Medicare KX Modifore Medicare Claims Procesing Manual

Medicare Claims Processing Manual
Chapter 5 - Part B Outpatient Rehabilitation

and CORF/OPT Services
Table of Contents
(Rev. 3995, 03-09-18)
Transmittals for Chapter 5
10 - Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation

Facility (CORF) Services - General
10.1 - New Payment Requirement for A/B MACs (A)
10.2 - The Financial Limitation Legislation
10.3 - Application of Financial Limitations
10.3.1 - Exceptions to Therapy Caps – General
10.3.2 - Exceptions Process
10.3.3 - Use of the KX Modifier for Therapy Cap Exceptions
10.3.4 - Therapy Cap Manual Review Threshold
10.3.5 - Identifying the Certifying Physician
10.3.6 - MSN Messages Regarding the Therapy Cap
10.4 - Claims Processing Requirements for Financial Limitations
10.5 - Notification for Beneficiaries Exceeding Financial Limitations
10.6 - Functional Reporting
10.7 - Multiple Procedure Payment Reductions for Outpatient Rehabilitation
Services
20 - HCPCS Coding Requirement
20.1 - Discipline Specific Outpatient Rehabilitation Modifiers - All Claims
20.2 - Reporting of Service Units With HCPCS
20.3 - Determining What Time Counts Towards 15-Minute Timed Codes -
All Claims
20.4 - Coding Guidance for Certain CPT Codes – All Claims
20.5 - CORF/OPT Edit for Billing Inappropriate Supplies
30 - Special Claims Processing Rules for Outpatient Rehabilitation Claims - Form
CMS-1500
30.1 - Determining Payment Amounts
30.2 - Applicable A/B MAC (B) CWF Type of Service Codes
40 - Special Claims Processing Rules for Institutional Outpatient Rehabilitation Claims
40.1 - Determining Payment Amounts - Institutional Claims
40.2 - Applicable Types of Bill
40.3 - Applicable Revenue Codes
40.4 - Edit Requirements for Revenue Codes
40.5 - Line Item Date of Service Reporting
40.6 – Non-covered Charge Reporting
40.7 - Billing for Biofeedback Training for the Treatment of Urinary Incontinence
40.8 – Rebilling Therapy Services for Hospital Inpatients
50 - CWF and PS&R Requirements - A/B MAC (A)
100 - Special Rules for Comprehensive Outpatient Rehabilitation Facilities (CORFs)
100.1 - General
100.1.1 - Allowable Revenue Codes on CORF 75X Bill Types
100.2 - Obtaining Fee Schedule Amounts
100.3 - Proper Reporting of Nursing Services by CORFs - A/B MAC (A)
100.4 - Outpatient Mental Health Treatment Limitation
100.5 - Off-Site CORF Services
100.6 - Notifying Patient of Service Denial
100.7 - Payment of Drugs, Biologicals, and Supplies in a CORF
100.8 - Billing for DME, Prosthetic and Orthotic Devices, and Surgical
Dressings
100.10 - Group Therapy Services (Code 97150)
100.10.1 - Therapy Students
100.11 - Billing for Social Work and Psychological Services in a CORF
100.12 - Billing for Respiratory Therapy Services in a CORF
Exhibit 1 - Physician Fee Schedule Abstract File
Addendum A - Chapter 5, Section 20.4 – Coding Guidance for Certain CPT Codes – All
Claims
10 - Part B Outpatient Rehabilitation and Comprehensive Outpatient
Rehabilitation Facility (CORF) Services - General
(Rev. 3454, Issued: 02-04-16, Effective: 07-01-16, Implementation: 07-05-16)
Language in this section is defined or described in Pub. 100-02, chapter 15, sections 220
and 230.
Section §1834(k)(5) to the Social Security Act (the Act), requires that all claims for
outpatient rehabilitation services and comprehensive outpatient rehabilitation facility
(CORF) services, be reported using a uniform coding system. The CMS chose HCPCS
(Healthcare Common Procedure Coding System) as the coding system to be used for the
reporting of these services. This coding requirement is effective for all claims for
outpatient rehabilitation services and CORF services submitted on or after April 1, 1998.
The Act also requires payment under a prospective payment system for outpatient
rehabilitation services including CORF services. Effective for claims with dates of
service on or after January 1, 1999, the Medicare Physician Fee Schedule (MPFS)
became the method of payment for outpatient therapy services furnished by:
• Comprehensive outpatient rehabilitation facilities (CORFs);
• Outpatient physical therapy providers (OPTs), also known as rehabilitation

