERVICES
Emergency Department Evaluation and Management Codes

99281 Problem focused

99282 Expanded problem focused, low complexity
99283 Expanded problem focused, moderate complexity
99284 Detailed
99285 Comprehensive
108
E/M Level Codes

E/M LEVEL
INJURY SICKNESS

9077 1 9016
9081 2 9028
9090 3 9039
9103 4 9046
9120 5 9055

109
Medical Decision Making Summary Table
MEDICAL DECISION MAKING
E&M # of diagnoses/ Amount and/ or Risk of complications/
level management complexity of morbidity/ mortality
options data to be
reviewed
99281 Straightforward MDM
Minimal Minimal or none Minimal

99282 Low complexity MDM

Limited Limited Low

99283 Moderate complexity MDM

Multiple Moderate Moderate

99284 Moderate complexity MDM

Multiple Moderate Moderate

99285 High complexity MDM

Extensive Extensive High

REMINDER: AT LEAST TWO OUT OF THREE MDM COMPONENTS MUST MEET OR EXCEED THE STATED REQUIREMENTS TO
QUALIFY FOR A GIVEN LEVEL OF MEDICAL DECISION MAKING.

NOTE: TO QUALIFY FOR HIGH COMPLEXITY MEDICAL DECISION MAKING, “RISK OF COMPLICATIONS AND/OR MORBIDITY OR
MORTALITY” MUST BE ONE OF THE TWO KEY ELEMENTS MEETING THE STATED REQUIREMENTS FOR HIGH COMPLEXITY.

110
 ED Professional E/M Coding
Summary Table
HISTORY EXAMINATION MEDICAL DECISION MAKING
E&M HPI Review Past, Body area/ Type of exam # of Amount and/ Risk of
level elements of family, organ system diagnoses/ or complexity complications/
systems social requirements management of data to be morbidity/
histories options reviewed mortality
99281 Problem-focused history Problem-focused examination Straightforward MDM
1-3 None None 1 BA or OS Limited exam of Minimal Minimal or Minimal
elements affected BA/OS none
99282 Expanded problem-focused history Expanded problem-focused exam Low complexity MDM
1-3 1 system None 2-7 BA or OS Limited exam of Limited Limited Low
elements affected BA/OS +
symptomatic/
related OS
99283 Expanded problem-focused history Expanded problem-focused exam Moderate complexity MDM
1-3 1 system None 2-7 BA or OS Limited exam of Multiple Moderate Moderate
elements affected BA/OS +
symptomatic/
related OS
99284 Detailed history Detailed exam Moderate complexity MDM
4+ 2-9 1 of 3 2-7 BA or OS Extended exam of Multiple Moderate Moderate
elements systems (3 or > items affected BA/OS +
for affected symptomatic/
BA/OS) related OS
99285 Comprehensive history Comprehensive exam High complexity MDM
4+ 10+ 2 of 3 8 OS only General Extensive Extensive High
elements systems multisystem exam

111
112
History Summary Table
HISTORY
E&M History of present Review of systems Past, family, social histories
level illness (HPI) (ROS) (PFSH)
99281 Problem-focused history
Brief None None
1-3 elements
99282 Expanded problem-focused history
Brief Problem pertinent None
1-3 elements 1 system
99283 Expanded problem-focused history
Brief Problem pertinent None
1-3 elements 1 system
99284 Detailed history
Extended Extended Pertinent
4+ elements 2-9 systems 1 of 3
99285 Comprehensive history
Extended Complete Complete
4+ elements 10+ systems 2 of 3

Note: All levels of history require documentation of a chief complaint.

113
Elements of History – Chief Compliant
Elements of History
CHIEF COMPLAINT (CC):
A concise statement describing the symptom, problem,
condition, diagnosis or other factor that is the reason for the
encounter, usually stated in the patient's words. A chief
complaint must be taken by the MD/MLP/resident.

Note: Elements contained in the chief complaint may also

qualify for elements of the HPI, ROS, PFSH if applicable.
Positive elements of the HPI and ROS may also qualify as the
chief complaint, if applicable.

114
 Elements of History
HISTORY OF PRESENT ILLNESS (HPI):A chronological description of the development of the patient's present
illness from the first sign and/or symptom to the present.
The principal symptoms should be described in terms of the following elements:
⚫ Location (where is it, body location, organ system affected)
⚫ Quality (what is it like; i.e., pain is sharp, burning, dull, radiating, tearing; cough is productive; discharge is brown)
⚫ Severity (how bad is it, quantity; mild, worse, progressing, numerous, repeated)
⚫ Associated signs and symptoms (associated manifestations; swelling, nausea. This element can overlap with
Review of Systems and would include pertinent negatives.
• Timing (how long does it last, how often does it come, course of symptoms; start, steady, intermittent, frequency)
⚫ Context (the setting in which they occur, activity at onset, causation; can include environmental factors such as pollen,
smoke, personal activities, emotional reactions, or other circumstances that may have contributed to the illness)
⚫ Duration (length of overall problem)
⚫ Modifying factors (factors that have aggravated or relieved them; what helps, how relieved or worsened, how affected
and by what). This should be something the patient does to alleviate/relieve a symptom.

Note: Information contained in the HPI that is counted as an HPI element may also be counted as an ROS element.
Information contained in the ROS that is counted as an ROS element may also be counted as an HPI element, as
long as the ROS was completed by the physician.

115
 Example of History of Present Illness
For about three months Mrs. X. has been increasingly troubled by headaches: bi-frontal,
usually aching, occasionally throbbing, mild to moderate severe. She has missed work only
once because of headaches, when she felt nauseated and vomited several times. Otherwise,
nausea is rare. Headaches now average once a week, usually are present on waking and last
all day. They are relieved by lying down and using a cold wet towel on head. Little relief
from aspirin.

Elements of the HPI:

Location: “headaches”
Quality: “aching, throbbing”
Severity: “mild to moderate”
Associated signs and symptoms: “nausea and vomiting”
Timing: “last all day”
Context: “present on waking”
Duration: “for about three months”
Modifying factors: “relieved by lying down and using
wet towel on head, little relief from aspirin”

116
 Requirements for history of present
illness (HPI)
Count EITHER HPI elements OR status of chronic conditions to
determine level of HPI

⚫ Status of 1 or 2 chronic conditions for brief HPI [expanded

problem-focused history]
⚫ Status of 3 chronic conditions for extended HPI [comprehensive
history]

NOTE: This status will most often pertain to hospitalist charts.

117
 Levels of HPI:

Brief and extended HPI’s are distinguished by the

amount of detail needed to accurately characterize
the clinical problem (s). A brief HPI consists of
one to three elements of the HPI. An extended
HPI consists of four or more elements of the HPI.

The HPI must be taken by the MD/MLP/resident.

118
REVIEW OF SYSTEMS (ROS)
The ROS is an inventory of body systems obtained
through a series of questions asked by the provider or
ancillary staff (acceptable when reviewed by the
Provider) seeking to identify signs and/or symptoms
which the patient may be experiencing or has
experienced. The main purpose for the review of
systems is to make sure that the physician has not
missed any important symptoms or medical problems,
particularly in areas not discussed in the HPI.

119
 Body Systems recognized by
CPT-4 for ROS:
Constitutional symptoms (fever, weight loss, etc.) Musculoskeletal

Eyes Integumentary (skin and/or breast, nails)

Ear, Nose, Mouth and Throat Neurological

Cardiovascular Psychiatric

Respiratory Endocrine

Gastrointestinal Hematologic/Lymphatic

Genitourinary Allergic/Immunologic

120
 Types of ROS
Problem Pertinent:
• Related to the presenting problem
• Often times part of the HPI

Example of Problem Pertinent System Review

An adult female presents with a dog bite and is
requesting rabies vaccine. She is questioned about any
redness or pain at the site of the wound.

121
 Types of ROS
Extended System Review:
• Directly related to problem(s) identified in the HPI but also covers
body systems other than the primary system involved with the
presenting symptoms.
• Two to nine systems reviewed and documented.
Example of Extended System Review
An adult female presents to the emergency department with
complaints of urinary frequency and burning with urination. She
might be questioned about fever, chills, nausea, blood in her urine,
back pain or symptoms related to the GI system and/or reproductive
system in addition to the urinary tract system.

122
 Types of ROS
Complete System Review:
⚫ Ten or more systems reviewed and documented.
⚫ Each positive/pertinent response requires
individual documentation.
⚫ A notation “all other systems negative” is
acceptable after pertinent problems identified in
the HPI are documented.

123
Examples of signs and symptoms that may
be addressed in a ROS:
Constitutional/General: Usual weight, recent weight change, weakness, fatigue, fever, and vital
signs.

Integumentary/Skin: Rashes, lumps, sores, itching, dryness, color change, changes in hair or
nails.

Eyes: Vision, glasses or contact lenses, last eye exam, pain, redness, excessive tearing, double
vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts

ENT: Ears: Hearing, tinnitus, vertigo, earaches, infections, discharge. If hearing is decreased,
use of hearing aids
Nose and Sinuses: Frequent colds; nasal stuffiness, discharge, or itching; hay fever, nosebleeds,
sinus trouble
Mouth and Throat: Condition of the teeth and gums, bleeding gums, dentures, if any, and how
they fit, last dental exam, sore tongue, dry mouth, frequent sore throats, hoarseness

Respiratory: Cough, sputum (color, quantity), hemoptysis, wheezing, asthma, bronchitis,

emphysema, pneumonia, TB, pleurisy , last CXR

124
Examples of signs and symptoms that may
be addressed in a ROS:
Cardiovascular: Heart trouble, high blood pressure, rheumatic fever, heart murmurs; chest pain or
discomfort, palpitations; dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema; past EKG or other
heart tests. Peripheral Vascular: Intermittent claudication, leg cramps, varicose veins, past clots in the
vein

Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea, vomiting, regurgitation, vomiting of

blood, indigestion. Frequency of bowel movements, color and size of stool, changes in bowel habits,
rectal bleeding or black tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food
tolerance, excessive bleeding or passing of gas. Jaundice, liver or gallbladder trouble, hepatitis,
pancreatitis

Genitourinary: Frequency of urination, polyuria, nocturia, burning or pain on urination, hematuria,

urgency, reduced caliber or force of the urinary stream, hesitancy, dribbling, incontinence; urinary
infections, stones. Male: Hernias, discharge from or sores on the penis, testicular pain or masses, history
of STD’s and their treatments. Sexual preference, interest, function, satisfaction and problems. Females:
Age at menarche; regularity, frequency, and duration of periods; amount of bleeding, bleeding between
periods or after intercourse, LMP; dysmenorrhea, PMS; age at menopause, menopausal symptoms.
Number of pregnancies, number of deliveries, number of abortions; complications of pregnancy.
125
Examples of signs and symptoms that may
be addressed in a ROS:
Musculoskeletal: Muscle or joint pains, stiffness, arthritis, gout, backache. If present, describe
location and symptoms (swelling, redness, pain, tenderness, stiffness, weakness,
limitation of motion or activity)

Neurological: Fainting, blackouts, seizures, weakness, paralysis, numbness, or loss of sensation,

tingling or “pins and needles”, tremors or other involuntary movements

Hematologic/Lymphatic: Anemia, easy bruising or bleeding, past transfusions and any reactions
to them, limb swelling

Endocrine: Thyroid trouble, heat or cold intolerance, excessive sweating; diabetes, excessive
thirst or hunger, polyuria

Psychiatric: Nervousness, tension, mood including depression; memory

Allergic/Immunological: Allergies; “immune suppressed?”

126
History of present illness (HPI) and
review of systems (ROS) elements

Information contained in the HPI that is counted as an HPI element

may also be counted as an ROS element. Information contained in the
ROS that is counted as an ROS element may also be counted as an
HPI element, as long as the ROS was completed by the physician.

127
PAST, FAMILY, SOCIAL HISTORY (PFSH)

Past (Medical) History (PH): A review of the patient's past experiences

with illness, injuries, and treatments.

PH includes:
⚫ prior major illness and injuries
⚫ prior operations
⚫ prior hospitalizations
⚫ current medications
⚫ allergies (drug, food)
⚫ age appropriate immunization status
⚫ age appropriate feeding/dietary

128
PAST, FAMILY, SOCIAL HISTORY (PFSH)

Family History (FH): Review of medical events in the patient's

family that may influence the patient's health.

FH includes:
⚫ Health status or cause of death of parents, siblings, and children
⚫ Specific diseases related to problems identified in the chief
complaint or history of the present illness, and/or system review
⚫ Diseases of family members which may be hereditary or place the
patient at risk

129
PAST, FAMILY, SOCIAL HISTORY (PFSH)

Social History (SH): An age appropriate review of past and current

factors that may affect the patient's disease, condition or health status.

SH includes:
⚫ marital status and/or living arrangement (i.e. “Do you live in an
environment in which you feel threatened?”)
⚫ current employment (i.e. injured “at work”)
⚫ occupational history
⚫ use of drugs, alcohol and tobacco
⚫ level of education (i.e. “sent from student clinic”)
⚫ sexual history
⚫ other relevant social factors (i.e. “family at bedside”, “discharged
home with granddaughter”, “patient has no emotional, spiritual or
cognitive needs noted”)
⚫ no new or unusual activities (i.e. travel)
130
PAST, FAMILY, SOCIAL HISTORY (PFSH)
Elements can also be found in the nurses notes if the MD/MLP checks “NN
reviewed” or refers back to the nurses notes (as in allergies or medication
sections). In the below screenshot, even though “Nursing Assessment
Reviewed” isn’t checked, “see nurses notes” in medication and allergies is
circled. This allows you to use meds and allergies taken by the nurse for PH
elements.

131
PAST, FAMILY, SOCIAL HISTORY (PFSH)
PH and SH elements may be found in the HPI section. See below.
“Hx of CHF” can be used for PH and “son” as historian can be used
as SH.

132
PAST, FAMILY, SOCIAL HISTORY (PFSH)
Social history may also be found in discharge instructions. See
below. If the MD circles that he counseled “family” or that
additional history was received from “family or caretaker”, these can
both be used as relevant social factors for SH.

133
PAST, FAMILY, SOCIAL HISTORY (PFSH)
⚫ Patient discharged “home” is NOT acceptable as a
living arrangement for SH, as it is too vague.
However, patient discharged to “nursing home” or
patient discharged home “with sister” is acceptable
since the discharge instructions show “living
arrangement” and “relevant social factors”
respectively.

⚫ “Home oxygen” is acceptable as PH (as current

medication), it is NOT correct as a living arrangement
for SH.
134
 Levels of PFSH

Pertinent PFSH: One item from any of the three

history areas must be documented.

Complete PFSH: One item from any two-history

areas must be documented.

135
Reminders - Review of Systems/Past,
Family and/or Social History

⚫ Previous encounter can be reviewed and updated

⚫ May be recorded by ancillary staff with review documented by ERMD (does not
include the HPI which must be documented by the EDMD when coding a physician
service).
⚫ If unable to obtain, MD must record prohibitive condition or circumstances, which
precludes obtaining a history (for example, confused patient). This applies to all E/M
levels (99281 - 99285) for the history component. A patient’s condition may prohibit
the EDMD from obtaining all of the history elements but the patient’s condition may
not be acute enough to meet the caveat requirement. These patients do not have to
necessarily meet the 99285 “caveat” previously discussed.
⚫ May be included in HPI
⚫ AMA/HCFA Guidelines state, “The chief complaint, ROS, and PFSH, may be listed as
separate elements of history, or they may be included in the description of the HPI.”
⚫ Elements found in the PFSH can be used for ROS counting.
⚫ Brief statement of "all others negative or noncontributory or unremarkable" related to
unaffected areas is acceptable for completion of the ROS.
⚫ "Negative, noncontributory or unremarkable" is acceptable as documentation of the
past, family and/or social history elements.
136
 Body Area vs. Organ System
⚫ Body Area - Visual inspection and/or
minimal palpation.

⚫ Organ System - Auscultation, percussion,

deep palpation.

137
Elements of Physical Examination
(Key Component)
Recognized Organ Systems

⚫ Constitutional (vital signs, general appearance)

⚫ Eyes
⚫ Ears, nose, throat/mouth (ENT)
⚫ Respiratory
⚫ Cardiovascular
⚫ Genitourinary
⚫ Neurological
⚫ Skin
⚫ Gastrointestinal
⚫ Musculoskeletal
⚫ Psychiatric
⚫ Hematologic/lymphatic/immunologic

138
Elements of Physical Examination
(Key Component)
Recognized Body Areas
⚫ Head, including face
⚫ Neck
⚫ Chest, including breasts and axillae
⚫ Abdomen
⚫ Back, including spine
⚫ Genitalia, groin, buttocks
⚫ Extremities, each

139
 PHYSICAL EXAM
Requirements for expanded problem-focused exam and detailed exam

Expanded problem-focused exam requires 2 to 7 body areas and/or

organ systems (affected body area or organ system plus other
symptomatic or related organ system(s)).

Detailed exam requires 2 to 7 body areas and/or organ systems

(affected body area or organ system plus other symptomatic or related
organ system(s)). Exam component for the affected body area or
organ system must include documentation of at least 3 items.

140
 PHYSICAL EXAM – Minimum
Requirements
Organ systems:

Constitutional
T-system
Any check or indication under “General Appearance” or check or indication for “oriented x3” under “Neuro/Psych” or
documentation of “obese” or “obese abdomen”.
All other chart formats
Documentation of performance of any one of the following: Observe the patient’s general presentation, state of health,
height, build, or sexual development (“obese abdomen” is acceptable). Note dress, grooming, or personal hygiene. State of
awareness or level of consciousness. Vital signs taken by physician (do not accept as taken by physician if all VS are
identical to those in the Nurse’s notes).

Skin
T-system
Any check or indication under “Skin”.
All other chart formats
Documentation of performance of any one of the following: Observe the skin of the face and its characteristics. Identify any
lesions. Inspect the hair and nails. Study the hands.

141
 PHYSICAL EXAM – Minimum
Requirements

Eyes
T-system
Any check or indication under “EENT” or “HEENT” pertaining to eyes.
All other chart formats
Documentation of performance of any one of the following:
Check visual acuity. Note position or alignment of the eyes. Observe the eyelids or inspect the sclera and conjunctiva of
one or both eyes. Inspect the cornea, iris, or lens of one or both eyes. Compare the pupils and test their reactions to light.
Assess the extraocular movements.
Note: “EENT normal” or “HEENT normal” is acceptable for both Eyes and ENT.

ENT
T-system
Any check or indication under “EENT” or “HEENT” pertaining to ears, nose or throat.
All other chart formats
Documentation of performance of any one of the following:
Ears: Inspect the auricles, canals, or drums. Check acuity. Nose and sinuses: Examine the external nose, nasal mucosa,
septum, or turbinates. Palpate for tenderness of sinuses. Mouth and pharynx: Inspect the lips, oral mucosa, gums, teeth,
tongue, palate, tonsils, or pharynx.
Note: “EENT normal” or “HEENT normal” is acceptable for both Eyes and ENT.

142
 PHYSICAL EXAM – Minimum
Requirements
Respiratory
T-system
Any check or indication under “Respiratory” except “chest non-tender” (indicates body area, not organ system).
All other chart formats
Documentation of performance of any one of the following:
Percuss the chest. Evaluate the level of diaphragmatic dullness. Evaluate breath sounds.

Musculoskeletal
T-system
Check or indication for “Normal ROM” under “Extremities” or “Neck” (or pertinent positive), or any check or indication under
any joint exam, or any check or indication under “Extremities” reflecting an orthopedic exam (as opposed to a
cardiovascular exam).
All other chart formats
Documentation of performance of any one of the following:
Inspect and palpate any joint. Check their range of motion. Examine any aspect of musculoskeletal system. Straight-leg
raise test.

143
 PHYSICAL EXAM – Minimum
Requirements

Cardiovascular
T-system
Any check or indication under “CVS” or check or indication for “pedal edema”, “no pedal edema”, or “clubbing” (under
“Extremities”), “cyanosis” (under “Skin”), “bruit” or “carotid” (under “Neck”).
All other chart formats
Documentation of performance of any one of the following:
Inspect and palpate the carotid pulsations. Listen for carotid bruits. Observe for JVD. Inspect and palpate the
precordium. Listen for heart sounds. Inspect for cyanosis, clubbing or edema. Palpate peripheral pulses

Gastrointestinal
T-system
Any check or indication under “GI” or “heme” (negative, positive or trace positive stool) under “Rectal”.
All other chart formats
Documentation of performance of any one of the following:
Inspect, auscultate or percuss the abdomen. Assess liver or spleen. Palpate for hernias.
Note: “Abdomen soft/non-tender” is acceptable as an organ system.

144
 PHYSICAL EXAM – Minimum
Requirements
Neurological
T-system
Any check or indication under “Neuro/Psych” except “oriented x3” alone or “mood/affect nml” or “depressed affect”.
Both “oriented x3” (Neuro/Psych) and “alert” (General Appearance) qualifies for Neurological organ system.
Note: “oriented x3” or “alert” cannot be used for more than one (Neurological, Psychiatric, and Constitutional).
All other chart formats
Documentation of performance of any one of the following:
Examination of any of the cranial nerves, muscle tone, muscle strength, reflexes, or status or response to pain,
temperature, or light touch. Straight-leg raise test.

Genitourinary
T-system
Any check or indication under “Pelvic” or “Genital”, or check or indication for “non-tender” (or pertinent positive) under
“Rectal”, or check or indication for “CVA tenderness” under “Back”.
All other chart formats
Documentation of performance of any one of the following:
Male and Female: Inspect external genitalia. Inspect for CVA tenderness or flank pain. Try to palpate or percuss kidneys.
Male: Inspect for hernias, discharge from or sores on the penis, testicular pain or masses. Palpate anal canal, rectum or
prostate. Female: Pelvic or rectal exam. Palpate uterus or adnexa.