agencies;
• Hospitals (to outpatients and inpatients who are not in a covered Part A stay);
• Skilled nursing facilities (SNFs) (to residents not in a covered Part A stay and to
nonresidents who receive outpatient rehabilitation services from the SNF); and
• Home health agencies (HHAs) (to individuals who are not homebound or
otherwise are not receiving services under a home health plan of care (POC)).
NOTE: No provider or supplier other than the SNF will be paid for therapy services
during the time the beneficiary is in a covered SNF Part A stay. For information
regarding SNF consolidated billing see chapter 6, section 10 of this manual.
Similarly, under the HH prospective payment system, HHAs are responsible to provide,
either directly or under arrangements, all outpatient rehabilitation therapy services to
beneficiaries receiving services under a home health POC. No other provider or supplier
will be paid for these services during the time the beneficiary is in a covered Part A stay.
For information regarding HH consolidated billing see chapter10, section 20 of this
manual.
Section 143 of the Medicare Improvements for Patients and Provider’s Act of 2008
(MIPPA) authorizes the Centers for Medicare & Medicaid Services (CMS) to enroll
speech-language pathologists (SLP) as suppliers of Medicare services and for SLPs to
begin billing Medicare for outpatient speech-language pathology services furnished in
private practice beginning July 1, 2009. Enrollment will allow SLPs in private practice to
bill Medicare and receive direct payment for their services. Previously, the Medicare
program could only pay SLP services if an institution, physician or nonphysician
practitioner billed them.
In Chapter 23, as part of the CY 2009 Medicare Physician Fee Schedule Database, the
descriptor for PC/TC indicator “7”, as applied to certain HCPCS/CPT codes, is described
as specific to the services of privately practicing therapists. Payment may not be made if
the service is provided to either a hospital outpatient or a hospital inpatient by a physical
therapist, occupational therapist, or speech-language pathologist in private practice.
The MPFS is used as a method of payment for outpatient rehabilitation services furnished
under arrangement with any of these providers.
In addition, the MPFS is used as the payment system for CORF services identified by the
HCPCS codes in §20. Assignment is mandatory.
Services that are paid subject to the MPFS are adjusted based on the applicable payment
locality. Rehabilitation agencies and CORFs with service locations in different payment
localities shall follow the instructions for multiple service locations in chapter 1, section
170.1.1.
The Medicare allowed charge for the services is the lower of the actual charge or the
MPFS amount. The Medicare payment for the services is 80 percent of the allowed
charge after the Part B deductible is met. Coinsurance is made at 20 percent of the lower
of the actual charge or the MPFS amount. The general coinsurance rule (20 percent of
the actual charges) does not apply when making payment under the MPFS. This is a final
payment.
The MPFS does not apply to outpatient rehabilitation services furnished by critical access
hospitals (CAHs) or hospitals in Maryland. CAHs are to be paid on a reasonable cost
basis. Maryland hospitals are paid under the Maryland All-Payer Model.
Contractors process outpatient rehabilitation claims from hospitals, including CAHs,

SNFs, HHAs, CORFs, outpatient rehabilitation agencies, and outpatient physical therapy
providers for which they have received a tie in notice from the Regional Office (RO).
These provider types submit their claims to the contractors using the ASC X12 837
institutional claim format or the CMS-1450 paper form when permissible. Contractors
also process claims from physicians, certain nonphysician practitioners (NPPs),
therapists in private practices (TPPs), (which are limited to physical and occupational
therapists, and speech-language pathologists in private practices), and physician-directed
clinics that bill for services furnished incident to a physician’s service (see Pub. 100-02,
Medicare Benefit Policy Manual, chapter 15, for a definition of “incident to”). These
provider types submit their claims to the contractor using the ASC X 12 837 professional
claim format or the CMS-1500 paper form when permissible.
There are different fee rates for nonfacility and facility services. Chapter 23 describes the
differences in these two rates. (See fields 28 and 29 of the record therein described).
Facility rates apply to professional services performed in a facility other than the
professional’s office. Nonfacility rates apply when the service is performed in the
professional’s office. The nonfacility rate (that is paid when the provider performs the
services in its own facility) accommodates overhead and indirect expenses the provider
incurs by operating its own facility. Thus it is somewhat higher than the facility rate.
Contractors pay the nonfacility rate on institutional claims for services performed in the
provider’s facility. Contractors may pay professional claims using the facility or
nonfacility rate depending upon where the service is performed (place of service on the
claim), and the provider specialty.
Contractors pay the codes in §20 under the MPFS on professional claims regardless of
whether they may be considered rehabilitation services. However, contractors must use
this list for institutional claims to determine whether to pay under outpatient
rehabilitation rules or whether payment rules for other types of service may apply, e.g.,
OPPS for hospitals, reasonable costs for CAHs.
Note that because a service is considered an outpatient rehabilitation service does not
automatically imply payment for that service. Additional criteria, including coverage,
plan of care and physician certification must also be met. These criteria are described in
Pub. 100-02, Medicare Benefit Policy Manual, chapters 1 and 15.
Payment for rehabilitation services provided to Part A inpatients of hospitals or SNFs is

included in the respective PPS rate. Also, for SNFs (but not hospitals), if the beneficiary
has Part B, but not Part A coverage (e.g., Part A benefits are exhausted), the SNF must
bill for any rehabilitation service.
Payment for rehabilitation therapy services provided by home health agencies under a
home health plan of care is included in the home health PPS rate. HHAs may submit bill
type 34X and be paid under the MPFS if there are no home health services billed under a
home health plan of care at the same time, and there is a valid rehabilitation POC (e.g.,
the patient is not homebound).
An institutional employer (other than a SNF) of the TPPs, or physician performing

outpatient services, (e.g., hospital, CORF, etc.), or a clinic billing on behalf of the
physician or therapist may bill the contractor on a professional claim.
The MPFS is the basis of payment for outpatient rehabilitation services furnished by
TPPs, physicians, and certain nonphysician practitioners or for diagnostic tests provided
incident to the services of such physicians or nonphysician practitioners. (See Pub. 100-
02, Medicare Benefit Policy Manual, Chapter 15, for a definition of “incident to,
therapist, therapy and related instructions.") Such services are billed to the contractor on
the professional claim format. Assignment is mandatory.
The following table identifies the provider and supplier types, and identifies which claim
format they may use to submit claims for outpatient therapy services to the contractor.
“Provider/Supplier Service” Format Bill Type Comment