145
 PHYSICAL EXAM – Minimum
Requirements
Psychiatric
T-system
Check or indication for “mood/affect nml” (or pertinent positive) or check or indication for “depressed affect” under
“Neuro/Psych”, or alert in “General” or orientated x 3 in “Neuro/Psych” (if not used in conjunction with alert for Neuro or
constitutional element)
All other chart formats
Documentation of performance of any one of the following:
Assess mood, thought process, attention or memory.

Hematologic/lymphatic
T-system
Check or indication for “lymphadenopathy” under any heading.
All other chart formats
Documentation of performance of any one of the following:
Examine the skin for bruises/contusions, ecchymosis, bleeding, petechiae. Inspect and palpate lymph nodes located in the
arm (infraclavicular, axillary, epitrochlear), breast area (pectoral, central, lateral, subscapular), groin or head and neck
(preauricular, tonsillar, submental, submaxillary, deep cervical chain, occipital).

146
 PHYSICAL EXAM – Minimum
Requirements
BODY AREAS:

Head body area

Documentation of performance of any one of the following:
Visually examine the skull or face. “Normocephalic” is acceptable
Neck body area
Documentation of performance of any one of the following:
Feel for deviation of trachea. Inspect and palpate the thyroid gland.
Back body area
Documentation of performance of any one of the following:
Inspect and palpate the spine or muscles of the back.
Chest/breasts body area
Documentation of performance of any one of the following:
Palpate the chest, breasts, axillae. “Chest non-tender” under “Respiratory” on T-system chart is acceptable.
Abdomen body area
Documentation of performance of any one of the following:
Inspect abdomen. Note abdominal girth.
Genitalia, groin, buttocks body area
Documentation of performance of one of the following:
Visually examine external genitalia or buttock area.
Extremity body area (each)
Documentation of performance of any one of the following:
Examine for swelling or discoloration. Document obvious deformities.

147
PHYSICAL EXAM
Physical Exam Summary Table
PHYSICAL EXAMINATION
E&M Body area/organ system requirements Type of exam
level
99281 Problem-focused examination
1 BA or OS Limited exam of affected BA/OS
99282 Expanded problem-focused exam
2-7 BA or OS Limited exam of affected BA/OS + symptomatic/related OS
99283 Expanded problem-focused exam
2-7 BA or OS Limited exam of affected BA/OS + symptomatic/related OS
99284 Detailed exam
2-7 BA or OS Extended exam of affected BA/OS + symptomatic/related OS
(3 or > items for affected BA/OS)
99285 Comprehensive exam
8 OS only General multisystem exam

148
 E/M Policy When 1 OS/BA
Documented in Physical Exam
NON CMS Payors:
⚫ 1 BA/OS documented in the non-affected area – E/M level 1
Example: doc 120044012661 – patient is dx with back pain, exam addresses non-affected OS – E/M level 1

⚫ 1 BA/OS documented in the affected area – code appropriate E/M level

Example: doc 120794014502 – patient is dx with red eye & get Rx, exam addresses affected OS - E/M level 3

149
 E/M Policy When 1 OS/BA
Documented in Physical Exam
CMS Payors:
⚫ 1 BA/OS documented in the non-affected area – non-billable 0098
Example: 120174002053 – patient dx with chest wall pain, exam addresses non-affected OS – nb0098

⚫ 1 BA/OS documented in the affected area – E/M level 1

Example: 120044011725 – patient dx with hives, exam addresses affected OS – bill E/M level 1 and complete the down
code screen

Reminder – vital signs taken by provider (MD/MLP) can be utilized as an organ

system; vital signs taken by the nurse cannot.

150
 SELECTING THE APPROPRIATE LEVEL OF
EVALUATION AND MANAGEMENT SERVICE

The Emergency Medicine “Caveat” - 99285 Emergency department visit for

the evaluation and management of a patient, which requires these three key
components within the constraints imposed by the urgency of the patient’s
clinical condition and mental status.” The caveat applies to all key elements
of the E/M level; history, physical examination and decision making. In the
emergency department, if the decision making level is high complexity it is
generally an indication that the two remaining key elements (history and
physical examination) should be of equal acuity. When one is not, the coder
should review the record for signs or discussion that indicate whether the
urgency of the patient’s condition interfered with the physician’s ability to
obtain the required key information through discussion or examination.

All Level 5 patients present to the ED with high severity problem(s) but all do
not meet the requirement for a caveat. Use of the caveat is truly an exception
and not the norm.

151
Keep the following in mind when assigning the caveat:

⚫ The coder should review the record for signs or discussion that indicate whether the
urgency of the patient’s condition interfered with the physician’s ability to obtain the
required key information through discussion or examination.
⚫ Before determining whether or not to use the caveat make certain that the patient’s
condition is high acuity and would warrant a 99285 E/M code. The case should meet
the requirement for high medical decision making. While the caveat applies to all three
key components, keep in mind that MDM is an independent activity that requires little
participation from the patient. The H&P are the elements most affected and require use
of the caveat.
⚫ As a coder, you should not have to “search through” the record when deciding whether
or not the caveat is appropriate. The reason(s) for the caveat should be obvious.
⚫ Key words that should go through your mind include immediate instability, immediate
crisis, and/or obvious urgent condition (assuming CCT doesn’t apply).
⚫ In these cases, the performance/documentation of a comprehensive H&P is clinically
inappropriate or may adversely delay timely initiation of treatment.
⚫ The majority of caveat patients are most likely to be admitted (transferred) or
re-evaluated on an urgent basis.

152
Ask yourself the following questions when
assigning a caveat for the 99285 level of service:

1. Is the medical decision making high complexity?

2. Is the presenting problem high severity?

3. What is the obvious condition/reason that prevents/prohibits the

EDMD from obtaining a comprehensive H&P?

153
 Possible scenarios for assigning a caveat:
Less than a comprehensive history and examination is justified when a serious
presenting problem is identified by the treating physician. Below are
examples of possible scenarios for use of the caveat. The entire content and
context of the medical record (not just the diagnosis or chief complaint) has to
be evaluated.

⚫ Chest pain consistent with coronary artery disease (CAD),

pulmonary embolus or serious respiratory system disease.
⚫ Abdominal pain with altered vital signs or evidence of major
discomfort.
⚫ Altered mental status from an acute illness or injury.
⚫ Respiratory distress, including severe shortness of breath or asthma,
requiring urgent medication by injection or inhalation.

154
 Possible scenarios for assigning a caveat:
⚫ Overdoes or medication with possible suicidal intention
(unconscious, altered mental status).
⚫ Most cases requiring immediate attention by the physician
and/or triage nurse (and CCT is not indicated).
⚫ Active GI bleeding.
⚫ Multiple severe injuries/trauma.
⚫ Evidence of severe pain that would impair a patient’s ability or
willingness to answer questions.
⚫ Acute CVA.
⚫ Acute loss or impairment of memory.
⚫ Intubated and/or unconscious patient.

155
 Caveat vs. Unobtainable History

The 1995 AMA/HCFA guidelines state “if the physician is unable to obtain a
history from the patient or other source, the record should describe the patient’s
condition or other circumstance which precludes obtaining the history.”
Therefore, patients who cannot provide a history and the reason(s) is documented
by the physician, it is not always appropriate to “downcode” or “caveat” the
service. The “history exception” would apply in these cases. Instances where
use of the unobtainable history exception is appropriate are not always a Level 5
service. Unlike the “caveat” this “history exception” applies to all E/M levels
(81-85). Examples include but are not limited to patients who are:
⚫ Confused
⚫ Aphasic
⚫ Demented
⚫ Poor historians

156
 Unobtainable Physical Exam
⚫ We also want to waive a physical exam when a PE cannot be taken AND the
reason(s) is documented by the ED provider.

157
 Unobtainable History Reminders
Notes:
⚫ History includes HPI, ROS and PFSH

⚫ This applies to all E/M levels, not just level 5

⚫ ED provider may document patient’s inability to provide a

history or inability to perform a PE anywhere on the
medical record.
⚫ If provider does not document the reason to waive history,
check PE to see if patient is A&Ox1 or A&Ox2 on exam.
If yes, the history can be waived
⚫ Do not down code the E/M level due to history or PE

158
 THE CRITICAL CARE EQUATION

⚫ Time (>29 minutes) Spent by Provider in Activities Related

to Above (excluding procedures)
+
⚫ Is at least one vital organ system acutely impaired?

+
⚫ Is there a high probability of imminent life-threatening deterioration?
+
⚫ Did the provider’s efforts prevent further deterioration of the patient’s
condition?
__________________________________
⚫ Equals: Critical Care Services

159
 CRITICAL CARE TIME
When CCT has been requested and meets the minimum time requirement of >29
minutes spent by provider in CCT related Activities (excluding procedures),
then ask the following questions:

1. Is at least one vital organ system acutely impaired?

2. Is there a high probability of imminent life-threatening deterioration?
3. Did the provider’s efforts prevent further deterioration of the patient’s
condition?

If the answer to all three questions is “YES”, then assign CCT.

160
Factor # 1- Is at least one vital organ system
acutely impaired?
Vital organ systems most commonly include:
Circulatory
✓ Acute cardiac rhythm disturbances

✓ Severe labile hypertension or hypotension

✓ Acute coronary event

✓ Cerebral vascular accident

✓ Acute GI bleed

✓ Shock or severe dehydration

✓ Sepsis with unstable vital signs

Central Nervous System

✓ Acute seizure activity

✓ Intracranial process requiring measures to reduce swelling or seizure activity

161
Factor # 1- Is at least one vital organ system
acutely impaired? – cont.
Renal
✓ Acute renal failure with: decreased urine output, N/V, or confusion
Hepatic
✓ Acute liver failure
✓ Hepatic encephalopathy
Metabolic
✓ Diabetic ketoacidosis
✓ Severe electrolyte imbalance
Respiratory
✓ Severe respiratory decompensation
✓ Tension pneumonthorax with chest tube
✓ Anaphylaxis

Note: Injury or illness that jeopardizes an eye or digit, for example, does not meet this
requirement.

162
153
 Factor # 1 - cont

It is not necessary for symptoms to reflect impairment, if the

documented condition connotes impairment of a vital organ system.

However, you may determine that a vital organ is acutely impaired based
on symptoms and/or test results even if the condition does not
necessarily connote vital organ system impairment.

163
 Factor # 1 - cont

Remember: Documentation should indicate that the

condition impacting the vital organ system is present
– not simply being ruled out.

164
Factor # 2 - Is there a high probability of imminent
life-threatening deterioration?

⚫ This is subjective. Use your judgment to determine if you feel that the
patient could “crash” with no intervention.

⚫ The condition or diagnosis may imply sufficient risk of life-threatening

deterioration by itself to meet this requirement (most life-threatening
diagnoses, such as MI and CVA, fulfill this requirement). You may also
use any other information contained in the chart to make this determination
if needed.

165
 Factor # 2 - Is there a high probability of imminent
life-threatening deterioration- cont

Examples of documentation that may help you establish a high probability :

1. It may be apparent from the diagnosis

✓ MI
✓ CVA
✓ Acute Respiratory Failure

2. Or Physical Exam
✓ Condition guarded
✓ Abnormal vital signs
✓ “Patient in acute distress”

3. Or Interventions
✓ Bipap or non-rebreather (NRB) or HHHF /Vapotherm therapy
✓ IV fluids – wide open
✓ IV hypertensive meds

166
 Factor # 3 - Did the provider’s efforts prevent
further deterioration of the patient’s condition?

These efforts may simply include stabilization, monitoring, or

transferring to a higher level of care. They need not include
more aggressive interventions, as long as you feel they
prevented the patient from deteriorating.

Note: these efforts are intended to stabilize, monitor, or transfer patient to a

high level of care.

167
 COMMON CRITICAL CARE INTERVENTIONS

▪ Thrombolytics
▪ Heparin/Integrilin
▪ Bipap or non-rebreather (NRB) or HHHF /Vapotherm therapy
▪ IV antihypertensives
▪ Decadron
▪ IV fluid resuscitation w/repeat vitals
▪ Insulin drips
▪ Dopamine
▪ Blood products given in the ED
▪ IV Epinephrine
▪ Cardizem
▪ IV fluid bolus > 2L in adult or 20cc/Kg. in peds

168
Critical Care Time CPT Codes

169
 CRITICAL CARE TIME
Provider must spend at least 30 minutes on CC-related activities. Includes
time spent on the following procedures:

▪ Interpretation of cardiac output measurements

▪ Interpretation of chest x-rays
▪ Interpretation of pulse ox/blood gas
▪ Review of information/data stored in computers (EKG’s, blood
pressures, hematologic data)
▪ Gastric intubation
▪ Temporary transcutaneous pacing
▪ Ventilator management
▪ Vascular access procedures
Note: The above procedures are not separately billable with CCT.

170
 CRITICAL CARE TIME - CONT

CC time also includes, but is not limited to, these activities:

▪ Review of test results or images.
▪ Evaluation and treatment at the bedside.
▪ Conversations with medical staff.
▪ Charting, writing orders, etc. as it relates to the critical care period.
▪ Time spent engaged in work directly related to the individual patient’s
care, whether at bedside or elsewhere on the floor or unit.
▪ Making arrangements for transfer to another facility or the OR on an
immediate basis.
▪ Face-to-face patient care discussions with emergency personnel, police,
family members, and other healthcare personnel regarding treatment
options when the patient is unable or incompetent to assist. Must be
absolutely necessary to treatment decisions being considered that day.

171
 CRITICAL CARE TIME -CONT

CC time does not include separately billable procedures,

such as:
▪ CPR
▪ Endotracheal intubation
▪ CVP line(s)
▪ Chest tube
▪ EKG and rhythm strip interpretations
▪ Additional miscellaneous procedures not listed on previous slide
Note: Time does not need to be continuous.

172
 Denied Critical Care Time Process

⚫ Provider requests CCT

⚫ Coding Analyst codes or denies CCT based on
documentation provided
⚫ The denied CCT charts are sent to a special
holding queue where they await review by a
Quality Assurance Analyst
⚫ The QA analyst will review (prior to bill drop)
and make the decision to keep denial or recode as
CCT
173
 Split Shared Critical Care
Please note the following rules for coding/billing CCT when patient is seen by a MLP and a
MD:

➢ Non- Medicare payors –99291/99292 may be billed to a supervising physician and

tracked to a performing MLP.

➢ Medicare payors–99291/99292 may ONLY be billed to the provider who wrote the
CCT request, and ONLY if there is sufficient documentation by that provider to
warrant CCT. If there is not sufficient documentation by the provider who wrote the
CCT request to warrant CCT, then the coder should determine the appropriate E&M
level (99281-99285) using documentation from all providers according to the payor’s
rules regarding shared/split services.

174
 CCT DOWNCODES

There are two types of CCT downcodes:

1. CCT Denied
The MD requests CCT (9225), coder determines chart does not
warrant CCT, and codes an E/M level instead.

2. CCT Reduced
The MD requests CCT greater than 74 minutes (9225 plus one
or more units of 9233), coder determines chart warrants CCT
but less time than was requested, and codes fewer units (or no
units) of 9233 than were requested.

175
 CCT DENIED
1. Enter the E/M level and dx pointer.
2. Enter “C” in downcode field (“D”).
3. Press F1.

176
 CCT DENIED (cont.)
4. Type 9225 in “from” field; press enter.
5. Press “enter” three more times, to Section “IV.C. Critical Care Denied”.

177
 CCT DENIED (cont.)
6. Press “space bar” – the “X” will come up to flag the CC denied field.
7. Press F1 to return to coding charge entry screen.

178
 CCT REDUCED
1. Enter all CCT charges (9225 and/or 9233) that you approve, and dx pointers.
2. On last CCT charge, enter “C” in downcode field (“D”). If quantity for this charge is 1
unit, press F1. If quantity is more than 1 unit, hit “enter” to “EXN” window, enter “Y”,
and press F1.

179
 CCT REDUCED (cont.)
4. Type 9233 in “from” field; press enter.
5. Press “enter” again, to Section “IV.A. Critical Care Reduced From”.

180
 CCT REDUCED (cont.)
6. In “Reduced From” field, enter the units of 9233 ONLY corresponding to the
time requested by MD; press enter.
7. In “Reduced To” field, enter the units of 9233 ONLY corresponding to the time
you approve; press F1 to return to charge entry screen.

181
 CCT REDUCED (cont.)
Example: MD requests 120 minutes CCT (9225 + 9233x2). Coder reduces CCT
to 90 minutes (9225 + 9233x1). Enter 2 in “Reduced From” field; enter 1 in
“Reduced To” field.

182
 CCT DOWNCODES

CCT accounts flagged as denied or reduced

will go automatically to the CCT queue to be
reviewed by QA.

Notify SV immediately if dropdown list

appears after denying or reducing CCT.

183
 DOA Patients
These guidelines apply to ED Clients only.

DOA’s
⚫ Code EM level 1 or EM level 2

⚫ Documentation requirements:
➢ Level 1 - a brief physical exam by our provider (ex. no cardiac activity, pupil fixed
and dilated) and patient pronounced dead
➢ Level 2 – more than above was performed/documented by provider(s)

184
 Cardiac Arrest Patients
These guidelines apply to ED Clients only.

Cardiac Arrest
1) Look for CCT time – only deny if does not meet time requirement

2) If no CCT request, this is high risk and you should look for additional w/u
➢ Additional w/u – code a level 5 (no CMS counting needed; medical caveat)
➢ No additional w/u – 4 (no CMS counting needed; medical caveat)
3) If CCT is requested and CPR is performed
➢ If CCT is only 30 minutes (or range of 30-74): deny the CCT (fill out down code screen), code the
E/M and CPR (unless the provider specifically states procedures excluded from CCT)
➢ If CCT is more than 30 minutes: Code the CCT and CPR
CPR reminders:
⚫ ED provider must either perform CPR or supervise.
⚫ If provider supervised CPR, must document chest compression or “CPR” started or continued or in
progress, etc.

185
Computer Training
186
 New User Login Instructions
Convention used
BOLD – outputted by the computer
Italics – requires you to enter something. Note: after entering information you MUST press the
ENTER key.
Normal – Section Headings and or Description
Note:
⚫ The computer you’re logging into IS case sensitive, your login name is lowercase.
⚫ Users will be prompted to change their password.
⚫ Company policy dictates that sharing your password with anyone is grounds for dismissal.

Password Requirements:
⚫ A password must have at least six characters. Only the first 8 characters are significant
⚫ Letters must be of the English Alphabet
⚫ Password must contain at least two uppercase and/or lowercase letters and at least one numeric or special character.
⚫ A password must differ from the user’s login name and any reverse or circular shift of that login name.
For comparison purposes an uppercase letter and its corresponding lowercase equivalent are treated as identical.
⚫ A new password must differ from the old one by at least three characters. For comparison purposes an
uppercase letter and its corresponding lowercase equivalent are treated as identical.

Instructions for logging in and changing your password:

⚫Initial login and password prompt

HP-UX rti B.10.20 U 9000/867 (ttyp2)

187
New User Login Instructions
Login:
Enter your LOGIN NAME and press ENTER (usually your login name will be the first letter of your first name and your
last name up to 8 characters. (I.E. Jane Signinalot’s login name would be jsignina)

Password:
Enter the password assigned to you.

⚫ Password changing procedure

Your password has expired. Choose a new one

Changing password for <your login name will be here>
Old NIS password:
Enter the password assigned to you
New Password:

Enter a new password. See above for rules on passwords.

Retype new password:

Enter you new password again

The NIS password has been changed on rtidsva. The master NIS password server.

⚫ Login with your login name and new password (see “Initial login and password prompt”)

188
 What is a Non-Billable
Medical records that have been sent to RTI for billing but cannot have charges entered on a patient account due to
deficiencies in documentation are categorized as non-billable.

Listed below are the most frequently used non-billable codes and a brief description of each:
0098 – No Documentation – One or more key components (History, Physical Exam, and/or Medical Decision Making) is
missing from the ED chart. Suspend first time through before making non-bill for EMRs

0085 – Insufficient inpatient documentation – Missing part of the inpatient medical record necessary in order to bill. Ex:
procedure note.

0009 – Missing Scribe Attestation – The scribe attestation is missing or incomplete after it was sent back to the facility for
missing attestation or missing attestation and signature.

0038 – Unlicensed Student Practitioner – An unlicensed student is the performing provider without documentation from
the attending provider.

0041 – Resident – The teaching physician (EDMD) did not include documentation to indicate that they either:
• Performed the service or were physically present during the key or critical portions of a service performed by the
resident and
• Noted their participation in the management of the patient.

0039 – Nurse Practitioner – The supervising provider did not complete the attestation statement and the visit could not be
billed to the mid-level provider (NP) due to state/payor regulations.

189
 What is a Non-Billable
0040 – Physician Assistant -- The supervising provider did not complete the attestation statement and the visit could not be billed to the
mid-level provider (PA) due to state/payor regulations.

0065 – MLP no EDMD Co-signature (Payor Specific) – The supervising provider did not co-sign the chart after it was sent back to the
facility for signature request.

0034 – Private Medical Doctor - Patient seen by a non-Emcare physician in the Emergency Department.

0077 – Unable to locate MD notes (Non T-Sheet formats) – Missing dictation or other physician notes remain missing after chart has
been sent back to the facility for signature request.