Type
Inpatient SNF Part A Institutional 21X Included in PPS
Inpatient hospital Part B Institutional 12X Hospital may obtain services
under arrangements and bill, or
rendering provider may bill.
Inpatient SNF Part B Institutional 22X SNF must provide and bill, or
(audiology tests are not obtain under arrangements and
included) bill.
Outpatient hospital Institutional 13X Hospital may provide and bill
or obtain under arrangements
and bill.
Outpatient SNF Institutional 23X SNF must provide and bill or

obtain under arrangements and
bill.
HHA billing for services not Institutional 34X Service not under home health
rendered under a Part A or plan of care.
Part B home health plan of
care, but rendered under a
therapy plan of care.
Outpatient physical therapy Institutional 74X Paid MPFS for outpatient
providers (OPTs), also known rehabilitation services.
as rehabilitation agencies
Comprehensive Outpatient Institutional 75X Paid MPFS for outpatient

Rehabilitation Facility rehabilitation services and all
(CORF) other services except drugs.
Drugs are paid 95% of the
AWP.
Physician, NPPs, TPPs, Professional See Chapter Payment may not be made for
(therapy services in hospital 26 for place therapy services to Part A
or SNF) of service inpatients of hospitals or SNFs,
coding. or for Part B SNF residents.
NOTE: Payment may be made

to physicians and NPPs for
their professional services
defined as “sometimes therapy”
(not part of a therapy plan) in
certain situations; for example,
when furnished to a beneficiary
“Provider/Supplier Service” Format Bill Type Comment
Type
registered as an outpatient of a
hospital.
Physician/NPP/TPPs office, Professional See Chapter Paid via MPFS.

or patient’s home 26 for place
of service
coding.
Critical Access Hospital - Institutional 12X Rehabilitation services are paid
inpatient Part B at cost.
Critical Access Hospital – Institutional 85X Rehabilitation services are paid
outpatient Part B at cost.
For a list of the outpatient rehabilitation HCPCS codes see §20.
If a contractor receives an institutional claim for one of these HCPCS codes with dates of
service on or after July 1, 2003, that does not appear on the supplemental file it currently
uses to pay the therapy claims, it contacts its professional claims area to obtain the non-
facility price in order to pay the claim.
NOTE: The list of codes in §20 contains commonly utilized codes for outpatient
rehabilitation services. Contractors may consider other codes on institutional claims for
payment under the MPFS as outpatient rehabilitation services to the extent that such
codes are determined to be medically reasonable and necessary and could be performed
within the scope of practice of the therapist providing the service.
10.1 - New Payment Requirement for A/B MACs (A)

(Rev. 1, 10-01-03)
Effective with claims with dates of service on or after July 1, 2003, OPTs/outpatient
rehabilitation facilities (ORFs), (74X and 75X bill type) are required to report all their
services utilizing HCPCS. A/B MACs (A) are required to make payment for these
services under the MPFS unless the item or service is currently being paid under the
orthotic fee schedule or the item is a drug, biological, supply or vaccine (see below for an
explanation of these services).
The CMS currently provides A/B MACs (A) with a CORF supplemental file that
contains all physician fee schedule services and their related prices. A/B MACs (A) use
this file to price and pay OPT claims. The format of the record layout is provided in
Attachment E of PM A-02-090, dated September 27, 2002. This is located in Chapter 23,
section 50.3.
A/B MACs (A) will be notified in a one-time instruction of updates to this file and when
it will be available for retrieval.
If an A/B MAC (A) receives a claim for one of the above HCPCS codes with dates of
service on or after July 1, 2003, that does not appear on the CORF supplemental file it
currently uses to pay the CORF claims, it contacts its local A/B MAC (B) to obtain the
price in order to pay the claim. When requesting the pricing data, it advises the A/B
MAC (B) to provide it with the nonfacility fee.
10.2 - The Financial Limitation Legislation