0078 – Missing T-Sheet(s) -- T-sheet(s) still missing after chart has been sent back to facility with missing T-sheet request.

0083 – DOA – Patient is dead upon arrival with history and/or PE missing. Death pronouncement by EDMD. (Exception: If the client
bills death pronouncements).

0108 – Wound check or Dressing Change – Patient is arriving (within the global period) for wound check or dressing change with no
new signs, symptoms or problems.

0109 – Suture Removal – For clients that do not bill simple suture removals or for all clients when laceration repair was intermediate or
complex (the system will determine).

190
 What is a Non-Billable
0509 -- Suture Removal (Client Specific) – Simple laceration suture removal without an exam by the EDMD/MLP.

0125 – LWBS (left without being seen)/LWOT (left without treatment) – Patient left without being seen by the ED provider,
or left without treatment or patient refuses the examination.

0091 – Void -- To be used when the non-billable fits no other scenario.

Reminders:

*Some clients have client-specific non-billables: special screenings, sexual assault non-billable codes, etc. (refer to the
client fact sheet).

*Look through the entire medical record to see that all pages are present and there is no additional information.

*Please alert your Supervisor if you notice an increase in non-billables.

191
 SUSPENDED CHARTS
Internally suspended charts are charts that will remain at RTI. These charts will be sent back to the hospital for further information
that is necessary to code the chart or taken care of by the supervisor on the account.

Charts are Internally Suspended for several reasons:

1. Procedure not in system
2. Provider not in system
3. Signature Missing
4. Dictation/Physician Notes Missing
5. Supervising MD Co-Signature Missing
6. Clear Copy Needed
7. Clinical Record Missing
8. First or Second Page of Template Missing
9. Scribe Attestation Needed
10. Scribe Attestation and Provider Sig Needed
11. Attestation not Legible
12. Incomplete H&P
13. Documentation is missing (HCA clients/pdoc format)
14. Cancelled (HCA clients/pdoc format)
15. Draft (HCA clients/pdoc format)
16. Other
The reason stated “Other” should only be used for specific requests for which no other description applies. When choosing “Other” as
your reason, you must type over the word other and insert your reason. If you are using “Other” frequently, please notify your
supervisor. We may be able to add another description to the computer.

DO NOT Suspend charts for the following reasons:

1. Pulse Oximetry Interpretations
2. Cardiac Monitor/EKG Interpretations
3. Bone Fracture Site—If unable to distinguish which bone, bill an E/M level
4. X-ray Interpretation 192
 Missing Provider Documentation
First time through:
⚫ Suspend a chart for IHP if history OR physical exam is missing.

⚫ Suspend a chart for H if history AND physical exam are missing.

Return Sendback:
⚫ NB 0098 - This NB code is used for returned sendbacks (suspended
for “INCOMPLETE H&P DUE TO AUTO TRANSFER”) that do not
contain the needed information to code/bill.

⚫ NB 0077/78 - This NB code is used for returned sendbacks

(suspended when a chart did not have any provider documentation)
that do not contain the needed information to code/bill.

193
 Red Screen Survival Guide
Why do red screens occur? Red screens are created when:

1) More than one chart was scanned for the same account number

⚫ duplicate of original chart

⚫ second visit
⚫ inpatient encounter
⚫ wrong patient
2) A suspended chart has been returned for coding

⚫ B – as is back – with no extra document number is ready for release

⚫ E – as in external – with an extra document number may need to be married
or replaced – then released

3) An ‘ADJUSTED’ chart is returned to you for re-coding

4) Non-billable T00000 chart now has the chart attached to the account

194
Red Screen Survival Guide -
Flowchart
RED SCREEN

DUPLICATE INPATIENT WRONG T000000… SENDBACK

PATIENT

Press (P) Select doc ‘40’ doc is Send to M(A)arry or

And ext susp sup…….. (R)eplace
For Code chart not ‘40’ to Once then
Du(P)licate With IP loc RL for ‘ADJUSTED’ release
rescan M(A)rry and
then code

With the exception of the T00000 charts, ‘extra’ documents in the red
screen need to be reviewed before you can decide on an action.

195
Surgical Procedures

196
Procedure Descriptions
RTI CODE CPT CODE DECRIPTION GLOBAL PERIOD
NON BILLABLE SERVICES

0009 Scribe attestation missing

0034 Private MD visit

(seen in ER by one’s own physician with NO ERMD involvement)

0038 Unlicensed student practitioner

0039 NP Non-billable

0040 PA Non-billable

0041 Resident non billable

(Medicare charts without proper attestation)

0065 Non-billable MLP w/o MD co-signature

0077 Missing MD notes

(No additional information per batcher. “Bill as is”)

0078 Missing T Sheet

(Externally suspended chart is returned with T sheet still missing)

0083 Dead on arrival

0085 Insufficient inpatient documentation.

197
 Procedure Descriptions
RTI CODE CPT CODE DECRIPTION GLOBAL PERIOD

NON BILLABLE SERVICES

0091 Void

0098 Insufficient MD documentation

(For all payors when missing one or more of the 3 key components-history, physical
exam, and/or medical decision making)

0108 Non-bill wound check/dressing change

0109 Suture removal

0125 Left without being seen

0509 Simple suture removal-nursing only; no ERMD/MLP involvement

EVALUATION & MANAGEMENT SERVICES (SICKNESS)

9016 99281 Emergency medical evaluation & management level 1

9028 99282 Emergency medical evaluation & management level 2

9039 99283 Emergency medical evaluation & management level 3

9046 99284 Emergency medical evaluation & management level 4

9055 99285 Emergency medical evaluation & management level 5

198
Procedure Descriptions
EVALUATION & MANAGEMENT SERVICES (INJURY)

9077 99281 Emergency medical evaluation & management level 1

9081 99282 Emergency medical evaluation & management level 2

9090 99283 Emergency medical evaluation & management level 3

9103 99284 Emergency medical evaluation & management level 4

9120 99285 Emergency medical evaluation & management level 5

SUBSEQUENT OBSERVATION CARE SERVICES

9244 99224 Subsequent Observation 1 – 15 min

9245 99225 Subsequent Observation 2 – 25 min

9246 99226 Subsequent Observation 3 – 35 min

OBSERVATION CARE SERVICES Admit and Discharge Same Day

9234 99234 Initial observation care level 1

9235 99235 Initial observation care level 2

9236 99236 Initial observation care level 3

199
Procedure Descriptions
OBSERVATION CARE SERVICES More than one calendar date

9218 99218 Initial observation care level 1 – 30 min at bedside and on floor

9219 99219 Initial observation care level 2 – 50 min at bedside and on floor

9220 99220 Initial observation care level 3 – 70 min at bedside and on floor

9217 99217 Observation care discharge day summary

RTI CODE CPT CODE DECRIPTION GLOBAL PERIOD

CRITICAL CARE

9225 (Sickness) 99291 Critical care services 30 minutes to 74 minutes in duration

9325 ( Injury) 99291 Critical care services 30 minutes to 74 minutes in duration

9233 99292 Critical care services each 30 minute increment over initial 74 minutes

9274 92950 CPR (includes defibrillation) – performed on patients in cardiac arrest

9226 92960 Cardioversion – Electrical conversion of a cardiac arrhythmia; performed for patients
with heart irregularities or arrhythmias, billable with CCT and CPR
when indicated and performed.

9241 99288 MD directed EMS/ALS (pre-hospital)

200
Procedure Descriptions
INVASIVE PROCEDURES

ARTERIAL/VENOUS ACCESS

3004 36420 Venous cutdown in patient LT one year of age

3012 36425 Venous cutdown in patient one + year of age 0 days

(Incision made in skin over vein- needle inserted into vein to
wiithdraw blood or to infuse medications or fluids)

3025 36555 Insertion of a non-tunneled centrally inserted venous catheter 0 days

in patient LT 5 years of age
(venous catheter inserted directly through skin into vein)

3026 36556 Insertion of a non-tunneled centrally inserted venous catheter 0 days

in patient GT5 years of age

3027 36557 Insertion of a tunneled centrally inserted venous catheter in 0 days

patient LT 5 years of age
(venous catheter is threaded through a surgically created subcutaneous
tunnel and then into vein)

3028 36558 Insertion of a tunneled centrally inserted venous catheter in 0 days

patient GT 5 years of age

3030 36571 Insert PICC catheter – 5+ years 0 days

3040 36491 Insert PICCC catheter – GT 2 years

201
Procedure Descriptions
3046 36410 Physician venipuncture in patient GT 3 years of age 0 days
(nursing procedure; ERMD must state medical necessity and “performed by me”)

3053 36600 Arterial puncture for blood gases 0 days

3142 36140 Arterial introduction of a needle/intra-catheter 0 days

(“A-Line”)

3139 36680 Placement of needle for intra-osseous infusion 0 days

(needle inserted into bone marrow to administer medications/fluids)

3129 36000 Insert peripheral IV, unilateral 0 days

(nursing procedure; billable when ERMD performs and documents procedure)

3137 36000 Insert peripheral IV, bilateral 0 days

3145 36400 Venipuncture, jugular or femoral in patient - LT 3 years of age 0 days

3152 36405 Venipuncture, scalp in patient - LT 3 years of age 0 days

3154 36406 Venipuncture other vein – LT 3 years of age 0 days

3591 36591 Collection of blood specimen from a completely implantable 0 days

venous access device

3592 36592 Collection of blood specimen using established central or peripheral 0 days
catheter, venous, not otherwise specified

202
Procedure Descriptions
3593 36593 Declotting by thrombolytic agent of implanted vascular access device 0 days
or catheter

CARDIOTHORACIC

3061 33210 Insert temporary transvenous pacemaker 0 days

(pacer wire inserted through subclavian or jugular vein)

3087 33010 Pericardiocentesis

(drainage of fluid from pericardial space) 0 days

3554 32554 Thoracentesis, needle or catheter, aspiration of the pleura space,

without imaging guidance 0 days
(puncture of pleural cavity for aspiration, initial or subsequent)

9282 93503 Swanz-Ganz placement 0 days

(Catheter threaded through femoral vein to heart to monitor
cardiac pressures)

3555 32555 Thoracentesis, needle or catheter, with imaging guidance 0 days

3550 32550 Insertion of indwelling tunneled pleural catheter with cuff 0 days

203
Procedure Descriptions
3551 32551 Tube thoracostomy, includes water seal 0 days
(eg. for abscess, hemothorax ,empyema) when performed, separate
procedure

3560 32560 Chemical pleurodesis for recurrent or persistent pneumothorax 0 days

3119 32110 Thoracotomy, major, with control of traumatic hemorrhage 0-90 days
(chest is surgically opened)

3125 32160 Thoracotomy, major, with cardiac massage 0-90 days

(chest is surgically opened with internal massage of heart)

FOREIGN BODY REMOVAL

2014 28190 Removal of foreign body, subcutaneous foot 0-10 days

(incision must be made to bill procedure)

2029 20102 Exploration of a penetrating wound, abdomen/back/flank 0-10 days

6007 65220 Removal of foreign body, cornea, simple 0 days

(removed by beveled edge needle)

6015 65222 Removal of a foreign body, cornea, complex 0 days

(removed with eye spud/eye burr, slit lamp)

6017 65235 Removal of a foreign body, deep cornea 0-90 days

(incision made between cornea and sclera- rarely done by ERMD)

204
Procedure Descriptions
6023 65205 Removal of a foreign body, conjunctiva, superficial 0 days
(removed by irrigation, cotton swab, or needle)

6031 65210 Removal of a foreign body, conjunctiva, embedded

(may require a small incision) 0 days

3228 30300 Rhinoscopy/foreign body removal from nasal passage 0-10 days
(requires removal by forceps or suction)

6049 69200 Otoscopy/foreign body removal from external ear canal 0 days
(requires removal by forceps, cerumen scoop, suction, or
irrigation;if removed by irrigation, ERMD must state that he
did the procedure)

4044 46608 Anoscopy with foreign body removal from anal canal 0 days

1107 10120 Removal of a foreign body from subcutaneous tissue, simple 0-10 days
(incision must be made into skin, skin may or may not be
sutured after removal)

1115 10121 Removal of a foreign body from subcutaneous tissue, complex 0-10 days
(incision must be made into the skin for embedded foreign
body requiring deep tissue dissection)

3290 42809 Removal of a foreign body, pharynx 0-10 days

(topical anesthetic to mouth and pharynx; foreign body
removed with forceps)

205
Procedure Descriptions
EARS, NOSE, AND THROAT (ENT)

3160 30901 Control nose bleed, anterior, simple, limited cautery, unilateral 0 days
(electrical or chemical coagulation, silver nitrate, epinephrine
soaked pledgets, topical cocaine, may require some packing)

3178 30901 Control nose bleed, anterior, simple, limited cautery, bilateral 0 days

3194 30903 Control nose bleed, anterior, complex, any method, unilateral 0 days
(nose bleed not responsive to simple coagulation or packing,
requires extensive electrical coagulation and/or packing)

3202 30903 Control nose bleed, anterior, complex, any method, bilateral 0 days

3210 30905 Control nose bleed with posterior packs, initial, any method 0 days
(MD must document posterior bleeding and packing)

3236 31505 Indirect laryngoscopy (diagnostic) 0 days

(laryngeal mirror used to exam larynx and tongue, often used
to evalforeign body sensation)

3240 31525 Direct laryngoscopy (diagnostic), other than newborn, rigid 0 days
(laryngoscope used to examine larynx)

3244 31511 Indirect laryngoscopy with foreign body removal 0 days

3291 41250 Simple laceration repair anterior 2/3 tongue/floor of mouth 0-10 days
2.5cm. or less

2394 41251 Simple laceration repair posterior 1/3 tongue 2.5 cm. or less 0-10 days

6054 69209 Removal impacted cerumen using irrigation/lavage, unilateral

Add modifier 50 for bilateral procedure. Do not code with 6056

6056 69210 Remove impacted cerumen using suction, cerumen spoon, 0 days
forceps unilateral Add modifier 50 for bilateral procedure.
Do not code with 6054

206
Procedure Descriptions
AIRWAY/RESPIRATORY

3233 31502 Change tracheostomy tube 0 days

(used to bill replacement of dislodged tracheostomy tube)

3251 31500 Endotracheal intubation 0 days

(orally or nasally) (Modifier 51 exempt)

3269 31603 Tracheostomy, emergent 0 days

(surgical opening into trachea)

3277 31605 Cricothyroidostomy, emergent 0 days

(large bore needle inserted into cricothyroid membrane to maintain airway)

9337 94656 Ventilator management (note: inpatient charge only)

(MD must document ventilator settings and/or changes) 0 days

31632 Bronchoscopy, rigid or flexible, including fluoroscopic guidance,

When performed; with transbronchial lung biopsy(s), each additional lobe
(list separately in addition to code for primary procedure)

31633 With transbronchial needle aspiration biopsy(s), each additional lobe

(list separately in addition to code for primary procedure)

GASTROINTESTINAL

4001 43762 Change gastrostomy tube, percutaneous, without imaging or 0 days

endoscopic guidance

4003 43761 Repositioning of the gastric feeding tube, through the duodenum 0 days
for enteric nutrition
207
Procedure Descriptions
4004 43763 Replace gastric feeding tube requiring revision (complex). Includes incision into skin 0 days
and fascia.

4440 49440 Insertion of gastrostomy tube, percutaneous, under fluoroscopic 0 days

guidance including contrast injection(s), image documentation
and report

4441 49441 Insertion of duodenostomy or jejunostomy tube, percutaneous, 0 days

under fluoroscopic guidance including contrast injection(s), image
documentation and report

4442 49442 Insertion of cecostomy or other coplonic tube, percutaneous, under 0 days
fluoroscopic guidance

4446 49446 Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous 0 days

under fluoroscopic guidance including contrast injection(s), image documentation

4450 49450 Replacement of gastrostomy or cecostomy (or other colonic) tube, 0 days
percutaneous, under fluoroscopic guidance including contrast injection(s),
image documentation and report

4451 49451 Replacement of duodenostomy or jejunostomy tube, percutaneous, under 0 days

fluoroscopic guidance including contrast injection(s), image documentation
and report

4460 49460 Mechanical removal of obstructive material from gastrostomy, duodenostomy, 0 days
jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any
method, under fluoroscopic guidance including contrast injection(s), if performed,
image documentation and report

208
Procedure Descriptions
4465 49465 Contrast injection(s) for radiological evacuation of existing gastrostomy, duo- 0 days
enostomy, jejunostomy, gastro-jejunostomy or cecostomy (or other colonic) tube,
from a percutaneous approach including image documentation and report

4011 49082 Abdominal pericentesis, peritoneal lavage, initial 0 days

(needle inserted into abdominal cavity to withdraw and/or infuse fluids,
without imaging guidance)

4948 49083 Abdominal pericentesis, peritoneal lavage, initial 0 days

(needle inserted into abdominal cavity to withdraw and/or infuse fluids,
with imaging guidance)

4036 46600 Anascopy, diagnostic 0 days

(exam of anal canal and rectal mucosa)

4051 45300 Proctosigmoidoscopy 0 days

(diagnostic exam of the sigmoid colon, commonly done to eval
GI bleed)

4067 46320 Enucleation of external thrombotic hemorrhoid 0-10 days

(incision and removal of clot or removal of hemorrhoid)

4028 45915 Fecal disimpaction under anesthesia 0-10 days

(MD must do the disimpaction)

9307 91105 Gastric intubation lavage for treatment 0 days

(NG tube or Ewald tube placed for lavage; MD must state that
he did the procedure)
209
Procedure Descriptions
INCISION AND DRAINAGE

4048 46040 I&D perirectal abscess 0-90 days

4065 46083 I&D thrombosed external hemorrhoid 0-10 days

4077 46050 I&D perianal abscess, superficial 0-10 days

5024 55100 I&D Scrotum abscess 0-10 days

5030 56405 I&D vulva or perineal abscess 0-10 days

5033 56420 I&D Bartholin’s gland cyst 0-10 days

6028 67700 I&D eyelid abscess 0-10 days

6033 69000 I&D external ear abscess or hematoma, simple 0-10 days
(ear lobe, pinna)

6044 69020 I&D external auditory canal abscess 0-10 days

1008 10080 I&D pilonidal cyst/abscess 0-10 days

1016 10060 I&D abscess, single, paronychia, carbuncle, sebaceous cyst 0-10 days
(wound usually left open for continued drainage)

1018 10061 I&D abscess, complicated or multiple sites 0-10 days

(drain or gauze packing placed to allow continued drainage)

1073 19020 I&D breast abscess (mastotomy) 0-90 days

210
Procedure Descriptions
1099 11740 I&D subungal hematoma (evacuation) 0-10 days
(releasing hematoma under fingernail or toenail; done usually
done by drilling or burning a hole to release blood)

1230 10140 I&D hematoma, seroma, or fluid collection 0-10 days

(may include drain, packing, and/or pressure dressing)

2006 26011 I&D felon 0-10 days

(abscess of deep subcutaneous tissue of a finger, requiring
debridement and irrigation)

2025 26010 I&D finger abscess, simple 0-10 days

(abscess of cutaneous tissue, does not require debridement
and irrigation)

3285 38300 I&D lymph node abscess 0-10 days

(wound is irrigated and closed with sutures or steri strips)

3293 41800 I&D dental abscess 0-10 days

4075 42700 I&D peritonsillar abscess 0-10 days

1081 10160 Puncture aspiration of hematoma, abscess, etc. 0-10 days

(fluid is drained by large bore needle, no incision)

4233 42330 Sialolithotomy, uncomplicated, intraoral 0-10 days

(removal of a stone from submandibular, sublingual, or
parotid duct)

GENITOURINARY 211
5058 51702 Insert urethral catheter, simple 0 days
(nursing procedure; ERMD must state medical necessity and
Procedure Descriptions
4341 53620 Dilation of urethral stricture, male 0 days

5100 51100 Aspiration of bladder by needle 0 days

(urine withdrawn from bladder for drainage)

5101 51101 Aspiration of bladder by trochar or catheter 0 days

(trochar or intracatheter inserted into bladder for drainage)

5102 51102 Suprapubic tube is placed into bladder 0-10 days

(simple cystostomy/suprapubic tube replacement)

4309 50398 Change nephrostomy or pyelostomy tube 0 days

5385 50385 Removal (via snare/capture) and replacement of internally dwelling 0 days
ureteral stent via transurethral approach, without use of cystoscopy,
including radiological supervision and interpretation

5386 50386 Removal (via snare/capture) of internally dwelling ureteral stent via 0 days
transurethral approach, without use of cystoscopy, including radiological
supervision and interpretation

5017 51705 Change cystostomy tube, the MD uses a guidewire to insert the tube 0-10 days
then sutures it into place.