A. Legislation on Limitations
The dollar amount of the limitations (caps) on outpatient therapy services is established
by statute. The updated amount of the caps is released annually via Recurring Update
Notifications and posted on the CMS Website www.cms.gov/TherapyServices, on
contractor Websites, and on each beneficiary’s Medicare Summary Notice. Medicare
contractors shall publish the financial limitation amount in educational articles. It is also
available at 1-800-Medicare.
Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, which added
§1834(k)(5) to the Act, required payment under a prospective payment system (PPS) for
outpatient rehabilitation services (except those furnished by or under arrangements with a
hospital). Outpatient rehabilitation services include the following services:
• Physical therapy
• Speech-language pathology; and
• Occupational therapy.
Section 4541(c) of the BBA required application of financial limitations to all outpatient
rehabilitation services (except those furnished by or under arrangements with a hospital).
In 1999, an annual per beneficiary limit of $1,500 was applied, including all outpatient
physical therapy services and speech-language pathology services. A separate limit
applied to all occupational therapy services. The limits were based on incurred expenses
and included applicable deductible and coinsurance. The BBA provided that the limits be
indexed by the Medicare Economic Index (MEI) each year beginning in 2002.
Since the limitations apply to outpatient services, they do not apply to skilled nursing
facility (SNF) residents in a covered Part A stay, including patients occupying swing
beds. Rehabilitation services are included within the global Part A per diem payment that
the SNF receives under the prospective payment system (PPS) for the covered stay.
Also, limitations do not apply to any therapy services covered under prospective payment
systems for home health or inpatient hospitals, including critical access hospitals.
The limitation is based on therapy services the Medicare beneficiary receives, not the
type of practitioner who provides the service. Physical therapists, speech-language
pathologists, and occupational therapists, as well as physicians and certain nonphysician
practitioners, could render a therapy service.
B. Moratoria and Exceptions for Therapy Claims
Since the creation of therapy caps, Congress has enacted several moratoria. The Deficit
Reduction Act of 2005 directed CMS to develop exceptions to therapy caps for calendar
year 2006 and the exceptions have been extended periodically. The cap exception for
therapy services billed by outpatient hospitals was part of the original legislation and
applies as long as caps are in effect. Exceptions to caps based on the medical necessity of
the service are in effect only when Congress legislates the exceptions.
10.3 - Application of Financial Limitations

(Rev. 3367 Issued: 10-07-15, Effective: 01-01-16, Implementation: 01-04-16)
(Additions, deletions or changes to the therapy code list are updated via a Recurring
Update Notification)
Financial limitations on outpatient therapy services, as described above, began for

therapy services rendered on or after on January 1, 2006. References and polices relevant
to the exceptions process in this chapter apply only when exceptions to therapy caps are
in effect. For dates of service before October 1, 2012, limits apply to outpatient Part B
therapy services furnished in all settings except outpatient hospitals, including hospital
emergency departments. These excluded hospital services are reported on types of bill
12x or 13x, or 85x. Effective for dates of service on or after October 1, 2012, the limits
also apply to outpatient Part B therapy services furnished in outpatient hospitals other
than CAHs and hospitals in Maryland. During this period, only type of bill 12x claims
with a CMS certification number in the CAH range, type of bill 12x and 13x claims with
a CMS certification number beginning with the State code for Maryland, and type of bill
85x claims are excluded. Effective for dates of service on or after January 1, 2014, the
limits also apply to CAHs. Effective for dates of service on or after January 1, 2016, the
limits also apply to hospitals in Maryland.
Contractors apply the financial limitations to the MPFS amount (or the amount charged if
it is smaller) for therapy services for each beneficiary.
As with any Medicare payment, beneficiaries pay the coinsurance (20 percent) and any
deductible that may apply. Medicare will pay the remaining 80 percent of the limit after
the deductible is met. These amounts will change each calendar year.
Medicare shall apply these financial limitations in order, according to the dates when the
claims were received. When limitations apply, the Common Working File (CWF) tracks
the limits. Shared system maintainers are not responsible for tracking the dollar amounts
of incurred expenses of rehabilitation services for each therapy limit.
In processing claims where Medicare is the secondary payer, the shared system takes the
lowest secondary payment amount from MSPPAY and sends this amount on to CWF as
the amount applied to therapy limits.
10.3.1 - Exceptions to Therapy Caps – General
The following policies concerning exceptions to caps due to medical necessity apply only
when the exceptions process is in effect. Except for the requirement to use the KX
modifier, the guidance in this section concerning medical necessity applies as well to
services provided before caps are reached.
Provider and supplier information concerning exceptions is in this chapter and in Pub.
100-02, Chapter 15, section 220.3. Exceptions shall be identified by a modifier on the
claim and supported by documentation.
The beneficiary may qualify for use of the cap exceptions process at any time during the
episode when documented medically necessary services exceed caps. All covered and
medically necessary services qualify for exceptions to caps. All requests for exception
are in the form of a KX modifier added to claim lines. (See subsection D. for use of the
KX modifier.)
Use of the exception process does not exempt services from manual or other medical
review processes as described in Pub. 100-08. Rather, atypical use of the exception
process may invite contractor scrutiny, for example, when the KX modifier is applied to
all services on claims that are below the therapy caps or when the KX modifier is used
for all beneficiaries of a therapy provider. To substantiate the medical necessity of the
therapy services, document in the medical record (see Pub. 100-02, chapter 15, sections
220.2, 220.3, and 230).
The KX modifier, described in subsection D., is added to claim lines to indicate that the
clinician attests that services at and above the therapy caps are medically necessary and
justification is documented in the medical record.
10.3.2 - Exceptions Process