5025 57020 Colpocentesis 0 days

(aspiration of fluid from peritoneum through vaginal wall)

5074 59409 Vaginal delivery only (ED or hosp setting) 0 days

(vaginal delivery of an infant and placenta; includes
episiotomy)
212
Procedure Descriptions
5041 59410 Vaginal delivery inc PP care 0 days
(vaginal delivery including post-partum care – hosp only)

4366 59414 Delivery of placenta 0 days

(performed to remove retained placenta after delivery)

7587 50690 Injection for visualization- ileal conduit 0 days

(x-ray study of kidneys using contrast medium)

INJECTIONS
6064 62270 Lumbar puncture/spinal tap 0 days

6066 64402 Injection of a facial nerve 0 days

6060 64400 Injection of trigeminal nerve (dental block) 0 days

6072 64450 Peripheral nerve block, digital (finger/toe) 0 days

(included in global procedures, not billable to Medicare)

6070 64421 Intercostal nerve block 0 days

(block chest wall pain; multiple sites may be blocked)

64461 Paravertebral block (PVB) (paraspinous block), thoracic;

single injection site (includes imaging guidance, when performed)

64462 Second and any additional injection site(s) (including imaging guidance,
when perfomed) (List separately in addition to code for primary procedure)

64463 Continuous infusion by catheter (includes imaging guidance, when performed)

213
Procedure Descriptions
2061 19101 Biopsy of breast, incisional 0-10 days

2030 20600 Arthrocentesis, small joint (fingers, toes) , bursa, or ganglion cyst 0 days
(fluid may be withdrawn or medication injected into the joint)

20604 Arthrocentesis, aspiration and/or injection small joint or bursa, with US guidance

2048 20605 Arthrocentesis, medium joint (wrist, elbow), bursa, ganglion cyst 0 days

2049 20606 Arthrocentesis, medium joint (wrist, elbow), bursa, ganglion cyst, with US guidance

2052 20552 Injection, trigger point – 1 or 2 muscles 0 days

2053 20553 Injection, trigger point – GT 3 0 days

2055 20610 Arthrocentesis, large joint (shoulder, hip, knee), bursa, 0 days
ganglion cyst

2056 20611 Arthrocentesis, large joint (shoulder, hip, knee), bursa, 0 days
ganglion cyst, with US guidance

2063 20550 Injection, tendon sheath, ligament, 0 days

MODERATE SEDATION
9151 99151 Moderate sedation –LT 5 yrs old; same physician; 10min or more 0 days
(Modifier 51 exempt)

9152 99152 Moderate sedation – 5 + yrs old; same physician; 10 min or more 0 days
(Modifier 51 exempt)

214
Procedure Descriptions
RTI CODE CPT CODE DECRIPTION GLOBAL PERIOD
MODERATE SEDATION

9153 99153 Moderate sedation; same physician; Add’l 15 minutes 0 days

9161 99155 Moderate sedation –LT 5 yrs old; different physician; 10 min or more 0 days

9162 99156 Moderate sedation 5 + yrs old; different physician; 10 min or more 0 days

9163 99157 Moderate sedation; different physician; Add’l 15 minutes 0 days

NAILS & SKIN

2148 11760 Repair of nail bed/nail matrix 0-10 days
(removal of nail and digital block is included)

2151 11762 Reconstruction of nail bed with graft 0-10 days

1136 11752 Excision nail bed with amputation of distal phalynx tuft 0-10 days

1123 11750 Nail excision, partial/complete for permanent removal, non 0-10 days
traumatic (ingrown toenail)

1119 11730 Avulsion of nail, partial, complete, traumatic 0-10 days

(removal of avulsed nail)

1128 11765 Wedge excision of skin of nail fold 0-10 days

(skin around nail)

1131 11401 Excision benign lesion 0.6-1.0 cm, trunk, limbs 0-10 days

215
Procedure Descriptions
1133 11403 Excision benign lesion 2.1-3.0 cm, trunk, limbs 0-10 days

1149 11421 Excision benign lesion 0.6-1.0 cm, scalp, hands, feet 0-10 days

1156 11442 Excision benign lesion 1.0-2.5 cm face, ears 0-10 days
(excludes skin tags)

1116 11200 Skin tag removal 0-10 days

1161 11000 Debridement -LT 10 PCT of body surface 0 days

(ERMD removes dead or damaged surface skin, such as with abrasions, minor burns)
Other debridement codes listed with burns

1171 17250 Chemical cauterization of granulation tissue 0 days

(cauterization of healing wound tissue)

1172 15851 Removal of sutures from another MD with anesthesia or sedation 0 days

8255 12020 Wound dehiscence repair (Simple repair; single layer closure) 0-10 days

BURNS No burn treatment will be billed if the procedure is performed by nursing staff

1198 16000 Treat 1st degree burn (unbroken skin), local treatment only 0 days
(treatment includes cleansing and applicaton of ointment with or w/o dressing)

1206 16020 Treat 2nd- 3rd degree burn (broken skin, blistering, partial thickness) 0 days
(treatment includes cleansing, debridement and/or application of ointment or cream w or w/o dressing)

216
 Procedure Descriptions
1214 16025 Treat medium burn (whole face or entire extremity) w/o anesthesia 0 days
(includes cleansing, debridement, and/or application of ointment or cream with or w/o dressing)

1222 16030 Treat large burn (more than one entire extremity) w/o 0 days
anesthesia

MUSCULOSKELETAL
2017 26410 Repair extensor tendon, hand, primary repair, w/o graft 0-90 days
(incision must be made)

2022 26418 Repair extensor tendon, finger, primary repair, w/o graft 0-90 days
(incision must be made)

2028 26432 Repair extensor tendon, finger, with splinting 0-90 days
(No incision made; finger is splinted in an extended position)

2225 26951 Amputation, finger or thumb, primary, joint or phalynx, single 0-90 days
with direct closure
(MD removes bone following an acute injury)

NON-INVASIVE PROCEDURES

DISLOCATIONS
2071 21480-54 Treat closed temporomandibular dislocation, initial or 0 days
subsequent (manual reduction)

2089 23520-54 Treat closed sternoclavicular dislocation , no reduction 0-90 days

(splint or brace applied, no manual manipulation)

217
 Procedure Descriptions
2097 23540-54 Treat closed acromioclavicular dislocation (AC separation), 0-90 days
no reduction (affected shoulder or arm placed in a sling or other brace)

2170 23545-54 Reduce acromioclavicular dislocation 0-90 days

2105 26670-54 Reduce carpometacarpal dislocation (other than the thumb), 0-90 days
single (Bennett fx)

2113 23650-54 Reduce closed shoulder dislocation 0-90 days

2125 23665-54 Reduce closed shoulder dislocation w/ fracture of greater 0-90 days
tuberosity

2139 24600-54 Reduce closed elbow dislocation 0-90 days

(manual reduction, elbow placed in splint or brace)
2220 26770-54 Reduce interphalangeal joint dislocation 0-90 days

2162 24640-54 Reduce radial head dislocation in child, nursemaid’s elbow or 0-10 days
subluxation (partially dislocated)
(often reduces spontaneously)

2329 25675-54 Reduce distal radius and/or ulna (wrist) dislocation 0-90 days

2188 26700-54 Reduce metacarpophalangeal (knuckle) dislocation 0-90 days

2253 27560-54 Reduce closed patellar dislocation 0-90 days

218
 Procedure Descriptions
2265 27250-54 Reduce closed hip dislocation, traumatic 0-90 days

2267 27265-54 Reduce closed post hip arthroplasty dislocation 0-90 days

2279 27840-54 Reduce ankle dislocation (cast or brace is applied after reduction) 0-90 days

2287 28630-54 Reduce metatarsophalangeal (foot) dislocation 0-10 days

2311 28660-54 Reduce toe dislocation 0-10 days

FRACTURE CARE

2263 27200-54 Treat coccyx fracture, no reduction 0-90 days

(bed rest, use of rubber ring, may require closed manipulation)

2342 21450-54 Treat closed mandibular fracture, no reduction 0-90 days

(close observation, soft diet, and/or restriction of activity

2337 21310-54 Closed treatment of non-displaced nasal fracture 0 days

(Treatment includes external agents, i.e. ice therapy and
pharmacological agents for pain control done in ED or documented in discharge.)

2394 21820-54 Treat sternum (breast bone) fracture, no reduction 0-90 days
(modify activity)

219
Procedure Descriptions
UPPER EXTREMITIES
2352 23500-54 Treat clavicle fracture, without manipulation 0-90 days
(clavicle brace, strap, or splint applied)

2360 23505-54 Reduce clavicle fracture, with manipulation 0-90 days

2386 23570-54 Treat closed scapular (shoulder blade) fracture, without 0-90 days
manipulation (affected shoulder put in sling or brace)

2410 23600-54 Treat closed humeral neck (prox humerus) fracture, without 0-90 days
manipulation (sling applied)

2415 23620-54 Treat closed greater tuberosity fracture, without manipulation 0-90 days

2428 24500-54 Treat closed humeral shaft fracture, without manipulation 0-90 days

2431 24505-54 Treat closed humeral shaft fracture, with manipulation 0-90 days

2412 24530-54 Treat closed humeral supracondylar or transcondylar , fracture, 0-90 days
without manipulation

2402 24560-54 Treat closed epicondylar (medial or lateral condyle), (distal 0-90 days
humerus), elbow, without manipulation

2126 24565-54 Treat humeral epidondylar fracture,( medial or lateral condyle) 0-90 days
(distal humerus), with manipulation

2436 24650-54 Treat closed radial head or neck fracture, without manipulation 0-90 days

220
Procedure Descriptions
2444 24670-54 Treat closed ulnar fracture, proximal end (olecranon process, 0-90 days
elbow) without manipulation

2469 25600-54 Treat closed distal radial fracture (colles, smith fracture) with 0-90 days
or without fracture of distal ulna, without manipulation

2496 25650-54 Treat closed distal ulnar fracture, without manipulation 0-90 days

2477 25605-54 Reduce closed distal radial fracture with or without fracture of 0-90 days
distal ulna

2493 25530-54 Treat closed ulnar shaft (forearm) fracture, without manipulation 0-90 days

2451 25500-54 Treat closed radial shaft (forearm) fracture, without manipulation 0-90 days

2519 25560-54 Treat closed radial and ulnar shaft fracture, without manipulation 0-90 days

2455 25505-54 Treat closed radial shaft fracture, with manipulation 0-90 days

2521 25565-54 Treat closed radial and ulnar shaft fracture, with manipulation 0-90 days

2527 25630-54 Treat closed carpal bone fracture, each bone, without manipulation 0-90 days
(triquettrium, trapezium, hamate, capitate, lunate, and
episiform bones only)

2535 25622-54 Treat closed carpal scaphoid (navicular bone) fracture, without 0-90 days
manipulation

221
Procedure Descriptions
2543 26600-54 Treat closed metacarpal fracture, without manipulation 0-90 days

2550 26605-54 Treat closed metacarpal fracture, with manipulation 0-90 days

2560 26645-54 Treat closed carpometacarpal fracture dislocation,with manipulation 0-90 days

2568 26720-54 Treat closed proximal or middle phalangeal shaft fracture, 0-90 days
each, (finger/thumb), without manipulation

2576 26725-54 Treat closed proximal or middle phalangeal shaft fracture, each 0-90 days
each (finger/thumb), with manipulation

2592 26750-54 Treat closed distal phalangeal fracture, each, (finger/thumb) 0-90 days
without manipulation

2600 26755-54 Treat closed distal phalangeal fracture, each, (finger/thumb) 0-90 days
with manipulation

LOWER EXTREMITIES

2620 27508-54 Treat condylar fracture (distal femur), without manipulation 0-90 days

2626 27520-54 Treat closed patella fracture, without manipulation 0-90 days

2727 27267-54 Treat closed femoral fracture, proximal end, head: 0-90 days
without manipulation

222
Procedure Descriptions
2728 27268-54 Treat closed femoral fracture, proximal end; with manipulation 0-90 days

2636 27501-54 Treat closed supracondylar fracture (distal femur), without manipulation 0-90 days

2634 27500-54 Treat femoral shaft fracture, without manipulation 0-90 days

2638 27502-54 Treat femoral shaft fracture, with manipulation 0-90 days

2808 27530-54 Treat tibial plateau fracture (proximal tibia), without manipulation 0-90 days

2667 27760-54 Treat closed distal tibia (medial malleolus, ankle) fracture, without 0-90 days
manipulation

2670 27762-54 Treat closed distal tibia (medial malleolus, ankle) fracture, with 0-90 days
manipulation

2675 27780-54 Treat closed fibula fracture, proximal or shaft, without manipulation 0-90 days

2683 27788-54 Treat closed distal fibular fracture (lateral malleolus, ankle) 0-90 days
with manipulation

2684 27786-54 Treat closed distal fibular fracture (lateral malleolus, ankle), 0-90 days
without manipulation

2777 27767-54 Treat closed posterior malleolus fracture; without manipulation 0-90 days

2778 27768-54 Treat closed posterior malleolus fracture; with manipulation

223
Procedure Descriptions
2659 27750-54 Treat closed tibial shaft fracture with or without fibular shaft, 0-90 days
without manipulation

2709 27808-54 Treat closed distal fibular and tibial fracture (bimalleolar, 0-90 days
medial and lateral malleolus, ankle includes Potts fracture),
without manipulation

2715 27810-54 Treat closed distal fibular and tibial fracture (bimalleolar, 0-90 days
medial and lateral malleolus, ankle), (includes Potts fracture)
with manipulation

2790 27816-54 Treat closed trimalleolar (lateral, medial, and posterior 0-90 days
malleoli, ankle), without manipulation

2795 27818-54 Treat closed trimalleolar (lateral, medial, and posterior 0-90 days
malleoli, ankle), with manipulation

2717 28400-54 Treat closed calcaneous (heel) fracture, without manipulation 0-90 days

2725 28430-54 Treat closed talus (ankle) fracture, without manipulation 0-90 days

2733 28450-54 Treat closed tarsal bone fracture, without manipulation 0-90 days
(navicular, cuboid, and cuneiform only)

2741 28530-54 Treat closed sesamoid (foot) fracture, without manipulation 0-90 days

2758 28470-54 Treat closed metatarsal (foot) fracture, without manipulation 0-90 days

224
Procedure Descriptions
2766 28475-54 Treat closed metatarsal fracture, with manipulation 0-90 days

2774 28510-54 Treat closed toe fracture (other than great toe), without manipulation 0-90 days

2782 28515-54 Treat closed toe fracture (other than great toe), with manipulation 0-90 days

2816 28490-54 Treat great toe fracture, without manipulation 0-90 days

2824 28495-54 Treat great toe fracture , with manipulation 0-90 days

SPLINTS AND STRAPS

MD MUST APPLY THE SPLINT OR CHECK PLACEMENT AND /OR NEUROVASCULAR STATUS DISTAL TO SPLINT AFTER
APPLICATION BY NURSE, TECH, ETC. MEDICARE: THE PHYSICIAN MUST APPLY.

2915 29130 Apply finger splint 0 days

2923 29105 Apply long arm splint (shoulder to hand) 0 days

2931 29125 Apply short arm splint (forearm to hand) 0 days

2949 29505 Apply long leg splint (thigh to ankle or toes) 0 days

2956 29515 Apply short leg splint (calf to foot) 0 days

2840 29260 Apply elbow/wrist Ace wrap 0 days

2857 29280 Apply hand/finger Ace wrap 0 days

225
Procedure Descriptions
2865 29530 Apply knee Ace wrap 0 days

2881 29540 Apply ankle Ace wrap 0 days

CASTS

2964 29705 Remove full arm or leg cast 0 days

(only when applied by another physician)

2050 29360 Apply ankle to thigh cast 0 days

2059 29425 Apply walking leg cast 0 days

2238 29405 Apply below knee to toes cast 0 days

2246 29085 Apply hand to wrist cast 0 days

2501 29075 Apply elbow to fingers cast 0 days

2972 29730 Cast windowing 0 days

(section of cast removed to assess status of wound or check for
infection)

2980 29740 Wedging of cast 0 days

(cast is cut and piece of wood or plastic is inserted into cut to
redirect pressure or correct malignment)

226
Procedure Descriptions
DIAGNOSTIC INTERPRETATIONS AND REPORTS

X-RAY INTERPRETATIONS

HEAD AND NECK

7097 70140-26 Facial bones,1-2 views

7005 70150-26 Facial bones, 3+ views

7090 70320-26 Teeth, full mouth (panorex)

7625 70355-26 Orthopantogram

7013 70160-26 Nasal bones, 3+ views

7021 70210-26 Sinuses, 1-2 views

7039 70220-26 Sinuses, 3+ views

7045 70250-26 Skull, 1-3 views

7047 70260-26 Skull, 4+ views

7054 70328-26 Temporomandibular joint, unilateral

7062 70330-26 Temporomandibular joint, bilateral

7070 70360-26 Neck, soft tissue

227
Procedure Descriptions
7010 70100-26 Mandible, 1-3 views

7088 70110-26 Mandible, 4+ views

7096 70130-26 Mastoids, 3+ views per side

7104 70200-26 Orbits, 4+ views

7609 70310-26 Teeth, less than full mouth

CHEST
7139 71045-26 Chest, 1 view (portable)

7140 71046-26 Chest, 2 views (PA & lat)

7141 71048-26 Chest, complete 4+ views

7161 71100-26 Ribs, 2 views unilateral

7179 71101-26 Ribs, unilateral and PA chest 3 views

7112 71111-26 Ribs, bilateral and PA chest 4 views

7120 71110-26 Ribs, bilateral 3 views

7187 71120-26 Sternum, 2+ views

7732 76010 Babygram, nose to rectum

228
Procedure Descriptions
SPINE & PELVIS

7195 72040-26 Cervical spine, 2 views

7203 72050-26 Cervical spine, 4+ views

7211 72010-26 Spine survey, entire

7229 72070-26 Thoracic/dorsal spine, 2 views

7237 72080-26 Thoracolumbar spine, AP & lat

7245 72100-26 Lumbosacral spine, 2 views

7666 72114-26 Lumbosacral spine, complete – 6 views

72081-26 Spine, entire thoracis and lumbar, including skull, vervical and sacral spine if performed, 1 view

72082-26 Spine, entire thoracis and lumbar, including skull, vervical and sacral spine if performed, 2-3 views

72083-26 Spine, entire thoracis and lumbar, including skull, vervical and sacral spine if performed, 4-5 views

72084-26 Spine, entire thoracis and lumbar, including skull, vervical and sacral spine if performed, 6+ views

7252 72170-26 Pelvis, 1 view

7260 72190-26 Pelvis, complete 3+ views

229
Procedure Descriptions
7286 72220-26 Sacrum & coccyx

7682 72200-26 Sacroiliac joint, 1-2 views

7278 72202-26 Sacroiliac joints, 3+ views

UPPER EXTREMITY

7302 73010-26 Scapula, complete

7310 73000-26 Clavicle, complete

7328 73020-26 Shoulder, 1 view

7336 73030-26 Shoulder, 2+ views

7344 73050-26 A/C joints, bilateral

7351 73060-26 Humerus, 2+ views

7355 73070-26 Elbow, AP & lat views

7369 73080-26 Elbow, 3+ views

7377 73090-26 Forearm, 2 views

7385 73092-26 Infant upper extremity, 2+ views

230
 Procedure Descriptions
7393 73100-26 Wrist, 2 views

7395 73110-26 Wrist, 3 views

7399 73120-26 Hand, 2 views

7401 73130-26 Hand, 3+ views

7419 73140-26 Fingers, 2 views

LOWER EXTREMITY
7361 73501-26 Hip, unilateral, with pelvis when performed, 1 view

7362 73502-26 Hip, unilateral, with pelvis when performed, 2-3 views

7363 73503-26 Hip, unilateral, with pelvis when performed, 4+ views

7364 73521-26 Hips, bilateral, with pelvis when performed, 2 views

7365 73522-26 Hips, bilateral, with pelvis when performed, 3-4 views

7366 73523-26 Hips, bilateral, with pelvis when performed, 5+ views

7444 73551-26 Femur, 1 view

7445 73552-26 Femur, 2+ views

231
Procedure Descriptions
7468 73560-26 Knee, 2 views

7472 73562-26 Knee, 3 views

7476 73564-26 Knee and patella, complete, 4+ views

7484 73590-26 Tibia and fibula, 2 views

7492 73592-26 Infant lower extremity, 2+ views

7511 73600-26 Ankle, AP & lat

7518 73610-26 Ankle, 3+ views

7526 73620-26 Foot, 2 views

7690 73630-26 Foot, 3+ views

7534 73650-26 Calcaneus, 2+ views

7542 73660-26 Toes, 2+ views

232
ABDOMEN
Procedure Descriptions
7142 74018-26 Abdomen, 1 view (KUB)

7143 74019-26 Abdomen, 2 views

7144 74021-26 Abdomen, 3+ views (abdominal series)

7575 74022-26 Acute abdominal series (obstruction series, 3+ views and chest x-ray)

7583 74400-26 IVP

7716 74430-26 Cystography

7765 74240-26 GI tract without KUB

RTI CODE CPT CODE DECRIPTION

BILLING FOR ULTRASOUND INTERPRETATIONS

(“+” behind a code is a CPT add-on code)

7604 76604 Ultrasound Chest, thorax, upper back

7655 76642 Ultrasound Breast - Limited

7915 76815 OB Ultrasound; Limited Fetus(s)

233
RTI CODE
Procedure Descriptions
CPT CODE DECRIPTION
BILLING FOR ULTRASOUND INTERPRETATIONS

(“+” behind a code is a CPT add-on code)

7916 76816 OB Ultrasound; transabdominal approach, follow-up

7927 76817 Transvaginal Ultrasound; Obstetric

7940 76830 Transvaginal Ultrasound; Non – OB

7856 76856 Pelvis ECHO Exam; Complete

7957 76857 Pelvis ECHO Exam; Limited

7700 76700 Abdomen ECHO Exam; Complete

7945 76705 Abdomen ECHO Exam; Limited

7955 76775 Ultrasound abdominal backwall; limited

7975 76975 GI Endoscp. Ultrasound

7942 76942 ECHO Guide for Biopsy

7937 76937+ Ultrasound Guidance for Vascular Access (i.e. Central Line Placement)
[this is an add on code and must be billed with CVP catheter placement]

9376 93976 Limited evaluation of scrotal contents

9371 93971 Limited evaluation of extremity veins (duplex scan)

9271 93308 ECHO Exam Chest/Heart Transthoracic Approach

7881 76882 Limited evaluation of joint or nonvascular (tendon, muscle, nerve, etc.) extremity structure

7605 76536 Ultrasound evaluation of head and neck 234

7853 76512 Limited evaluation ophthalmic – B Scan
 Procedure Description
RTI CPT
Code Code Description Indication
9272 93308 Trauma "Fast Exam" includes 3 separate CPT Cardiac evaluation for pericardial fluid and a three view abdominal evaluation for hemoperitoneum.
7845 76705 ultrasounds. Bill ultrasounds that you have
7804 76604 billable interps.
Cardiac 9272
Abdominal 7845
Thoracic 7804

7815 76815 Uterine Ultrasound of Pregnant Uterus For evaluation of one or more of the following: Fetal heartbeat, placental location, fetal position and/or
"Limited Evaluation" Employing qualitative amniotic fluid volume.
Transabdominal Approach

7826 76816 Uterine Ultrasound of Pregnant Uterus To reasses fetal size, interval growth, amniotic fluid volume or organ system determined abnormal on a
"Follow-up Study" Employing previous exam.
Transabdominal Approach

7827 76817 Uterine Ultrasound of Pregnant Uterus For evaluation of one or more of the following: Fetal heartbeat, placental location, fetal position and/or
Employing Transvaginal Approach qualitative amniotic fluid volume.

7840 76830 Uterine Ultrasound of Nonimpregnated Uterus Ultrasound exam of nonpregnant uterus for the evaluation of gynecologic complaints, i.e. pelvic pain,
Employing Transvaginal Approach amenorrhea, vaginal bleeding.

7857 76857 Pelvic Ultrasound "Limited Evaluation" of Evaluation could include evaluation of the urinary bladder alone (not including the kidneys) of either
Male or Female Pelvic Anatomy gender, prostate or seminal vesicles in males, the pelvis in females to rule out free pelvic fluid, pelvic
*Transabdominal Approach abscess.
7845 76705 Abdominal Ultrasound "Limited" Abdominal pain to rule out conditions such as cholelithiasis, common bile duct obstruction,
appendicitis.

235
 Procedure Description
7800 76700 Abdominal Ultrasound "Complete"
Assess liver, gallbladder, spleen, pancreas, and kidneys (rather than just a limited
area)
7855 76775 "Limited" evaluation of Evaluation for abdominal aortic aneurysm or renal disease including renal vessels and
retroperitoneum, renal structures aorta.
and/or vasculature "Backwall"

7930 76930 Ultrasound Guidance for Used for guidance of needle placement for the removal of pericardial fluid.
Pericardiocentesis
7937 76937+ Ultrasound Guidance for Vascular This is an add-on code used in conjunction with Central Line placement. There must
Access (Central Line Placement) be an additional procedural note containing all factors as noted.

9272 93308ECHO Exam Chest/Heart Follow-up/Limited Study

Transthoracic Approach
7942 76942+ Ultrasound Guidance for Needle An add-on code that accompanies needle placement for paracentesis, thoracentesis,
Placement lumbar puncture and location of abscess for drainage (e.g. peritonsillar abscess)

9376 93976 "Limited" evaluation of scrotal Duplex study of scrotal and/or pelvic contents and vasculature. Used to evaluate for
contents the existence of testicular torsion.

9372 93971 "Limited" evaluation of extremity Evaluation for deep vein thrombosis (DVT)
veins
236
 Procedure Description
"Limited" evaluation soft tissue
7878 76882 Evaluation of muscles, tendons, joints, nerves, soft tissues, or other nonvascular
extremity or axilla
extremity with a focused evaluation on the specific area of concern, such as a lump,
mass, cellulitis
7854 76642
"Limited" evaluation breast Evaluation of breast lumps or other abnormalities

"Limited" evaluation chest, thorax,

7804 76604 Evaluation organs and structures within the chest, such as lungs, mediastinum, and
upper back
pleural space for conditions such as pleural effusion, pneumothorax, pneumonia,
neoplasms, chest wall abnormalities. Upper back done for back pain or other upper back
issues.

"Limited" evaluation face, head,

7818 76536
neck Evaluate soft tissue of the face, head, neck (thyroid, parathyroid, parotid, etc.) for
conditions like lump, cellulitis, and abscesses.

7853 76512 "Limited" evaluation Ophthalmic Evaluate eye and adjacent structures for conditions such as globe perforation, retrobulbar
hematoma, retinal detachment, lens subluxatioin, vitreous hemorrhage and intraocular
foreign body

237
Procedure Descriptions
OTHER ANCILLARY INTERPRETATIONS/SPECIAL SERVICES

9406 99406 Smoking Cessation Counseling GT 3 up to 10 minutes (Asymptomatic & Symptomatic)

9407 99407 Smoking Cessation Counseling GT 10 minutes (Asymptomatic & Symptomatic)

9541 99497 Advanced Care Planning – 16 min

9542 99498 Advanced Care Planning – Add’l 30 min (at 46 min)

9264 96127 Suicide risk assessment

9324 93010 12 lead EKG interpretation

9332 93042 1-3 lead rhythm strip interpretation (cardiac monitor)

9258 94760-26 Pulse oximetry interpretation, single

9260 94761-26 Pulse oximetry interpretation, multiple

(bill only once)

9277 92953 Temporary transcutaneous pacing (TTP, external pacer)

9160 99053 Special services 10:00 pm – 8:00 am daily

238
Procedure Descriptions
CT SCAN INTERPRETATIONS

7757 70460-26 CT head with contrast

7075 70450-26 CT head without contrast

7080 70480-26 CT orbits without contrast

7085 70490-26 CT neck without contrast

7633 70486-26 CT face without contrast

7641 71260-26 CT chest with contrast

7658 71270-26 CT chest without contrast

7065 72193-26 CT pelvis with contrast

7083 72192-26 CT pelvis without contrast

7708 74150-26 CT abdomen without contrast

7071 74160-26 CT abdomen with contrast

7089 72128-26 CT thoracic spine without contrast

7674 72131-26 CT lumbar spine without contrast

239
 DOCUMENTATION REQUIREMENTS FOR TOBACCO USE
CESSATION COUNSELING
⚫ Documentation that patient is alert and competent – could be in History or PE by MD/MLP.
⚫ Documented history of current tobacco use – could be in social history by MD/MLP or RN (if
provider reviews and agrees)
⚫ Documentation of cessation discussion, including:
✓ time spent with patient
✓ treatment plan recommended

EXAMPLE OF ACCEPTABLE DOCUMENTATION:

Counseled pt re smoking cessation for 5 min, rx for patch provided.

Reminder: Counseling may be provided by physician or midlevel, and will be billed to the provider
performing the counseling.

240
 DOCUMENTATION REQUIREMENTS FOR TOBACCO USE
CESSATION COUNSELING

NOTE: Your diagnosis must have one of the following as a secondary dx code. Link the counseling procedure
CPT to one of the below ICD10 codes.

Use Z720 Tobacco use with no documentation or dx of nicotine dependence

241
Introduction to CPT
Terms and Definitions
What is CPT?
Physicians’ Current Procedural Terminology, Fourth Edition (CPT) is
a systematic listing and coding of procedures and services performed by
physicians.
CPT codes describe procedures and services rendered in a medical setting.
The original idea of procedural coding began in 1956 when the California
Medical Association (CMA) created and adopted the California Relative
Value Study (CRVS). Initially, the system was designed to describe
physician services.
CPT-4 codes were authored ten years later (1966) by the American
Medical Association (AMA). CPT codes are updated yearly by the
AMA in November, with an average of 300-700 changes per year.
The Health Care Financing Administration (HCFA/Medicaid, and most
other commercial carriers now require the use of CPT codes. Some state
Medicaid and Workman’s Compensation programs use their own unique
five-digit codes similar to CPT codes.

242
 Introduction to CPT
Terms and Definitions
Federal OBRA (Omnibus Budget Reconciliation Act) legislation has been instrumental in
expanding the usage of CPT codes to describe services in a variety of medical settings.
In 1984, all laboratories were required to report outpatient lab tests using CPT codes

By 1987, HCFA required all hospital and outpatient facilities to report specific ambulatory
surgical procedures from a selected Ambulatory Surgical List (ASC) with CPT codes.
Those reportable services now specified by HCFA include select diagnostic tests, and all surgical,
radiological and laboratory services described in the current hospital services CPT manual.

CPT is the most commonly recognized system.

HCPCS (Health Care Financing Administration Common Procedure Coding System).

How are CPT codes identified?

Each procedure or service is identified with a five digit code. The use of
CPT codes simplifies the reporting of services.

243
 Introduction to CPT
Terms and Definitions
Organization of the CPT Manual
CPT is organized into the following chapters, appendices, instructions for
using the CPT index, and the index itself.

• Introduction (Explanation and Instructions)

• Evaluation and Management
• Anesthesia
• Surgery
• Radiology, Nuclear Medicine, and Diagnostic Ultrasound
• Pathology and Laboratory
• Medicine
• Appendix A-Modifiers
• Appendix B-Summary of Deletions, Additions, and Revisions
• Appendix C-Short Procedure Tape Revision
• Appendix D-Clinical Examples supplement
• Instructions for the Use of CPT Index
• Index

244
 Introduction to CPT
Terms and Definitions
Instructions for Use of CPT

1. A coder selects the name of the procedure or service that most accurately
identifies the service performed.
2. The coder may then list other additional procedures performed or pertinent
special services.
3. When necessary, any modifying or extenuating circumstances may be listed.
4. Any service or procedure should be adequately documented in the medical
record.
5. Listings of a service or procedure and its code number in a specific section of
the CPT book does not restrict its use to a specific specialty group. Any
procedure or service in any section of this book may be used to designate the
services rendered by any qualified physician.

245
 Introduction to CPT
Terms and Definitions
Format of the Terminology

1. CPT procedure terminology has been developed as stand-alone descriptions

of medical procedures
2. Some procedures in CPT are not printed in their entirety but refer back to a
common portion of the procedure listed in a preceding entry.

Example: 25100 Arthrotomy, wrist joint; with biopsy-PA 100-CPT

25105 with synovectomy

NOTE: The common part of code 25100 (that part before the semicolon) should be considered
part of code 25105. Therefore the full procedure represented by code 25105 should read:

25105 arthrotomy, writ joint; with synovectomy

246
Introduction to CPT
Terms and Definitions

Cross References

Cross References provide instructions to either:

“SEE”-This directs the user to refer to the term listed after

the word “See”

“SEE ALSO” this directs the user to look under another

main term if the procedure is not listed under the first
main index entry.

247
Introduction to CPT
Terms and Definitions
Code Location: Key Coding Concepts
Use of CPT index
⚫ increase coding efficiency and effectiveness
⚫ provides a range of codes from which individual code
selection can be made
⚫ never code directly from the Index, use as a tool for quick
reference
Codes can be referenced in the following manner
⚫ by surgery performed
⚫ by anatomical site
⚫ by condition
⚫ by synonym, eponym, abbreviation
Code ranges listed are separated by hyphen
⚫ all codes within the sequential range should be reviewed
prior to selecting the code(s)
Indented Code Format
⚫ whenever a description is indented refer back to a common
portion of the procedure listed in the entry.
248
Introduction to CPT
Terms and Definitions
Code Changes

A summary listing of additions, deletions and revisions applicable to CPT

is found in Appendix B.
New procedure numbers added to CPT identified throughout the text with
the symbol “.” placed before the code number. When a code has been
substantially altered the symbol “^” is placed before the code number.

Alphabetical Reference index

A complete alphabetical index is found in the back of the book. It includes

listing by procedure and anatomic site.

249
Introduction to CPT
Terms and Definitions
Main Terms

The index is organized by main terms. It can either stand alone, or be

followed by up to 3 modifying terms. There are 4 primary classes of main
entries:
1. Procedure or service
2. Organ or other anatomic site
3. Condition
4. Synonyms, eponyms and abbreviations

Modifying Terms-a main term may be followed by a series of up to 3

indented terms that modify the main term.

Code Ranges-whenever more than one code applies to a given index

entry, a code range is listed.

250
Surgical Procedures

Surgery is the largest section of CPT and is

divided into several subsections by body
system. The services in these sections are
subdivided by site and type of service.

251
Surgical Package
Pre-Operative Service
The pre-operative service is directly related to the injury, which necessitates the
operation. The pre-operative period begins the day before the operative procedure
for non-starred procedures and the day of the procedure for minor procedures.

Operative Service
The operative service includes examination of wound, exploration for foreign body,
evaluation of for tendon and/or nerve involvement, injection of anesthesia, and
digital block required for repair of the injury and any other service that is normally
a usual and necessary part of a surgical procedure.

Post-Operative Service
All normal, uncomplicated follow-up visits or services directly related to the
surgery are considered to be part of the global surgery package. Unrelated services
or complications requiring additional service by the emergency physician are billed
with the appropriate E/M or surgery code.

252
Levels of Procedures
Simple and Complicated
With the exception of lacerations that have their own defined levels, surgical procedures
may be described as either simple or complicated. No definitions are provided in CPT to
assist the coder in clearly differentiating these levels of procedure. The type of
procedure and the level of detail provided in the physician's procedure note will be the
determining factor for selecting the appropriate level of procedure. Below are some
examples for each:

Simple Procedure Example: Incision and removal of foreign body, simple.

Complicated Procedure Example: Cyst or Abscess that is unusually deep,
requires IV therapy, needs extensive dissection and/or requires placement of
drain.

253
Integumentary Section
(CODES 10021-19499)
The integumentary system is made up of structures that cover
the body: skin, hair, nails, sebaceous and sweat glands. The
breasts and subcutaneous tissue are also included in the
integumentary system. This sub-section of Surgery includes
services performed to treat skin infections, laceration repairs
and foreign body removals. Treatment of abscesses, cysts,
burns and debridement are also listed in this section.

254
Incision and Drainage of Abscess and Cysts
(Codes 10040 - 10081)
Treatment of these lesions will depend on the type of lesion
(abscess or cyst) and the complexity of treatment. Simple
generally describes a small incision through overlying skin,
opening of the lesion, drainage of fluid and possible removal of
lesion with no suturing; complicated generally defines the
lesion that requires a drain or packing to facilitate continued
drainage and may require surgical closure. The appropriate
Incision and Drainage code may be located in the related
anatomical section of CPT.

255
Foreign Body Removals - Skin
(Codes 10120 - 10121)
Most foreign body removals listed in CPT require incision (the
FB removal section for the eyes is an exception). The layers of
skin requiring incision and the presence of additional
complicating factors will determine whether the incision and
removal is simple (usually skin only) or complicated (deep
dissection of underlying tissues, possible packing if
contaminated by the foreign body, etc.). Most foreign body
removals include administration of local anesthetic. Never code
for foreign body removal when none is removed! Codes for
foreign body removals are located in each related anatomical
section of CPT (for example CPT codes 20520 and 20525
describe foreign body removals from muscle).

256
Foreign Body Removals - Eye
(Codes 65205-65222)
Treatment of eye foreign bodies is a common process in the
emergency department. The foreign body may be removed from
the conjunctiva with the edge of a needle or a Q-tip (65205
conjunctiva; 65220 cornea); or the embedded foreign body may
require that a small incision be made to remove the foreign body
(65210 conjunctiva; 65222 cornea). The use of a slit lamp is
generally required for removal for the embedded foreign body.
The decision as to whether or not the foreign body is embedded
will depend upon the physician’s procedure note description.

257
 Debridement
(Codes 11000 - 11047)

Debridement is a separately identified service when provided as a

stand-alone service or when required for gross contamination and
prolonged cleansing in addition to a simple or intermediate repair.
Debridement may be applicable for skin, subcutaneous tissue,
muscle, bone or for nail avulsions. The exception is when routine
debridement is provided with a complex laceration repair. With a
complex laceration repair, the debridement is included in the
complex laceration repair package unless the injury includes gross
contamination requiring prolonged cleansing or removal of
significant devitalized or contaminated tissue.

258
Nails - Debridement and Avulsion
(Codes 11720-11721 and 11730-11732)

Debridement of nails and/or removal of nail fragments constitutes a

separately identifiable service. Nail avulsions differ somewhat
from debridement in that avulsion describes complete removal of
all or a portion of the nail and includes administration of the
Anesthesia (digital block) and dissection of the nail bed.

259
Nails/Evacuation of Subungual Hematoma
(Code 11740)
A common blunt injury is the subungual hematoma resulting
from striking the finger or catching it in a door or between two
objects.

Treatment of the Subungual Hematoma (bleeding under the

nail) requires draining of the collected blood by drilling into the
nail plate, often accomplished with a heated paper clip. This
injury often accompanies a bony fracture.

Often, nail removal is required to inspect the nail matrix for

more serious damage.

260
 Nailbed Laceration Repair
(Code 11760)
Treatment of nail-bed injury is a common emergency department
service and may present a challenge to the experienced coder.
Often, the injury includes treatment of a subungual hematoma and
removal of the nail bed to examine for presence or extent of the
nailbed laceration. Removal of the nail is an integral part of the
procedure. Often the nail is replaced to serve as a splint for the
5-7 day healing process.

261
 Nail injury with Wedge excision
(Code 11765)

The wedge excision procedure is another common emergency

department service, which involves removing a wedge of skin and
subcutaneous tissue around the ingrown portion of the nail. This
code should not be confused with the excision of nail and nail
matrix, which is performed for permanent removal of all or part of
the nail.

262
Laceration/Wound Repair
Laceration repair is listed under three levels, simple, intermediate
and complex. These levels of repair are also sub-divided into body
areas. Use these codes to designate wound closure utilizing
sutures, staples, or tissue adhesives (dermabond), either singly or
in combination with each other, or in combination with adhesive
strips (steri-strips). Wounds closed with steri-strips or as the sole
repair should be identified with the appropriate level of E/M code.

263
Laceration/Wound Repair
⚫ Simple laceration/wound repair (Codes 12001 - 12018)
describes the superficial injury to the primary epidermis,
dermis, and/or subcutaneous tissues w/o deeper involvement.
The repair is accomplished through a simple, one-layer closure,
which includes local anesthesia. CPT divides the simple
laceration codes into 2 body groupings.

264
Laceration/Wound Repair
⚫ Intermediate laceration/wound repair (Codes 12031 - 12057)
requires layered closure into deep subcutaneous tissue or
superficial (non-muscle) or fascia, or skin (epidermal/dermal).
Intermediate repair can also pertain to single layered closure of
heavily contaminated wounds that require extensive cleansing
and/or removal of particulate matter. CPT divides the
intermediate laceration codes into 3 body groupings.

265
Laceration/Wound Repair
⚫ Complex laceration/wound repair (Codes 13100 - 13153) is
more than layered closure and includes any required
debridement unless gross contamination is present. Removal of
foreign material or damaged tissue, placement of stents,
retention sutures, and creation of defect may also be included in
the complex laceration/wound repair. In general, the complex
laceration is considered to be essential for both cosmetic and
functional purposes. CPT divides the complex laceration codes
into 4 body groupings.

266
Laceration/Wound Repair
Laceration/Wound Repair Reminders

1. Measurement of the laceration/wound requires identification in

centimeters. Code the smallest laceration repair when length is not
defined.
2. When the wound is listed as stellate, the components are combined
and reported as one single length for each level of injury.
3. Wounds should be coded and listed in order of complexity.
4. If debridement was performed, it is coded as separate item if gross
contamination occurs which requires prolonged cleansing for
removal of an appreciable amount of tissue.

267
Laceration/Wound Repair
Laceration/Wound Repair Reminders

5. Tendon repairs should be coded separately and in addition to wound

repair only if tendon repair requires complex closure.
6. Simple ligation, exploration for foreign bodies, irrigation are
considered part of wound repair and not reported separately unless
extensive.
7. Make certain that the correct body grouping and complexity of the
laceration has been identified.
8. Procedures D8003, D8011, D8037, D8045, D8052, D8060
(12001 - 12007) were added to the system to be used when the
following criteria are met: Medicare is the payor and tissue adhesive
(dermabond) is the sole method of repair. Medicare expects a
different output code (G0168) to be reported in these circumstance
and the use of these procedures will fulfill that requirement.
268
 LACERATION MATRIX
LACERATION MATRIX

Neck, Hand,
Eyelid, Ear, Lip, Scalp, Arms,
Laceration Size Axillae Face, Mouth Foot, Trunk
Nose Legs
Genitatlia
Simple:
0-2.5 CM 8003/D8003 8193/D8193 8193/D8193 8003/D8003 8003/D8003 8003/D8003
2.6-5 CM 8011/D8011 8201/D8201 8201/D8201 8011/D8011 8011/D8011 8011/D8011
5.1-7.5 CM 8011/D8011 8219/D8219 8219/D8219 8011/D8011 8011/D8011 8011/D8011
7.6-12.5 CM 8037/D8037 8227/D8227 8227/D8227 8037/D8037 8037/D8037 8037/D8037
12.6-20 CM 8045/D8045 8235/D8235 8235/D8235 8045/D8045 8045/D8045 8045/D8045
20.1-30 CM 8052/D8052 8243/D8243 8243/D8243 8052/D8052 8052/D8052 8052/D8052
OVER 30 CM 8060/D8060 8250/D8250 8250/D8250 8060/D8060 8060/D8060 8060/D8060
Intermediate:
0-2.5 CM 8078 8268 8268 8649 8078 8078
2.6-5 CM 8086 8276 8276 8656 8086 8086
5.1-7.5 CM 8086 8284 8284 8656 8086 8086
7.6-12.5 CM 8102 8292 8292 8672 8102 8102
12.6-20 CM 8110 8300 8300 8680 8110 8110
20.1-30 CM 8128 8318 8318 8698 8128 8128
OVER 30 CM 8136 8326 8326 8706 8136 8136
Complex:
0-1 CM 8078 8268 8524 8649 8078 8078
1.1-2.5 CM 8151 8151 8532 8151 8912 8383
2.6-7.5 CM 8177 8177 8540 8177 8920 8391
Each add'l 5 CM
(or less) 8928 8928 8931 8928 8925 8922

Reminder: Procedures D (bold faced type) are to be used only when the payor is Medicare and tissue adhesive (dermabond) is the sole method of repair.