An exception may be made when the patient’s condition is justified by documentation

indicating that the beneficiary requires continued skilled therapy, i.e., therapy beyond the
amount payable under the therapy cap, to achieve their prior functional status or
maximum expected functional status within a reasonable amount of time.
No special documentation is submitted to the contractor for exceptions. The clinician is

responsible for consulting guidance in the Medicare manuals and in the professional
literature to determine if the beneficiary may qualify for the exception because
documentation justifies medically necessary services above the caps. The clinician’s
opinion is not binding on the Medicare contractor who makes the final determination
concerning whether the claim is payable.
Documentation justifying the services shall be submitted in response to any Additional
Documentation Request (ADR) for claims that are selected for medical review. Follow
the documentation requirements in Pub. 100-02, chapter 15, section 220.3. If medical
records are requested for review, clinicians may include, at their discretion, a summary
that specifically addresses the justification for therapy cap exception.
In making a decision about whether to utilize the exception, clinicians shall consider, for
example, whether services are appropriate to--
The patient’s condition, including the diagnosis, complexities, and severity;

The services provided, including their type, frequency, and duration;
The interaction of current active conditions and complexities that directly and
significantly influence the treatment such that it causes services to exceed caps.
In addition, the following should be considered before using the exception process:
1. Exceptions for Evaluation Services
Evaluation. The CMS will accept therapy evaluations from caps after the therapy caps
are reached when evaluation is necessary, e.g., to determine if the current status of the
beneficiary requires therapy services. For example, the following CPT codes for
evaluation procedures may be appropriate:
92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612, 92614,
92616, 96105, 96125. 97161, 97162, 97163, 97164, 97165, 97166, 97167, and
97168.
These codes will continue to be reported as outpatient therapy procedures as listed in the
Annual Therapy Update for the current year at:
http://www.cms.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage.
They are not diagnostic tests. Definitions of evaluations and documentation are found in
Pub. 100-02, chapter 15, sections 220 and 230.
Other Services. There are a number of sources that suggest the amount of certain
services that may be typical, either per service, per episode, per condition, or per
discipline. For example, see the CSC - Therapy Cap Report, 3/21/2008, and CSC –
Therapy Edits Tables 4/14/2008 at www.cms.hhs.gov/TherapyServices (Studies and
Reports), or more recent utilization reports. Professional literature and guidelines from
professional associations also provide a basis on which to estimate whether the type,
frequency, and intensity of services are appropriate to an individual. Clinicians and
contractors should utilize available evidence related to the patient’s condition to justify
provision of medically necessary services to individual beneficiaries, especially when
they exceed caps. Contractors shall not limit medically necessary services that are
justified by scientific research applicable to the beneficiary. Neither contractors nor
clinicians shall utilize professional literature and scientific reports to justify payment for
continued services after an individual’s goals have been met earlier than is typical.
Conversely, professional literature and scientific reports shall not be used as justification
to deny payment to patients whose needs are greater than is typical or when the patient’s
condition is not represented by the literature.
2. Exceptions for Medically Necessary Services
Clinicians may utilize the process for exception for any diagnosis or condition for which
they can justify services exceeding the cap. Regardless of the diagnosis or condition, the
patient must also meet other requirements for coverage.
Bill the most relevant diagnosis. As always, when billing for therapy services, the
diagnosis code that best relates to the reason for the treatment shall be on the claim,
unless there is a compelling reason to report another diagnosis code. For example, when
a patient with diabetes is being treated with therapy for gait training due to amputation,
the preferred diagnosis is abnormality of gait (which characterizes the treatment). Where
it is possible in accordance with State and local laws and the contractors’ local coverage
determinations, avoid using vague or general diagnoses. When a claim includes several
types of services, or where the physician/NPP must supply the diagnosis, it may not be
possible to use the most relevant therapy diagnosis code in the primary position. In that
case, the relevant diagnosis code should, if possible, be on the claim in another position.
Codes representing the medical condition that caused the treatment are used when there is
no code representing the treatment. Complicating conditions are preferably used in non-
primary positions on the claim and are billed in the primary position only in the rare
circumstance that there is no more relevant code.
The condition or complexity that caused treatment to exceed caps must be related to the
therapy goals and must either be the condition that is being treated or a complexity that
directly and significantly impacts the rate of recovery of the condition being treated such
that it is appropriate to exceed the caps. Documentation for an exception should indicate
how the complexity (or combination of complexities) directly and significantly affects
treatment for a therapy condition.
If the contractor has determined that certain codes do not characterize patients who
require medically necessary services, providers/suppliers may not use those codes, but
must utilize a billable diagnosis code allowed by their contractor to describe the patient’s
condition. Contractors shall not apply therapy caps to services based on the patient’s
condition, but only on the medical necessity of the service for the condition. If a service
would be payable before the cap is reached and is still medically necessary after the cap
is reached, that service is excepted.
Contact your contractor for interpretation if you are not sure that a service is applicable
for exception.
It is very important to recognize that most conditions would not ordinarily result in
services exceeding the cap. Use the KX modifier only in cases where the condition of
the individual patient is such that services are APPROPRIATELY provided in an episode
that exceeds the cap. Routine use of the KX modifier for all patients with these
conditions will likely show up on data analysis as aberrant and invite inquiry. Be sure
that documentation is sufficiently detailed to support the use of the modifier.
In justifying exceptions for therapy caps, clinicians and contractors should not only
consider the medical diagnoses and medical complications that might directly and
significantly influence the amount of treatment required. Other variables (such as the
availability of a caregiver at home) that affect appropriate treatment shall also be
considered. Factors that influence the need for treatment should be supportable by
published research, clinical guidelines from professional sources, and/or clinical or
common sense. See Pub. 100-02, chapter 15, section 220.3 for information related to
documentation of the evaluation, and section 220.2 on medical necessity for some factors
that complicate treatment.
NOTE: The patient’s lack of access to outpatient hospital therapy services alone, when
outpatient hospital therapy services are excluded from the limitation, does not justify
excepted services. Residents of skilled nursing facilities prevented by consolidated
billing from accessing hospital services, debilitated patients for whom transportation to
the hospital is a physical hardship, or lack of therapy services at hospitals in the
beneficiary’s county may or may not qualify as justification for continued services above
the caps. The patient’s condition and complexities might justify extended services, but
their location does not. For dates of service on or after October 1, 2012, therapy services
furnished in an outpatient hospital are not excluded from the limitation.
10.3.3 - Use of the KX Modifier for Therapy Cap Exceptions