269
BILLABLE SIMPLE SUTURE REMOVALS
⚫ Sutures removals and laceration rechecks are now billable following simple laceration repairs.
⚫ CPT code 99281 (Level 1 Evaluation and Management services) will be assigned for these
visits with the required documentation of an HPI (1 element) & PE (1 BA or OS). It is not
required for the provider to personally remove the sutures; they may be removed by
ancillary staff.

⚫ Example of provider documentation:

• Pt presents for removal of sutures (HPI). Wound healed completely (PE). Sutures removed. Provider Signature

⚫ Use the laceration ICD-10 code first followed by one of the below Z-codes and E/M level 1
(9016) - suture removal/wound recheck (do not use when complications are present)
Z4802 = encounter for removal of sutures
Z4801 = encounter for change or removal of surgical wound dressing

Important reminder: Suture removals that involve complications have never been covered by the
Global Surgical Period and have always been billable at E&M levels typically higher than 1 as
determined by the complexity/MDM of the case.

270
BILLABLE SIMPLE SUTURE REMOVALS
Exception Screens
⚫ The system will check to see if the patient had a visit for a simple, intermediate, or
complex laceration repair within the past 10 days. You will need to code all suture
removals as billable, unless you see the message below.

271
BILLABLE SIMPLE SUTURE REMOVALS

272
BILLABLE SIMPLE SUTURE REMOVALS
The following non-billable codes are to be used:
⚫ 0109 – non-billable suture removal -used when identified by system
as NB suture removal
⚫ 0509 – non-billable “suture removal-nursing only; no provider
involvement” – used when patient is not seen/examined by MD or
MLP
⚫ 0098 – insufficient documentation to bill – pt seen by MD or MLP;
one or more key components missing from documentation

Important – remember all suture removals are billable unless the

system directs you to code it as a NB!

273
 Burn Treatment
(16000 - 16030)
Burn Degree Definitions
When coding burn treatment(16000-16030), use the Lund-Browder Table on page 267 of
this manual or on page 86 of the CPT book to figure the TBSA.
First-degree burns involve damage to the epidermis (outermost layer of skin)
Debridement of a first-degree burn includes a simple cleansing of the wound and
application of medication for local treatment only. ERMD must perform in order to bill
CPT 16000 (RTI 1198)
Second-degree burns involve damage to the epidermis and part of the dermis (the
second layer of skin, located beneath the epidermis).
• Debridement of a small (<5% TBSA) second-degree burn includes cleansing of the
wound and application of medication for local treatment only. ERMD must perform in
order to bill CPT 16020 (RTI 1206).
• Debridement of a medium (5%-10% TBSA) second-degree burn includes cleansing of
the wound and application of medication for local treatment only. ERMD must perform
in order to bill CPT 16025 (RTI 1214).
• Debridement of a large (>10% TBSA) second-degree burn includes cleansing of the
wound and application of medication for local treatment only. ERMD must perform in
order to bill CPT 16030 (RTI 1222).

274
 Burn Treatment
(16000 - 16030)
Third degree burns involve damage to the epidermis and dermis and extends into the subcutaneous
tissue (the fatty tissue beneath the epidermis and dermis).

Dressing/Debridement (16020 - 16030) includes washing the burned area with mild soap and water or
saline solution and antimicrobial application; and/or loose scabs are removed with forceps
(debridement), washed with saline or water and application of antimicrobial agent. Burn may/may
not be covered with a dressing. Codes 16020 and 16025 require anesthesia and are not typically
performed in the ED.

The burn care CPT codes all have 0 global days. If a patient comes back in for a re-check, the chart is
billable. If the ERMD/MLP meets documentation requirements for burn care treatment, it can be
billed. Please note: these are ok to bill if the documentation that the ERMD/MLP performed the
procedure is in the nurse’s notes.

With proper documentation present an E/M code would also be assigned with modifier.

275
The Lund-Browder Table for TBSA
• The Lund-Browder classification
method applies only to CPT coding.

• Use the Lund-Browder Table when

coding local treatment of
burns(16000-16036) to figure
TBSA.

• ICD-9-CM continues to use the rule

of nines when calculating TBSA for
ICD-9 codes from Category 948.

276
Surgery: Musculoskeletal System
(Codes 20005 - 29999)

Coding for orthopedic services includes the identification of fractures

and dislocations. Sprains are not identified with a separate code and
treatment of the sprain is coded with the appropriate level of
Evaluation and Management service.

The orthopedic code that is selected by the coder should describe the
content of the total service. As most orthopedic services are
considered global surgery procedures, the related pre-operative,
operative, and normal, uncomplicated post-operative services are
included.

277
Surgery: Musculoskeletal System
(Codes 20005 - 29999)

The emergency physician typically does not provide the post-operative, or follow-
up, service. Therefore, orthopedic service codes usually require the addition of the
-54 modifier to advise the payer that no follow-up service by the emergency
physician will be provided. This modifier is automatically assigned by the
EMBILLZ system.

According to the AMA, restorative treatment is defined as surgical repair, closed or

open reduction of a fracture or joint dislocation. In order to use the orthopedic
codes definitive care for that type of fracture must have been performed.

The orthopedic codes include the initial application and removal of casts, straps and
the restorative treatment as identified by the code descriptor must be performed.
There is no correlation between the type of treatment performed and type of
fracture.

278
Surgery: Musculoskeletal System
(Codes 20005 - 29999)
The types of Orthopedic treatments include the following:

Closed (not surgically opened) - applies to injuries with and without manipulation.
Manipulation is defined as the reduction or restorative treatment of a fracture/dislocation
through application of manually applied forces to achieve normal anatomical alignment.

Open - applies to injuries surgically opened where the fracture is visualized. In some
instances, internal fixation may be used.

Percutaneous - applies to injuries requiring treatment performed through the skin.

The types of Fractures include the following:

Open applies to the wound that is open through the tissue to the site of the break.

Compound applies to an open fracture

Closed applies to the fracture that does not produce an open wound of the skin

279
 Billing E/M and Fracture Care Codes –
Minor and Major
MEDICARE OTHER PAYORS
Minor Fracture Care Code fracture care if all necessary criteria are met. Code fracture care if all necessary criteria are met.
Procedures • Add E/M (with modifier 25) if exam is expanded • Add E/M (with modifier 25) if exam is expanded
problem focused or higher. problem focused or higher.
• If unable to bill fracture care, check if strap/splint • If unable to bill fracture care, check if strap/splint
can be billed. If EDMD personally performed the can be billed. If EDMD personally performed the
application, bill strap/splint in addition to E/M (with application and/or checked the neurovascular status,
modifier 25). bill strap/splint in addition to E/M (with modifier 25).

Major Fracture Care Code fracture care if all necessary criteria are met. Code fracture care if all necessary criteria are met.
Procedures • Add E/M (with modifier 25) when other symptoms • Add E/M (with modifier 25) when other symptoms
and/or diagnoses are identified. and/or diagnoses are identified.
• If no other symptoms and/or diagnoses are • If no other symptoms and/or diagnoses are
identified, then add E/M (with modifier 57) if need for identified, then add E/M (with modifier 57) if need for
fracture care was determined by EDMD (all cases fracture care was determined by EDMD (all cases
except when the patient was sent to the ED by except when the patient was sent to the ED by
another provider who initially diagnosed the fracture). another provider who initially diagnosed the fracture).

Notes to remember:
⚫ Refer to your list of minor and major procedure codes for accurate identification of minor vs. major fracture care.
⚫ Utilize the coding guidelines in determining the E/M level.
⚫ Drug Administration:
1. Medications that are part of the procedure should be excluded from determining the E/M level (ex: moderate sedation, pain medications).
2. Medications that are not part of the procedure should be included in determining the E/M level (ex: medications for pain control).

280
FRACTURE CARE UPDATE
Fracture care is coded when the following criteria are met:
1. The specific bone is identified as fractured.
2. The area is immobilized; and
3. The ED physician rendered definitive fracture care – documented
follow-up care is after 24 hours.

If a “window” of time is documented for follow-up, the outside of the window determines
whether fracture care may be billed. For example, “Follow-up with ortho/MD in 1 to 3
days” is considered to be 3 days, and fracture care should be billed (assuming all other
criteria are met). “Within 3 days” is similarly considered to be 3 days, and fracture care
should be billed.

Note: For fractures that needs restorative treatment and ERMD did not
performed the procedure, only bill the splint/strap. EX. Displaced fracture,
ERMD applied the splint and referred to Ortho/MD after 24 hours = we can
only bill the splint/strap application.
281
FRACTURE CARE UPDATE
Acceptable (bill fracture care):

Follow-up with ortho in 3 days

Follow-up with MD within 3 days
Follow-up with PMD in 1 to 3 days
Follow-up in a few days
(List is not conclusive – any documented time frame that is not definitively within 24 hours is
acceptable.)

Not acceptable (do not bill fracture care):

Follow-up with ortho tomorrow

Follow-up with in 1 day
Follow-up with ortho

If follow-up care is not documented, RTI assumes that the patient will see orthopedics within 24
hours, and therefore, fracture care cannot be coded.

282
 Fracture Care Without Strap/Splint
The following injuries can be coded with fracture care when the follow-up care to the Orthopedics or PMD is after 24 hours:

27200/2263 – Closed treatment of a coccygeal/sacral fracture, the physician will prescribe bed rest to alleviate symptoms;
sitting on a rubber ring may also lessen symptoms.

21310/2337 – Closed treatment of a nasal fracture; the physician treats a stable, non-displaced nasal fracture; no physical
manipulation of the nasal bones or stabilization from splints is necessary.
Treatment includes external agents (i.e. ice therapy) and prescribing pharmacologic agents in the ED or
discharge instructions. 0 days

23500/2352 – Closed treatment of a clavicle fracture; the physician may apply a clavicle brace, tape, sling or splint
until the fracture heals. 0-90 days

23570/2386 – Closed treatment of a scapular fracture; the physician place the shoulder in a sling or other brace until
the fracture heals. 0-90 days

21820/2394 – Closed treatment of a sternum fracture; braces or splints are not used, the physician will modify the patient’s
activity while the fracture heals. 0-90 days

283
 Splinting and Strapping
(Codes 29049 - 29580)
BILLING FOR SPLINT APPLICATION

Splint application is included in the orthopedic procedure package when a definitive

treatment is performed. However, many orthopedic injuries ( i.e. sprains/strains)
may require temporary immobilization with a splint/strap. When there is no
definitive orthopedic treatment code, it may be appropriate to bill for the splint
application in addition to the E/M level of service. The physician must personally
perform the procedure or perform a post application check of neurovascular status
when applied by another health care professional. For Medicare, the physician
must personally apply the splint in order to bill the splint application.

Splint application and E/M level of service may also be billed when a fracture is
treated but the documentation is insufficient to bill the treatment code. The
physician must still meet the documentation requirements for billing.

Check State Billing Guidelines and the Location Tracker for client specific “rules”

Apply modifier 25 to E/M when applicable.

284
 Splinting and Strapping
(Codes 29049 - 29580)
The following devices are not considered splints/straps and should not be billed:
⚫ Buddy Tape

⚫ Cast Shoe

⚫ Post Op Shoe

⚫ Sling

⚫ Unna Boot

⚫ Walking Shoe

⚫ Neoprene Sleeve

The following devices are considered splints/straps and should be billed:

⚫ ACE bandages/Jones bandages (strap)

⚫ Air Splint/air strap (splint)

⚫ Knee immobilizers (splint)

⚫ Ortho boots (splint)

⚫ Splints

285
 CPT Surgical Procedures With
Global Period of 0-10 Days
EXAMPLES:
⚫ Procedures with 0-10 day global period that would NOT support an E/M-
Patient presents with laceration-MD documented the laceration repair and
performed an examination limited to the laceration area alone-an E/M is not
applicable.
⚫ Procedures with 0-10 day global period that WILL support an E/M (using a
modifier”25”)-Patient presented with laceration-MD documented in the history
that the patient is diabetic and the wound is contaminated. The PE includes a
limited neuro exam. This would allow for a separate E/M with a “25” modifier.
To summarize, if the MD performs a separately identifiable Evaluation and
Management service in addition to the procedure, code the procedure and an E/M
and using the modifier “25”.
⚫ Procedures with 0-90 day global period that will support an E/M with a
modifier “57”-Patient presented with a complex laceration-MD performed an
examination NOT limited to the laceration area alone, evaluated the extent of the
injury and the decision to perform a surgery was documented. Add an E/M using
the modifier “57”.
286
E/M Level of Service and Procedures
(All Payors)
Procedures with 0-10 days global period
An E/M level of service may be assigned when the patient’s condition required a significant,
separately identifiable service that is above and beyond the usual preoperative and
postoperative care associated with a procedure performed with 0-10 day global period.
A different diagnosis is not required – modifier 25 is attached to the E/M level of
service.

Services that are included in the pre-op and post-op care:

⚫ Examination of the affected area
⚫ Explanation of the procedure to the patient including obtaining a consent form
⚫ Wound cleansing (if needed)
⚫ Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
⚫ Dressing
⚫ Discharge summary instructions
⚫ Removal of sutures for an intermediate or complex wound repair
⚫ Re-check of well-healing wound

287
E/M Level of Service With Procedures
(All Payors)
If the ERMD performs services in addition to items listed above, an E/M level of service
may be assigned with modifier 25. Refer to the coding guidelines for the accurate
assignment of the E/M level of service.

Procedures with 0-90 days global period

An E/M level of service may be assigned when the ERMD provided the service that
resulted in the decision to perform the procedure – add modifier 57 or 25 to the E/M level
of service.
⚫ Refer to the coding guidelines for the accurate assignment of the E/M level of service
⚫ Drug administrations that are part of the procedure should be excluded from
determining the E/M level of service (ex: drugs used for moderate sedation).
⚫ Medications that are not part of the procedure should be included in determining the
level of service.

288
MODERATE SEDATION

289
MODERATE SEDATION
⚫ Drug induced depression of consciousness
⚫ Patients respond purposefully to verbal commands
a. alone
b. accompanied by light tactile stimulation
⚫ No intervention is required to maintain patent airway
⚫ Spontaneous ventilation is adequate
⚫ Cardiovascular function is maintained
⚫ Do not bill if sedation time is less than 10 minutes
⚫ Moderate sedation is considered a minor procedure, so a modifier
25 is placed on the E/M level. (Note: moderate sedation is mod 51
exempt)
⚫ Moderate sedation is paid by ALL payers, so it should be billed to
ALL payers.
290
…….does not include:
⚫ Minimal sedation (anxiolysis) – to eliminate
anxiety
⚫ Deep sedation (MAC – monitored anesthesia
care) – CPT codes 00100-01999

291
Two Families
First Family = 99151 – 99153
⚫ Provided by the same physician performing
the procedure that the sedation supports
⚫ Requires the presence of an independent
trained observer (ex: nursing staff or MLP)
⚫ The independent trained observer assists in
the monitoring of the patient’s level of
consciousness and physiological status

292
 Second Family = 99155 - 99157

⚫ moderate sedation services by a physician other

than the physician performing the diagnostic or
therapeutic service

293
Description of Each Family of
Sedation Codes
First Family
⚫ 99151 - moderate sedation service provided by the same physician
performing the diagnostic or therapeutic service that the sedation
supports, requiring the presence of a trained observer to assist in the
monitoring of the patient’s level of consciousness and physiological
status; under 5 years of age, first 15 min. (in order to report a code
with a unit of time of 15 minutes, 10 min or more of the service
described by the code must be provided)

⚫ 99152 – age 5 or older, first 15 min. (10 min or more)

294
 Second Family

⚫ 99155 – moderate sedation services provided by a physician other than the

physician performing the diagnostic or therapeutic service; under 5 years
of age, first 15 min (in order to report a code with a until of time of 15
min, 10 min or more of the service described by the code must be provided)

⚫ 99156 – age 5 years or older, first 15 min. (10 min or more)

295
 Documentation Required to Bill the
Moderate Sedation Codes:
⚫ A statement by the provider indicating intraservice work time of
10 min or greater. The statement must be in one of these
formats:
• ___ minutes intraservice time
• ___ minutes face to face time providing sedation
⚫ The additional items must be documented also (may be in the
nurse’s notes):
• Who provided sedation or trained monitoring of the patient
• Patient’s alertness and response to sedation
• Medication(s) used
296
Intra-service Time – billing time
Intraservice 1st Family 2nd Family

Time < 5 yrs > = 5 yrs < 5 yrs > = 5 yrs

0 - 9 min bill level bill level bill level bill level

10-22 min 9151 9152 9161 9162

23-37 min 9151 + 9153 9152 + 9153 9161 + 9163 9162 + 9163

38-52 min 9151 + 9153 x 2 9152 + 9153 x 2 9161 + 9163 x 2 9162 + 9163 x 2

53-67 min 9151 + 9153 x 3 9152 + 9153 x 3 9161 + 9163 x 3 9162 + 9163 x 3

68-82 min 9151 + 9153 x 4 9152 + 9153 x 4 9161 + 9163 x 4 9162 + 9163 x 4

297
 Moderate Sedation Reminders
⚫ Moderate sedation when performed is now reportable in addition to any
procedure.
⚫ Moderate sedation is paid by ALL payers, so it should be billed to ALL
payers.
⚫ If a chart has a procedure you would normally see performed with moderate
sedation, look for the sedation notes. If sedation is not documented, please let
your supervisor know so feedback can be given to the client.
⚫ Moderate (conscious) sedation is considered a minor procedure, so a modifier
25 is placed on the E/M level. (Note: Moderate sedation is mod 51 exempt)
⚫ If the above requirements are met, bill moderate sedation even if the other
procedure(s) performed is not billable. (i.e. A patient comes in with a fracture
and gets sedation. The chart does not qualify for fx care but meets moderate
sedation requirements. You should bill the sedation only.)
⚫ If moderate sedation is not billed, use the medication to determine the risk.

298
Endotracheal Intubation
⚫ Placement of ETT to provide air passage in emergency
situation
⚫ Patient is ventilated with a mask and bag
⚫ Sedation used qualifies for MAC (deep/monitored
anesthesia care – 00100-01999)
⚫ RSI – is a type of MAC
⚫ MAC – must be provided by qualified anesthesia
personnel per LCD

299
 USING MODIFIERS TO ILLUSTRATE
SPECIAL CIRCUMSTANCES
General Information
⚫ Provides the means to report or indicate that a service or procedure has
been performed and altered by some specific circumstance but not
changed in its definition or code
⚫ Payer policy will determine affect on payment from use of modifier
⚫ Use of appropriate modifier may be essential for correct level of
reimbursement
⚫ Knowledge of each major payer’s policy for recognition of each modifier
is essential
⚫ Payer’s may utilize unique modifiers or revise the descriptors for the CPT
modifiers which may result in a change in their meaning and use

300
 USING MODIFIERS TO ILLUSTRATE
SPECIAL CIRCUMSTANCES
Medicine Modifiers (Apply to Services Listed in E/M Section of CPT)
The following Medicine modifiers are affixed to the E/M or Medicine section code when
appropriate:
-25 Significant, Separately Identifiable Evaluation and Management Service by the same Physician on the day of a
Procedure or Other Service
When a significant, separately identifiable E/M service is performed by the same physician on the day of a
procedure this modifier alerts the payer that the E/M service is separate and should be considered for separate
payment.
⚫ This modifier is generally not for an E/M service required to determine the need to perform a global surgery
procedure. (review Modifier –57).
⚫ Carrier monitoring may be performed to determine whether or not the E/M service qualifies as significant and
separately identifiable.
⚫ The E/M service may be prompted by the symptom or condition for which the procedure and/or service was
provided. As such, different diagnoses are not required for reporting of the E/M services on the same
date.
⚫ When billing E & M levels with procedures with a global period of 0-10 days, use this modifier if the exam is
expanded problem focused or higher.
⚫ When billing E & M levels with procedures with a global period of 0-90 days, use this modifier when other
symptoms and/or diagnoses are identified.
⚫ This modifier is applied to the E/M level (81-85) or first hour of CCT (99291) when a separate procedure or
service is provided on the same date.

301
USING MODIFIERS TO ILLUSTRATE
SPECIAL CIRCUMSTANCES
-57 Decision for surgery
⚫ When E&M service determines need for a surgery that includes all related
post-operative service, the payer may require that the E/M service be
designated for separate payment with the -57 modifier. This generally occurs
with payers that include all related pre-operative service in the procedure
package.
⚫ Medicare does allow one visit to determine the need for the surgery and
requests the -57 modifier to designate the E/M service billed with a procedure
as this allowable visit.
⚫ The modifier is added to the E/M code.
⚫ When billing an E & M level with a major procedure, and no other symptoms
and/or diagnoses are identified, attach this modifier to the E & M level
⚫ The -57 modifier may be used for E/M services billed with global surgery
(non-starred) procedures.

302
USING MODIFIERS TO ILLUSTRATE
SPECIAL CIRCUMSTANCES

-GC Modifier
⚫ This modifier is placed on the E/M service when
there is a Resident/Teaching Physician service
provided. This modifier is recognized and required
by Medicare only.
⚫ This modifier is automatically added by Embillz.