When exceptions are in effect and the beneficiary qualifies for a therapy cap exception,
the provider shall add a KX modifier to the therapy HCPCS code subject to the cap
limits. The KX modifier shall not be added to any line of service that is not a medically
necessary service; this applies to services that, according to a local coverage
determination by the contractor, are not medically necessary services.
The codes subject to the therapy cap tracking requirements for a given calendar year are
listed at:
http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage.
The GN, GO, or GP therapy modifiers are currently required to be appended to therapy
services. In addition to the KX modifier, the GN, GP and GO modifiers shall continue to
be used. Providers may report the modifiers on claims in any order. If there is
insufficient room on a claim line for multiple modifiers, additional modifiers may be
reported in the remarks field. Follow the routine procedure for placing HCPCS modifiers
on a claim as described below.
• For professional claims, sent to the A/B MAC(B), refer to:
o Pub.100-04, Medicare Claims Processing Manual, chapter 26, for more

detail regarding completing Form CMS 1500, including the placement of
HCPCS modifiers. NOTE: The Form CMS 1500 currently has space for
providing four modifiers in block 24D, but, if the provider has more than
four to report, he/she can do so by placing the -99 modifier (which
indicates multiple modifiers) in block 24D and placing the additional
modifiers in block 19.
o The ASC X12N 837 Health Care Claim: Professional Implementation

Guide for more detail regarding how to electronically submit a health care
claim transaction, including the placement of HCPCS modifiers. The
ASC X12N 837 implementation guides are the standards adopted under
the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
for submitting health care claims electronically. The 837 professional
transaction currently permits the placement of up to four modifiers, in the
2400 loop, SV1 segment, and data elements SV101-3, SV101-4, SV101-5,
and SV101-6. Copies of the ASC X12N 837 implementation guides may
be obtained from the Washington Publishing Company.
o For claims paid by a carrier or an A/B MAC(B), it is only appropriate to

append the KX modifier to a service that reasonably may exceed the cap.
Use of the KX modifier when there is no indication that the cap is likely to
be exceeded is abusive. For example, use of the KX modifier for low cost
services early in an episode when there is no evidence of a previous
episode that might have exceeded the cap is inappropriate.
• For institutional claims, sent to the A/B MAC(A):
o When the cap is exceeded by at least one line on the claim, use the KX
modifier on all of the lines on that institutional claim that refer to the same
therapy cap (PT/SLP or OT), regardless of whether the other services
exceed the cap. For example, if one PT service line exceeds the cap, use
the KX modifier on all the PT and SLP service lines (also identified with
the GP or GN modifier) for that claim. When the PT/SLP cap is exceeded
by PT services, the SLP lines on the claim may meet the requirements for
an exception due to the complexity of two episodes of service.
o Use the KX modifier on either all or none of the SLP lines on the claim, as
appropriate. In contrast, if all the OT lines on the claim are below the cap,
do not use the KX modifier on any of the OT lines, even when the KX
modifier is appropriately used on all of the PT lines. Refer to Pub.100-04,
Medicare Claims Processing Manual, chapter 25, for more detail.
By appending the KX modifier, the provider is attesting that the services billed:
Are reasonable and necessary services that require the skills of a therapist; (See
Pub. 100-02, chapter 15, section 220.2); and
Are justified by appropriate documentation in the medical record, (See Pub. 100-
02, chapter 15, section 220.3); and
Qualify for an exception using the automatic process exception.
If this attestation is determined to be inaccurate, the provider/supplier is subject to

sanctions resulting from providing inaccurate information on a claim.
When the KX modifier is appended to a therapy HCPCS code, the contractor will
override the CWF system reject for services that exceed the caps and pay the claim if it is
otherwise payable.
Providers and suppliers shall continue to append correct coding initiative (CCI) HCPCS
modifiers under current instructions.
If a claim is submitted without KX modifiers and the cap is exceeded, those services will
be denied. In cases where appending the KX modifier would have been appropriate,
contractors may reopen and/or adjust the claim, if it is brought to their attention.
Services billed after the cap has been exceeded which are not eligible for exceptions may
be billed for the purpose of obtaining a denial using condition code 21.
10.3.4 - Therapy Cap Manual Review Threshold