303
 USING MODIFIERS TO ILLUSTRATE
SPECIAL CIRCUMSTANCES

Surgery Modifiers (Applies to Procedures listed in Surgery Section of CPT)

-26 Professional Component

⚫ When a procedure includes both a technical and professional component,

such as X-rays, this modifier differentiates the segments.
⚫ Use of this modifier denotes the professional component of the service.
⚫ This modifier is automatically added by Embillz.

304
 USING MODIFIERS TO ILLUSTRATE
SPECIAL CIRCUMSTANCES
-51 Multiple procedures
⚫ When multiple, separate procedures are performed on the same day or within the same operative
session, this modifier distinguishes each procedure as separately identifiable.
⚫ Many payers reduce the reimbursement rate for secondary procedures when performed at the same time
of the primary procedure. As the payer may utilize a unique procedure value system to determine which
of a list of multiple procedures is the primary procedure, this modifier assures that the primary
procedure designated by the physician is recognized for full payment.
⚫ The -51 is affixed to the secondary procedure, not the primary procedure. Please note that certain CPT
codes are modifier –51 exempt (see your CPT manual, Appendix E).
⚫ Payers may reduce payment for all procedures listed with this modifier so knowledge of payer policy is
necessary before utilizing this modifier.
⚫ This modifier is also used to identify primary service when a combination of medical and surgical
procedures are performed.
Example: If a patient is involved in an MVA and has multiple lacerations that total 2.5cm simple lac to the face
and 5cm simple lac to hand, provided wound closures meet documentation requirements, we could bill 8193
and 8011-51
Example: If a patient is involved in an accident and has a carpal bone fracture and 2.5cm lac to the forearm,
provided documentation requirements are met for both fx care and wound closure, we would code 2527 and
8003-51.

305
 USING MODIFIERS TO ILLUSTRATE
SPECIAL CIRCUMSTANCES
52 Reduced services
⚫ Generally used when a procedure cannot be completed because of circumstances that interfere
with the procedure.
⚫ The provider elects not to do part of the procedure or the case presented did not require a full
procedure
⚫ Use when procedures are unsuccessful or only partially complete

53 Discontinued service
⚫ Generally used when a procedure needs to be discontinued due to a patient’s declining health.
⚫ Provider shows a procedure is interrupted because the patient is not tolerating the procedure
or the patient’s well-being is threatened.
⚫ Example (for procedure only): ERMD is performing a lumbar puncture, when the patient
develops tingling and numbness in the right leg. The ERMD aborts the procedure before the
CSF is retrieved. Code 6064-53

306
 USING MODIFIERS TO ILLUSTRATE
SPECIAL CIRCUMSTANCES
-54 Surgical Care Only

⚫ Global surgery procedures consist of pre-operative, intra-

operative and post-operative elements. In emergency medicine, it
is common for an emergency physician to provide pre-operative
and intra-operative service but discharge the patient to another
physician to provide the follow-up service. When this follow-up
service is provided by another physician other than the ED
physician or member of the ED group practice, the payer must be
alerted that the global surgery package has been altered. The -54
indicates to the payer that the emergency physician has referred
either the pre-operative or, as in most cases, the post-operative
care to another physician.
⚫ This modifier is automatically added by Embillz
307
 USING MODIFIERS TO ILLUSTRATE
SPECIAL CIRCUMSTANCES

-76 Repeat Procedure by Same Physician

⚫ Use when procedure repeated subsequent to original

service
⚫ Not used for bi-lateral procedures
⚫ This modifier is automatically added by Embillz

308
 COMMONLY USED MODIFIERS IN
THE EMERGENCY DEPARTMENT
25—a significant, identifiable Evaluation and Management service is performed by the same physician
on the day of a procedure— Placed on the first hour of Critical Care when additional procedures
are performed.

26—use of this modifier denotes the professional component of a procedure when the physician interprets
and documents his findings of a study performed.

50—use of this modifier indicates that bilateral procedures are performed at the same operative session;
applied to procedure only

51—multiple procedures, other than Evaluation and Management Services, are performed at the same
session by the same provider, the primary procedure or service may be reported as listed. Additional
procedures or services are identified by adding the modifier 50 to each one.

52—use of this modifier indicates reduced services performed by MD

53 – indicates a discontinued procedure

309
COMMONLY USED MODIFIERS IN
THE EMERGENCY DEPARTMENT
54—when one physician performs a surgical procedure and another provides preoperative and/or
postoperative management, surgical services may be identified by adding the modifier 54 to the
procedure code.
57—alerts the payer that a separately identifiable Evaluation and Management Service has been
performed by the same physician in addition to a global procedure.

76—the physician may need to report that a procedure or service has been repeated. The modifier 76
will be applied to the repeat procedure.
RT—right side—used when billing epistaxis control procedures and bilateral procedures when billed
individually.
LT—left side—used when billing epistaxis control procedures and bilateral procedures when billed
individually.
GC—this modifier is placed on the Evaluation and Management Service when there is a
Resident/Teaching Physician relationship. This modifier is used with Medicare only.

310
Ancillary Procedures

311
 GENERAL GUIDELINES FOR BILLING
INTERPRETATIONS
EKG(9324) Rhythm Strip/Monitor (9332) X-ray’s/CT Scans Pulse ox
Examples of billable interps: Examples of billable interps: Ex. of billable
Examples of billable interps: 1. NSR 1. negative (-) interps:
1. Atrial fibrillation 2. Normal sinus rhythm 2. normal alignment 1. 99% on room
2. NSR 72-111, ST depression 3. Abnormal sinus rhythm 3. no infiltrates air
3. No ST elevation (abnormality specified) 4. negative for fracture 2. 99% on RA –
4. NSR – no acute changes 5. negative for pneumonia normal
5. NSR (-) BBB Examples of non-billable 6. Normal 3. 100% on 6L
6. Sinus tachycardia – LAD interps: 7. NAD (no acute disease) O2
7. Acute inferior wall MI 1. Normal 8. Unremarkable 4. 77% - hypoxia
8. NSR (normal sinus rhythm) 2. Negative 9. No abnormalities 5. 100% - well
Note: - see below for MED criteria 3. No acute changes Examples of non-billable interps: oxygenated
4. Abnormal 1. Abnormal 6. 100%
Examples of non-billable interps: 5. 96 (rate only) 2. 0
1. Normal 6. 0 3. remarkable Ex. of non-billable
2. Negative 7. paced or paced rhythm Billing for U/S Interp: interps:
3. No acute changes 1. U/S needs a narrative interp. (normal or NAD 1. negative
4. Abnormal etc.) is not acceptable 2. normal
5. 0 2. For bedside U/S, "interp by me" is not needed as 3. abnormal
6. paced or paced rhythm long as there is documentation that the U/S was 4. 0
done by the provider (this can be found in the
nurse's notes or if the procedure note was
documented by the provider).

312
GENERAL GUIDELINES FOR
BILLING INTERPRETATIONS
⚫ Universal Coding - all ancillary procedures must be entered for all clients and payors. The system will tell you if billable.

⚫ Chart Formats and Radiology Coding/billing:

1. T-System (or any check boxed format that has “interp by me, reviewed by me or discussed with rad”)
• The box “interp by me” should be checked for x-rays
• For billing U/S, please follow instructions above
2. Dictated/handwritten charts (w/o the check box)
• Billing for interps should follow the time frame given in client Fact Sheet and on your Location Tracker
• Notation from MD - “interp by me” outside the x-ray time is also billable
⚫ 3. EMR’s (electronic medical records)
• “Interp by me” should be documented to bill for x-rays
• Client exceptions exist. Check client Fact Sheet for exceptions to this process
⚫ Additional Notes for all chart formats:
⚫ Pulse ox
• Not billable - if NN and MD’s documentation is the same – do not bill
• Billable - if the value of MD is the same as the NN, but MD added a worded interp (see example – see above)
⚫ Special Services
• Use the registration time, if this is missing
• Use the triage time, if this is also missing
• Use the MD time

313
GENERAL GUIDELINES FOR
BILLING INTERPRETATIONS
⚫ EKG’s
• “interp by me” not required for coding/billing
• Multiple EKG – a separate interpretation is needed for each EKG in order to bill.
• Medicare and payors that follow CMS/Medicare guidelines - each billable EKG interpretation should have at least 3 items
from this list:
• Rhythm and rate
• Axis
• Intervals
• ST Segment change
• Comparison to prior EKG
• Summary of clinical condition
⚫ Radiology Studies
• For multiple x-rays – interpretation is needed for each ordered x-ray.
• If the physician does not clearly identify which interpretation goes with which x-ray, we are not able to bill all x-rays.
• For multiple x-rays, if the physician says “all” are negative/normal, we can bill all x-rays.
• For multiple x-rays, if the physician draws a bracket and says “all” are negative/normal, we can bill all.
• When the order is different from the interpretation (views), you code what the actual interpretation says.
• Examples of acceptable verbiage by ED provider for X-rays:
• The x-rays were independently viewed by me and interpreted by the radiologist
• Preliminary review of the x-rays by ED physician (scrolling chart – under “RADIOLOGY INTERPRETATION”)
• X-ray contemporaneously interpreted by me
• I have reviewed films, radiologist to provide official reading

314
Coding of EKG Interpretations
(CPT codes 93010 and 93042)
Payment for interpretations was reinstated in 1994 by OBRA
93's removal of the prohibition on payment for interpretations
with a visit or consultation. Prior to 1994, the value of the
interpretation was included in the value for the evaluation and
management service. When payment for interpretation was
reinstated, the value of the evaluation and management codes was
reduced to assure budget neutrality for the Medicare program.

Billing for EKG interpretations is still a state and payer specific issue.
The issue of over read payment (payment to cardiologist) requires
research of the individual payer policies for payment to understand
the implications for the emergency medicine group and the
cardiologists.

315
Coding of EKG Interpretations
(CPT codes 93010 and 93042)
In 1996, clarifications issued by Health Care Financing
Administration (HCFA), carriers have been instructed to pay the
emergency physician unless the cardiologist performs a reading
contemporaneously (during the visit at the time the patient diagnosis
and treatment are determined).

The emergency physician must provide a written report of the

findings when billing separately for the interpretation.

The written report may be incorporated into the emergency

department record but must clearly reflect an interpretation (findings,
relevant clinical issues and diagnosis), not a review of an
interpretation made by another physician.

316
Coding For Interpretation of X-ray’s
When coding for x-ray interpretation by the emergency physician, the -26
modifier must be applied to the basic x-ray procedure code. This denotes the
service as a “professional component” and excludes the technical service of
preparing and developing the film for payment purposes. This modifier is
automatically applied by the EMBILLZ system in this situation.

Individual client policy will determine how x-ray interpretations will be

identified and billed. Although there is currently no definitive description of
what constitutes a formal interpretation by the emergency physician, it is
minimally defined by HCFA as a notation in the emergency department
record, which addresses the findings, relevant clinical issues and diagnosis.

A simple review of the radiologist’s findings by the emergency physician

does not constitute an interpretation and such a review is included in the
evaluation and management service. The EDMD should be encouraged to
sign or initial the interpretation note to avoid confusion about that actually
provided the interpretation.
317
Documenting
Emergency Medicine Interpretations
There is a distinction between an interpretation and the review of a study.
The interpretation and report of an x-ray or EKG is a separately billable
service. Review of findings rendered by another physician
(cardiologist/radiologist) does not meet the requirements for separate
payment to the ED physician. The role of the ED physician in the review
process is credited as part of MDM criteria towards the selection of E & M
service.

⚫ The report need not be on a separate piece of paper and may be incorporated into the
emergency record or EKG tracing but must clearly reflect the impressions of the ED
physician.

318
Suggestions for the dictated or
handwritten chart
Provide complete statements. Phrases such as "the lungs
show no evidence of infiltrates" identify the absence of
the abnormality or disease process for which the study
was ordered.

You should not use phrases such as “chest x-ray

normal”. If prior studies are used as a resource, the
comparative changes should be noted.

319
Suggestions for the dictated or
handwritten chart
For Medicare, EKG interpretations must include as
least three of the following six elements:

⚫ Rhythm and rate

⚫ Axis

⚫ Intervals

⚫ ST Segment change

⚫ Comparison to a prior EKG

⚫ Summary of clinical condition

320
Suggestions for the dictated or
handwritten chart
The emergency physician must provide a written
report of the findings when billing separately for the
interpretation.

The written report may be incorporated into the

emergency department record but must clearly reflect an
interpretation (findings, relevant clinical issues,
comparative data when available, diagnosis), not a
review of an interpretation made by another physician.

321
Suggestions for the dictated or
handwritten chart
Example of acceptable EKG interpretation: EKG NSR, no ST changes, unchanged from
prior EKG with no evidence of ischemia.
An acceptable monitor interpretation includes cardiac rate and rhythm.
For most payors, specific worded interpretations are necessary, with an indication as to who
provided the initial interpretation. A billable interpretation should include the following:

⚫ A specific description in anatomic language of the imaged organ or body area.

⚫ The location and extent of any pertinent positives.
⚫ A conclusion on what was suspected/what was found (e.g. no infiltrate, no definitive
masses, and no fracture/no bony deformities).

Finally, the emergency physician is encouraged to sign or initial their interpretive note.
Alternatively including the phrase “interpreted by me” is acceptable.

322
Suggestions for the templated chart

As with the dictated or handwritten report, it is extremely important that the

reader be identified. Most template charting systems currently offer three
checkbox selections; Interpreted by me, Reviewed by me and Read by
radiologist. These are to be utilized as follows: Interpreted by me is for
those studies read initially by the ED provider. Reviewed by me is for those
occasions when the radiologist has performed the interpretation. Discussed
with radiologist may often be checked in conjunction with either of the
aforementioned.

323
PULSE OXIMETRIES
Pulse oximetry interpretations rendered for the assessment and
treatment of applicable patient care issues are a separately billable
service. While it is payer specific, all insurers require a note
originated by a physician (or midlevel). Documentation found in
nursing notes or reference made to triage vitals does not constitute an
interpretation. The note should include a percentage, whether the
patient was on room air or oxygenation and what this value is related
to – i.e. within normal limits, low normal, hypoxemic. Additionally,
if it is abnormal, a plan of action to remedy should be identifiable.
Ex.: 98% on room air, good oxygenation.

324
 PORTABLE DIAGNOSTIC
ULTRASOUNDS STUDIES
REVIEW

PORTABLE (HAND HELD, BEDSIDE) DIAGNOSTIC ULTRASOUNDS STUDIES

Ultrasounds are the reflections of high-frequency sound waves that create pictures of tissues and internal organs. These
images are used to help diagnose a wide range of diseases and abnormalities in the body.

Portable diagnostic ultrasound studies are being performed in some Emergency Departments. To bill for these procedures,
certain requirements must be met by the ERMD.

Requirements for billing portable ultrasounds:

• ERMD must document “done/performed by me”

• ERMD must document the findings of the study

When these requirements are met, we can bill for these procedures along with the E/M level and any other billable
procedures. The portable ultrasounds are billable for all payers.
• Follow Universal Coding and enter the correct portable ultrasound code for all payers.
• You need to know that the procedure and interpretation were performed by the ERMD.
• Remember to add modifier 25 or 57 to the E/M Level

Examples: U/S not billable Examples: U/S billable

092253403615 092363401694 092173406012
092173406088 092293400319 092173406141

325
326
PHYSICIAN DIRECTED CARE
CPT code 99288 – Physician direction of emergency medical systems (EMS)
emergency care, advanced life support.

In physician directed emergency care (advanced life support), the physician is located in a
hospital emergency or critical care department and is in two-way voice communication with
ambulance or rescue personnel outside the hospital. The physician directs the performance of
necessary medical procedures, including but not limited to:

⚫ Telemetry of cardiac rhythm

⚫ Cardiac and/or pulmonary resuscitation
⚫ Endotracheal or esophageal obturator airway intubation
⚫ Administration of IV fluids and/or administration of IM,
IT or SQ drugs
⚫ Electrical conversion of arrhythmia

327
PHYSICIAN DIRECTED CARE
While this CPT code may not be recognized as a separately billable service by
most major 3rd party payors (Medicare, Medicaid, Blue Shield), it is
reimbursable by many payors. Therefore when specific physician direction
of EMS care is documented in detail by the ED physician this may
constitute a separately billable service.

While there are no "official" documentation guidelines for use of this code, the
record must clearly reflect that a separate additional service was provides by
the EDMD. At a minimum, the physician needs to document his specific
"direction" provided to the EMS crew. A copy of the run sheet/order sheet also
helps support the billing of this code but is not required at the time of billing as
long as the separate service is supported by the ED physician documentation.

328
 Advance Care Planning (ACP)
These codes are used when the provider discusses the future healthcare needs of the patient with the patient, their
family or an individual representing the family.

Advance Care Planning CPT Codes:

➢ 99497/9541 - 1st 30 minutes (minimum of 16 minutes)
Includes the explanation and discussion of advance directives such as standard forms (with
completion of such forms, when performed), by the physician or other qualified health care
professional; face-to-face with the patient, family member(s), and/or surrogate

➢ 99498/9542 – each add’l 30 minutes (list separately in addition to code for primary procedure)

Reminders:
✓ These codes cannot be billed with critical care, but should be billed with other E&M levels.
✓ This could be documented on a form, the MDM or the discharge plan.

329
 Suicide Risk Assessment
⚫ When billing for suicide risk assessment, RTI 9264/CPT 96127, look for the series of questions to be asked.

• Q1: In the past few weeks, have you wished you were dead?
• Q2: In the past few weeks, have you felt that you or your family would be better off if you were dead?
• Q3: In the past few weeks, have you been having thoughts about killing yourself?
• Q4: Have you ever tried to kill yourself?
• Q5: Are you having thoughts of killing yourself right now?

• If patient answers “NO” to Q1-Q4 = code 9264/96127

• If patient answers “YES” to any Q1-Q4 or refuses to answer, and the response to Q5 is:
➢ YES = Look in PE for a full mental evaluation = code 9264/96127
➢ NO = code 9264/96127
⚫ Documentation requirements: Provider must initial the form or indicate in the medical record that the form was
reviewed.

330
Coding with Mid-Levels

331
 MLP in Triage
You may not utilize documentation by MLP’s in Triage UNLESS it is the only
documentation on the chart by an EmCare provider

⚫ MLP performed the triage and MD treated the patient = ignore the MLP
notes, code the account based on the MD’s documentation only and enter the
MD’s RTI# number only on the provider screen.

⚫ MLP performed the triage, however, patient was not seen by an MD – code
the account using the MLP notes, enter the MLP’s RTI# on the provider
screen

➢ Reminder: Refer to the client’s fact sheet for any exceptions.

332
 Transfer Of Care Policy
⚫ When care is transferred from one ERMD (the MD who
initially cares for the patient upon admission to the ED) to
another ERMD who ultimately discharges the patient from
the ED, the provider of record (POR) is the MD who
determines the patient’s final disposition, according to the
documentation in the chart.

⚫ See client fact sheet for special instructions

333
 Enhanced Clinician Assignment
You will have to enter all ED providers that document on the chart.
⚫ You are allowed to enter:
➢ 0 to 2 MDs
➢ 0 to 1 MLP
⚫ Reminder: since the documentation by a MLP in Triage is not to be used (unless exception process for
specific client or MLP is the only RTI provider that documented), do not enter the Triage MLP RTI number in
Embillz (unless client exception process in place).
• Example: Doc# 162094041794. Do not enter PA in enhanced clinician assignment.

⚫ Embillz may ask you follow-up questions to automatically determine which provider to bill to,
if the chart should be suspended, or if the chart should be made nonbillable.
⚫ If a provider did not sign the chart, put “?” after the provider number.
⚫ MLP’s now only have one provider number – the one that used to be the billing number.
334
 Enhanced Clinician Assignment
Scenario #1 – one provider (MD)
⚫ Proceed as usual in C1 Coding batch.

335
 Enhanced Clinician Assignment
⚫ At prov field, a new window will open.

336
 Enhanced Clinician Assignment
⚫ Enter each provider’s billing number and double check provider name for accuracy.

➢ The entry of provider’s billing number means you have a valid provider signature.

337
 Enhanced Clinician Assignment
Scenario # 2 – two providers (MLP and MD)
⚫ Enter each provider’s billing number and double check provider names for accuracy.
➢ MLPs only have one number (billing number). The tracking numbers have been made
inactive in the system.
➢ Entry order does not matter.

338
 Enhanced Clinician Assignment
⚫ Enter highest level of physician involvement.

339
 Enhanced Clinician Assignment
⚫ Coding screen will look the same.

340
 Enhanced Clinician Assignment
Scenario # 3 – auto nonbillable (MLP and MD)
⚫ Enter each provider’s billing number and double check provider names for accuracy.
➢ MLPs only have one number (billing number). The tracking numbers have been
made inactive.
➢ Entry order does not matter.

341
 Enhanced Clinician Assignment
⚫ The system will review the billing requirements (in background) and auto nonbill, if
needed.

342
Enhanced Clinician Assignment

343
 Enhanced Clinician Assignment
Scenario # 4 – 2 providers (2 MD’s)
⚫ Enter each provider’s billing number and double check provider name for accuracy.
➢ Again, entry order does not matter.
➢ The Provider of Record (POR) needs to be identified when 2 MD numbers are
entered. See Transfer of Care policy.
• The yellow arrow identifies the Provider of Record (POR).
• Answer “yes” to confirm the identified POR.

344
 Enhanced Clinician Assignment
⚫ Answer 'No' and the other MD will be set as provider of record. You will then be taken
directly to the diagnosis screen.