(Rev. 3814, Issued: 07-27-17, Effective: 01-01-18, Implementation: 01 -02-18)
A. Requirements – Institutional Claims
Regardless of financial limits on therapy services, CMS requires modifiers (See section
20.1 of this chapter) on specific codes for the purpose of data analysis. Beneficiaries may
not be simultaneously covered by Medicare as an outpatient of a hospital and as a patient
in another facility. When outpatient hospital therapy services are excluded from the
limitation, the beneficiary must be discharged from the other setting and registered as a
hospital outpatient in order to receive payment for outpatient rehabilitation services in a
hospital outpatient setting after the limitation has been reached.
A hospital may bill for services of a facility as hospital outpatient services if that facility
meets the requirements of a department of the provider (hospital) under 42 CFR 413.65.
Facilities that do not meet those requirements are not considered to be part of the hospital
and may not bill under the hospital’s provider number, even if they are owned by the
hospital. For example, services of a Comprehensive Outpatient Rehabilitation Facility
(CORF) must be billed as CORF services and not as hospital outpatient services, even if
the CORF is owned by the hospital.
The CWF applies the financial limitation to the following bill types 22X, 23X, 34X, 74X
and 75X using the MPFS allowed amount (before adjustment for beneficiary liability).
For SNFs, the financial limitation does apply to rehabilitation services furnished to those
SNF residents in noncovered stays (bill type 22X) who are in a Medicare-certified section
of the facility, i.e., one that is either certified by Medicare alone, or is dually certified by
Medicare as a SNF and by Medicaid as a nursing facility (NF). For SNF residents,
consolidated billing requires all outpatient rehabilitation services be billed to Part B by
the SNF. If a resident has reached the financial limitation, and remains in the Medicare-
certified section of the SNF, no further payment will be made to the SNF or any other
entity. Therefore, SNF residents who are subject to consolidated billing may not obtain
services from an outpatient hospital after the cap has been exceeded.
Once the financial limitation has been reached, services furnished to SNF residents who
are in a non-Medicare certified section of the facility, i.e., one that is certified only by
Medicaid as a NF or that is not certified at all by either program, use bill type 23X. For
SNF residents in non-Medicare certified portions of the facility and SNF nonresidents
who go to the SNF for outpatient treatment (bill type 23X), medically necessary
outpatient therapy may be covered at an outpatient hospital facility after the financial
limitation has been exceeded when outpatient hospital therapy services are excluded from
the limitation.
B. Requirements - Professional Claims
Claims containing any of the “always therapy” codes must have one of the therapy
modifiers appended (GN, GO, GP). Contractors shall return claims for “always therapy”
codes when they do not contain appropriate therapy modifiers for the applicable HCPCS
codes. In addition, when any code on the list of therapy codes is submitted with specialty
codes “65” (physical therapist in private practice), “67” (occupational therapist in private
practice), or “15” (speech-language pathologist in private practice) they always represent
therapy services, because they are provided by therapists. Contractors shall return claims
for these services when they do not contain therapy modifiers for the applicable HCPCS
codes.
The contractor shall use the following remittance advice messages and associated codes
when rejecting/denying claims under this policy. This CARC/RARC combination is
compliant with CAQH CORE Business Scenario 2.
Group Code: CO
CARC: 4
RARC: N/A
MSN: N/A
The CMS identifies certain codes listed at:

http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage
as “sometimes therapy” services, regardless of the presence of a financial limitation.
Claims from physicians (all specialty codes) and nonphysician practitioners, including
specialty codes “50” (Nurse Practitioner), “89,” (Clinical Nurse Specialist), and “97,”
(Physician Assistant) may be processed without therapy modifiers when they are not
therapy services. On review of these claims, “sometimes therapy” services that are not
accompanied by a therapy modifier must be documented, reasonable and necessary, and
payable as physician or nonphysician practitioner services, and not services that the
contractor interprets as therapy services.
The CWF will capture the amount and apply it to the limitation whenever a service is
billed using the GN, GO, or GP modifier.
C. Contractor Action Based on CWF Trailer
Upon receipt of the CWF error code/trailer, contractors are responsible for assuring that
payment does not exceed the financial limitations, when the limits are in effect, except as
noted below.
In cases where a claim line partially exceeds the limit, the contractor must adjust the line
based on information contained in the CWF trailer. For example, where the MPFS
allowed amount is greater than the financial limitation available, always report the MPFS
allowed amount in the “Financial Limitation” field of the CWF record and include the
CWF override code. See example below for situations where the claim contains multiple
lines that exceed the limit.
EXAMPLE:
Services received to date are $15 under the limit. There is a $15 allowed amount
remaining that Medicare will cover before the cap is reached.
Incoming claim: Line 1 MPFS allowed amount is $50.