345
 Enhanced Clinician Assignment
⚫ If you go back into the provider field, it shows '(*)' next to the provider of record. And
it can be changed, if needed.

346
 Enhanced Clinician Assignment
⚫ Provider of Record (POR) will be in the Prov field on main screen.

347
 Enhanced Clinician Assignment
Scenario # 5 – one provider (MLP)
⚫ Enter provider’s billing number and double check provider name for accuracy.
⚫ Enter the highest level of physician involvement and proceed as usual.

⚫ The system will review the billing requirements (in background) and auto suspend, if
needed.

348
 Enhanced Clinician Assignment
Scenerio #5 (cont) – one provider (MLP), autosuspend

349
 Enhanced Clinician Assignment
⚫ Enter “*?” in CPT field.

350
 Enhanced Clinician Assignment
⚫ Suspend abbreviation will auto-populate. Hit “enter” or “F1” to accept the suspend
reason. System will add the suspend reason detail. The reason code can be changed if
needed.

351
 Enhanced Clinician Assignment
Scenario # 6 – one provider (MD), missing signature
➢ Enter billing number followed by a “?” when you know the provider, but are
missing the provider’s signature.
➢ Enter “?” when you do not know the provider and do not have a provider
signature.
➢ System will autosuspend .

352
 Enhanced Clinician Assignment
Definitions of Highest level of Physician (MD/DO) Involvement:

Option 3. Face-to-face with any element(s) of any Key Component (H/P/MDM): to

validate face-to-face in cases with physician and MLP involvement, we require EITHER:
a. The physician attestation must include documentation of at least one element of the
history, physical exam, or MDM that denotes face-to-face

OR

b. The chart notes must include documentation by the physician of at least one element of
the history, physical exam, or MDM that denotes face-to-face
353
 Enhanced Clinician Assignment
Reminders for Option 3:
⚫ The physician must indicate any relevant finding(s) for at least 1 element of the 3
components, not simply state agreement with the MLP.
⚫ Evidence of face-to-face may be found in a procedure note documented by the physician
⚫ For Enhanced Clinician Assignment, we do not accept physician orders for MDM

Examples of acceptable MDM documentation:

⚫ Diagnosis or R/O or Differential Diagnosis
⚫ Disposition
⚫ Summary of findings or results
⚫ Plan of care
⚫ Prognosis

354
 Enhanced Clinician Assignment
Example 1: Doc 172854026753. This example shows face-to-face and the physician
documented MDM. The highest level of physician involvement is option 3.

355
 Enhanced Clinician Assignment
Example 2: Doc 162284016186. This example shows face-to-face and the physician
documented a History and PE (only one element is needed). The highest level of physician
involvement is option 3.

356
 Enhanced Clinician Assignment
Example 3: Doc 180154067232. This example shows face-to-face and the physician
documented an element of the History. The highest level of physician involvement is
option 3.

357
 Enhanced Clinician Assignment
Option 2. Any Physician Participation In Care
⚫ One of the following is present:
• Statement by the physician that shows face-to-face
• Physician documentation of face-to-face
• Documentation of physician participation

Acceptable examples of physician participation:

✓ Agreement with MLP documentation and/or findings
✓ Review labs/radiology studies
✓ Diagnosis or R/O or Differential Diagnosis
✓ Disposition
✓ Summary of findings or results
✓ Plan of care
✓ Prognosis

Unacceptable examples of physician participation:

✓ Physician orders
358
 Enhanced Clinician Assignment
Example 4: Doc 172844059522. This attestation shows face-to-face with the patient,
however there is no element(s) of history, PE or MDM documented by the physician. The
highest level of physician involvement is option 2.

Example 5: Doc 173634004440. This attestation shows face-to-face, however there is no

element(s) of history, PE or MDM documented by the physician. The highest level of
physician involvement is option 2.

359
 Enhanced Clinician Assignment
Example 6: Doc 173604061681. This attestation does not show face-to-face. The highlight
shows physician participation because he agreed with the MLP’s documentation. The
highest level of physician involvement is option 2.

Example 7: Doc 172304026929. This attestation does not show face-to-face. The highlight
shows physician participation because he agreed with the MLP’s documentation. The
highest level of physician involvement is option 2.

360
 Enhanced Clinician Assignment
Option 1. None of the Above or Co-signature Only – physician documentation does not
meet option 3 or 2.

Example 8: Doc 162444020221. This does not show face-to-face and there is no other
documentation by the physician. The highlight does not show agreement with the MLP’s
documentation. The highest level of physician involvement is option 1.

361
 Enhanced Clinician Assignment
Example 9: Doc 180154011410. This does not show face-to-face and there is no other
documentation by the physician. The attestation does not show agreement with the MLP’s
documentation. The highest level of physician involvement is option 1.

362
CMS CLARIFIES
TEACHING PHYSICIAN RULES
Clarification on the documentation requirements for evaluation and management (E/M) services
billed by teaching physicians has been published by Medicare via Transmittal 1780. The revised
language makes it clear that for E/M services, teaching physicians (TP) need not repeat
documentation already provided by a resident. In addition, the revisions clarify policies for services
involving students.

For purposes of payment E/M services billed by teaching physicians require that they personally
document at least the following:

⚫ That they performed the service or were physically present during the key or critical portions of
the service when performed by the resident; AND
⚫ Their (TP) participation in the management of the patient.

When assigning codes to services billed by the TP, reviewers will combine the documentation of both
the resident and the teaching physician.

363
 CMS CLARIFIES
TEACHING PHYSICIAN RULES

Scenario One

In the absence of a note by a resident, the teaching physician must document as he or she would document an E/M
service in a non-teaching setting.

When a resident has written notes, the TP’s note may reference the resident’s note. The TP must document that he or
she performed the critical or key portion(s) of the service and that he or she was directly involved in the management of
the patient. For payment, the composite of the teaching physician’s entry and the resident’s entry together must support
the medical necessity of the billed service and the level of the service billed by the TP.

Example of minimal acceptable documentation for Scenario One:

“I performed a history and physical examination of the patient and discussed his management with the resident. I
reviewed the resident’s note and agree with the documented findings and plan of care.”

364
CMS CLARIFIES
TEACHING PHYSICIAN RULES
Scenario Two

The resident performs the elements required for an E/M service in the presence of or jointly with the
TP and the resident documents the service. In this case, the TP must document that he or she was
present during the performance of the critical or key portion(s) of the service and that he or she was
directly involved in the management of the patient. The TP’s note should reference the resident’s
note. For payment, the composite of the teaching physician’s entry and the resident’s entry
together must support the medical necessity of the billed service and the level of the service billed
by the TP.

Example of minimal acceptable documentation for Scenario Two:

“ I was present with the resident during the history and exam. I discussed the case with the
resident and agree with the findings and plan as documented in the resident’s note.

365
 CMS CLARIFIES
TEACHING PHYSICIAN RULES
Scenario Three

The resident performs some or all of the required elements of the service in the absence of
the TP and documents his/her service. The TP independently performs the critical or key
portion(s) of the service with or without the resident present and, as appropriate, discusses
the case with the resident. In this instance, the TP must document that he or she
personally saw the patient, personally performed critical or key portions of the service, and
participated in the management of the patient. The TP’s note should reference the resident’s
note. For payment, the composite of the teaching physician’s entry and the resident’s entry
together must support the medical necessity of the billed service and the level of the service
billed by the TP.

Example of minimal acceptable documentation for Scenario Three:

“I saw and evaluated the patient. I reviewed the resident’s note and agree, except that picture is more
consistent with pericarditis than myocardial ischema. Will begin NSAIDs.”

366
 Unacceptable Documentation

⚫ “Agree with above.”, followed by legible countersignature or identity;

⚫ “Rounded, Reviewed, Agreed.”, followed by legible countersignature or
identity;
⚫ “Discussed with resident. Agree.” followed by legible countersignature
or identity;
⚫ “Seen and agree.” followed by legible countersignature or identity;
⚫ “Patient seen and evaluated.” followed by legible countersignature or
identity;
⚫ A legible countersignature or identity alone.

Such documentation is not acceptable because the documentation does not

make it possible to determine whether the TP was present, evaluated the
patient, and/or had any involvement with the plan of care.

367
PROCEDURES
No clarification or changes were made for these
services.

For procedures with 0-90 day global period on the fee schedule, the
TP must be physically present for all key portions and immediately
available to provide service throughout the entire procedure for
which payment is sought. This would mean that the TP cannot be
involved in other procedures from which he or she cannot return.
The procedure includes all related preoperative, operative and post
operative care of the patient. Physical presence may be documented
by the TP, resident or operating room nurse.

For overlapping surgeries, documentation must illustrate the TP’s

presence during the key portion of both. The documentation of the
TP’s presence in the key portion of both must be entered personally
by the TP.

368
Minor surgical procedures
Of primary interest to emergency physicians is the policy
governing the TP’s involvement in minor surgical procedures such
as simple suturing which is common in the emergency
department.

For procedures with a global period of 0-10 days, the TP must be

present for the entire procedure for which payment is sought.
(Authors note: As Medicare considers all related pre- and post-
operative service in the minor surgical procedure package, the TP
would be expected to document his or her involvement in the
entire surgical “package”.)

369
X-RAY INTERPRETATIONS
Payment will be made for interpretations performed
by a physician other than a resident which may be
indicated by the physician’s signature on the record
if no resident signature is present. If the resident
prepares and signs the interpretation, the TP must
indicate his/her personal review and interpretation
through agreement or revision of the resident’s
findings.

370
 CRITICAL CARE

The TP must be present for the entire time of the care of the unstable critically
ill or critically injured patient for which payment is sought. The minimum
personal attention requirement for the TP’s attention in order to bill for Critical
Care is 30 minutes excluding any time spent performing additionally billable
procedures, eg. intubation, CPR, laceration repair, etc. The time spent by the
resident can not be considered part of the TP’s critical care service.

Physical presence may be documented by the TP, resident or operating room

nurse.

371
 Resident & Teaching Physician Entry
Reminders:

⚫ Residents do not have a provider number in Embillz, so

you must check for the attestation before entering
provider numbers.
⚫ Do not suspend for missing resident attestation,
NB0041 the first time through.

372
E/M SERVICE DOCUMENTATION
PROVIDED BY STUDENTS
Any contribution of a student to the performance of a billable service (or than the review
of systems and/or past, family/social history) must be performed in the physical presence
of a TP or physical present of a resident in a service meeting the requirement set forth in
the TP billing guidelines.

Students may document services in the medical record. However, the documentation of
an E/M service by a student may be referred to by the TP only in a limited capacity (ROS
and/or PFSH only). TP must document “reviewed as agreed”The TP may not refer to a
student’s documentation of PE or MDM in his or her personal note. If the medical
student documents E/M services, the TP must verify and re-document the HPI as well as
perform and re-document the PE and MDM activities of the service.

Acting as scribe for:

The documentation accurately reflects work & decisions
made by me.
MD Signature:

373
THE USE OF SCRIBES AND
MEDICAL STUDENTS
PURPOSE:

The purpose of this policy is to set forth documentation guidelines for scribes and medical student documentation

POLICY:

This policy outlines the use of scribes and medical students who in their assigned roles may be responsible for recording
information in the patient record.

1. Scribes:

A scribe is also known as a Physician Record Assistant (PRA). Their line of responsibility is limited to being a documentation
technician. Their duties are limited to accompanying a physician during patient care services in order to transcribe a history
during the physician’s interview with the patient. The PRA records the physical examination or procedures as they are
rendered by the physician and orders any diagnostic tests as the physician explains them to the patient. The PRA may also
record test results, diagnostic impression, prescriptions and family discussions or follow-up instructions in accordance with
recommendations and practice design of the physician to whom he/she serves. The PRA is not licensed to perform patient
care activities and does not act independently.
.

To clearly delineate the scribe’s contribution to that record, it is recommended that the PRA (scribe) signature be footnoted by
the phrase “acting as scribe for…(i.e. Acting as scribe for Dr. Jones) The counter signature authenticates that the record
content reflects an accurate accounting of the care rendered by the attending physician. In this regard the physician would
append their signature with “the note accurately reflects work and decisions made by me.”

374
 THE USE OF SCRIBES AND
MEDICAL STUDENTS
2. Medical Student Documentation:

Most hospital organizations have policies and procedures outlining the activities of medical students and what documentation
from students can be entered in the patient record. As regards the recording of the history and physical by the medical
student, the history and physical entered into the patient record must be performed, documented and authenticated by a
licensed independent provider with approved clinical privileges, or delegated to a non-licensed provider (see exception below)
when allowed by the organizational bylaws. Since the medical student is not licensed, they do not meet the aforementioned
criteria. In their role as ancillary health care personnel, the medical student is able to solicit from the patient and record those
answers in the medical record regarding the system review (ROS) and past, family and social histories (PFSH).

Additionally, upon approval by individual organizational medical staff and governing bodies and in accordance with their by
laws and regulations, students may provide direct patient care activities under the direct supervision of a qualified licensed
practitioner. It then becomes the responsibility of the licensed practitioner (acting now as a teaching physician-TP) to
countersign and appropriately reference the above sections in the patient record. If the medical student documents E/M
services, the TP must verify and redocument the history of present illness (HPI), as well as perform and redocument the
physical exam (PE) and medical decision making (MDM) components of the encounter. The licensed physician ultimately is
legally accountable for the student’s activities and documentation.

A medical student (not a resident) may serve in the role of a PRA (scribe) so long as the delineation of responsibilities is in
accordance with those activities outlined above.

All departments and individuals shall comply with the Company's billing and coding policies, and interpretations different
from or actions inconsistent with this policy are prohibited.

375
 OBSERVATION SERVICES
DEFINITION

Observation services are performed in a hospital to evaluate a patient’s condition to determine whether
admission is reasonable and medically necessary. To admit a patient for observation, physician order must
explicitly state "admit to observation."

Observation services are services that include the use of a bed and periodic monitoring by a hospital’s nursing
or other staff, and are reasonable and necessary to evaluate an outpatient’s condition and determine the need for
a possible admission to the hospital as an inpatient. The Medicare program only recognizes observation
services that meet or exceed eight hours in duration. For Medicare with less than 8 hours observation
(admit/discharge on same day) – use 99218, 99219 or 99220 w/o 99217.

Observation is a "patient status" rather than a place. While most observation services are provided in an
observation area designated by the hospital, it is not necessary that the patient be located in such an area.
Observation care can take place in a regular bed in the emergency department or in an inpatient bed.

There are two sets of observation CPT codes, one is for medical care provided on one calendar date and the
other is for medical care that spans two calendar dates. Below you are two tables of observation codes that are
available for reporting outpatient observation services:

376
CODE OBSERVATION SERVICES
(observation stay spans more than one calendar date)
99218 Initial observation care for problems of low severity. Documentation requires:
▪ a detailed or comprehensive history;
▪ a detailed or comprehensive examination; and
▪ medical decision making that is straightforward or of low complexity.
▪ Physician typical spend 30 min at the bedside & on patient’s hospital floor/unit
99219 Initial observation care for problems of moderate severity.
Documentation requires:
▪ a comprehensive history;
▪ a comprehensive examination; and
▪ medical decision making of moderate complexity.
▪ Physician typical spend 50 min at the bedside & on patient’s hospital floor/unit
99220 Initial observation care for problems of high severity.
Documentation requires:
▪ a comprehensive history;
▪ a comprehensive examination; and
▪ medical decision making of high complexity.
▪ Physician typical spend 70 min at the bedside & on patient’s hospital floor/unit
99217 Observation care discharge, day management.
Includes services on the date of observation discharge (should only be used on a calendar day other than the initial day of
observation). This service include a final exam, discussion of the observation stay, follow-up instructions, and documentation

CODE OBSERVATION SERVICES

(same day observation admission and discharge)
99234 Observation or inpatient hospital care, for the evaluation and management of a patient including observation and discharge on the
same date which requires these three key components:
▪ a detailed or comprehensive history;
▪ a detailed or comprehensive examination; and
▪ medical decision making that is straightforward or of low complexity.
99235 Observation or inpatient hospital care, for the evaluation and management of a patient including observation and discharge on the
same date which requires these three key components:
▪ a comprehensive history;
▪ a comprehensive examination; and
▪ medical decision making of moderate complexity.
99236 Observation or inpatient hospital care, for the evaluation and management of a patient including observation and discharge on the
same date which requires these three key components:
▪ a comprehensive history;
▪ a comprehensive examination; and
377
**Note: 2002 RVUs- not locality adjusted.
▪ medical decision making of high complexity.
378
 OBSERVATION SERVICES
BILLING

Same day observation and discharge

Only the physician who admits the patient to “observation status” and is responsible for the patient during his
or her stay in observation may bill the observation codes. When “observation status” is initiated during the
course of an encounter in the hospital emergency department, the evaluation and management services
provided in the ED on the same date of service are considered part of the initial observation service.
Therefore, the emergency physician can bill either the emergency evaluation and management codes (99281-
99285) or the observation codes (99234-99236) when both services are provided on the same day.

Observation stay spans more than one calendar date

When the patient is admitted to “observation status” but not discharged from “observation status” on the same
day, the supervising physician should bill initial observation care codes 99218, 991219 or 99220. If the
patient remains in the observation area/unit after the first midnight census following the admission to
“observation status” and is later discharged, the supervising physician can bill CPT 99217 (observation care
discharge) for the second date of service. Occasionally, a patient may be held in observation status for more
than two calendar dates. In that case, the physician must bill subsequent services using the outpatient visit
codes (99211, 99212, 99213, 99214 or 99215).

379
 OBSERVATION SERVICES
HCFA guidelines for billing observation codes include:

⚫ Medicare Part B will not pay for more than two days (48 hours) of outpatient observation except in rare and exceptional cases.

⚫ The following services are not consider outpatient observation services:

⚫ Services not reasonable or necessary for the diagnosis or treatment of the patient
⚫ Services covered under another Part B benefit
⚫ Any substitution of an outpatient observation status for a medically appropriate inpatient admission.

DOCUMENTATION REQUIREMENTS:

In order to assign observation CPT codes, CPT documentation criteria must be met. In addition the Medicare programs requires that the
physician document the following items in a separate observation record:

– Observation admission order

– Admission time
– Medical necessity to justify the admission
– Treatment plan
– Progress notes
– Diagnosis
– Discharge summary
– Discharge time.

The observation record may refer to the history and exam documented in the ED record.

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OBSERVATION SERVICES
Observation or Inpatient Care Services – A patient admitted and discharged from the observation unit on the same
date, use the following codes:
99234 (9234) - Observation or inpatient hospital care
 a detailed or comprehensive history
 a detailed or comprehensive examination; and
 medical decision making that is straightforward or of low
complexity
Usually, the presenting problem(s) requiring admission are of low severity.

99235 (9235) - Observation or inpatient hospital care

 a comprehensive history
 a comprehensive examination; and
 medical decision making of moderate complexity
Usually, the problem(s) requiring admission are of moderate severity.

99236 (9236) - Observation or inpatient hospital care

 a comprehensive history
 a comprehensive examination; and
 medical decision making of high complexity
Usually, the problem(s) requiring admission are of high severity.

381
 OBSERVATION SERVICES
Initial observation care and Subsequent Observation care have designated time therefore can add prolonged
service code when warranted
Initial Observation Care – a patient admitted to the observation unit and discharged on the next calendar date
after being observed overnight requires the following codes:
First Day -
99218 (9218) - Initial observation care per day which these 3 key components:
 a detailed or comprehensive history
 a detailed or comprehensive examination; and
 medical decision making that is straightforward or of low complexity
Usually, the problem(s) requiring admission to “observation status” are of low severity.
The physician typically spends 30 minutes at the bedside and on the floor/unit.

99219 (9219) - Initial observation care per day which these 3 key components:
 a comprehensive history
 a comprehensive examination; and
 medical decision making of moderate complexity
Usually, the problem(s) requiring admission to “observation status” are of moderate severity.
The physician typically spends 50 minutes at the bedside and on the floor/unit.

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OBSERVATION SERVICES
99220 (9220) - Initial observation care per day which these 3 key components:
 a comprehensive history
 a comprehensive examination; and
 medical decision making of high complexity
Usually, the problem(s) requiring admission to “observation status” are of high severity.
The physician typically spends 70 minutes at the bedside and on the floor/unit.

Second day/Discharge day

99217 (9217) - Observation care discharge day – Observation care discharge of
patient from “observation status” includes the ff:
 final examination of the patient
 discussion of the hospital stay
 instruction for the continuing care
 preparation of discharge records

A patient admitted to the observation unit then admitted to the hospital on the same day, or the next
calendar day, for YRW location 62 use Observation care codes (9234, 9235 and 9236).

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Subsequent Observation Care
⚫ 99224 - physicians typically spend 15 minutes at the bedside and on the floor/unit
⚫ 99225 - physicians typically spend 25 minutes at the bedside and on the floor/unit
⚫ 99226 - physicians typically spend 35 minutes at the bedside and on the floor/unit

⚫ Prolonged Service
⚫ This service is reported in addition to the E/M service when a physician provides a prolonged service involving
direct (face to face) or without direct patient contact that is beyond the usual service even if the time spent is not
continuous. The time is counted after the usual time spent for the E/M.
⚫

⚫ With Direct Contact

• Less than 30 min. - not reported
• 30 – 74 min - 99356
• 75-104 min - 99356 and 99357x1
• 105-134 min - 99356 and 99357x2
⚫

⚫ Without Direct Contact

• Less than 30 min - not reported
• 30-74 min - 99358
• 75-104 min - 99358 and 99359x1
• 105-134 min - 99358 and 99359x1

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Thank you for your participation

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