Line 2 MPFS allowed amount is $25.
Line 3, MPFS allowed amount is $30.
Based on this example, lines 1 and 3 are denied and line 2 is paid. The contractor reports
in the “Financial Limitation" field of the CWF record “$25.00 along with the CWF
override code. The contractor always applies the amount that would least exceed the
limit. Since institutional claims systems cannot split the payment on a line, CWF will
allow payment on the line that least exceeds the limit and deny other lines.
D. Additional Information for Contractors During the Time Financial Limits Are
in Effect With or Without Exceptions
Once the limit is reached, if a claim is submitted, CWF returns an error code stating the
financial limitation has been met. Over applied lines will be identified at the line level.
The outpatient rehabilitation therapy services that exceed the limit should be denied.
compliant with CAQH CORE Business Scenario Three.
Group Code: CO or PR (as defined by section 10.5)

CARC: 119
RARC: N/A
MSN: 20.5
In situations where a beneficiary is close to reaching the financial limitation and a

particular claim might exceed the limitation, the provider/supplier should bill the usual
and customary charges for the services furnished even though such charges might exceed
the limit. The CWF will return an error code/trailer that will identify the line that
exceeds the limitation.
Because CWF applies the financial limitation according to the date when the claim was
received (when the date of service is within the effective date range for the limitation), it
is possible that the financial limitation will have been met before the date of service of a
given claim. Such claims will prompt the CWF error code and subsequent contractor
denial.
When the provider/supplier knows that the limit has been reached, and exceptions are
either not appropriate or not available, further billing should not occur. The
provider/supplier should inform the beneficiary of the limit and their option of receiving
further covered services from an outpatient hospital when outpatient hospital therapy
services are excluded from the limitation (unless consolidated billing rules prevent the
use of the outpatient hospital setting). If the beneficiary chooses to continue treatment at
a setting other than the outpatient hospital where medically necessary services may be
covered, the services may be billed at the rate the provider/supplier determines. Services
provided in a capped setting after the limitation has been reached are not Medicare
benefits and are not governed by Medicare policies.
If a beneficiary elects to receive services that exceed the cap limitation and a claim is
submitted for such services, the resulting determination is subject to the administrative
appeals process as described in subsection C. of section 10.3 and Pub. 100-04, Chapter
29.
10.3.5 - Identifying the Certifying Physician

Therapy plans of care must be certified by a physician or non-physician practitioner

(NPP), per the requirements in the Pub. 100-02, Medicare Benefit Policy Manual, chapter
15, section 220.1.3. Further, the National Provider Identifier (NPI) of the certifying
physician/NPP identified for a therapy plan of care must be included on the therapy
claim.
For the purposes of processing professional claims, the certifying physician/NPP is
considered a referring provider. At the time the certifying physician/NPP is identified for
a therapy plan of care, private practice therapists (PPTs), physicians or NPPs, as
appropriate, submitting therapy claims, are to treat it as if a referral has occurred for
purposes of completing the claim and to follow the instructions in the appropriate ASC
X12 837 Professional Health Care Claim Technical Report 3 (TR3) for reporting a
referring provider (for paper claims, they are to follow the instructions for identifying
referring providers per chapter 26 of this manual). These instructions include
requirements for reporting NPIs.
Currently, in the 5010 version of the ASC X12 837 Professional Health Care Claim TR3,
referring providers are first reported at the claim level; additional referring providers are
reported at the line level only when they are different from that identified at the claim
level. Therefore, there will be at least one referring provider identified at the claim level
on the ASC X12 837 Professional claim for therapy services. However, because of the
hierarchical nature of the ASC X12 837 health care claim transaction, and the possibility
of other types of referrals applying to the claim, the number of referring providers
identified on a professional claim may vary. For example, on a claim where one
physician/NPP has certified all the therapy plans of care, and there are no other referrals,
there would be only one referring provider identified at the claim level and none at the
line levels. Conversely, on a claim also containing a non-therapy referral made by a
different physician/NPP than the one certifying the therapy plan of care, the billing
provider may elect to identify either the nontherapy or the therapy referral at the claim
level, with the other referral(s) at the line levels. Similarly, on a claim having different
certifying physician/NPPs for different therapy plans of care, only one of these
physician/NPPs will be identified at the claim level, with the remainder identified at the
line levels. These scenarios are only examples: there may be other patterns of
representing referring providers at the claim and line levels depending upon the
circumstances of the care and the manner in which the provider applies the requirements
of the ASC X12 837 Professional Health Care Claim TR3.
For situations where the physician/NPP is both the certifier of the plan of care and
furnishes the therapy service, he/she supplies his/her own information, including the NPI,
in the appropriate referring provider loop (or, appropriate block on Form CMS 1500).
This is applicable to those therapy services that are personally furnished by the
physician/NPP as well as to those services that are furnished incident to their own and
delivered by “qualified personnel” (see section 230.5 of this manual for qualifications for
incident to personnel).
Contractors shall edit to ensure that there is at least one claim-level referring provider
identified on professional therapy claims, and shall use the presence of the therapy
modifiers (GN, GP, GO) to identify those claims subject to this requirement.
For the purposes of processing institutional claims, the certifying physician/NPP and their
NPI are reported in the Attending Provider fields on institutional claim formats. Since
the physician/NPP is certifying the therapy plan of care for the services on the claim, this
is consistent with the National Uniform Billing Committee definition of the Attending
Provider as “the individual who has overall responsibility for the patient’s medical care
and treatment” that is reported on the claim. In cases where a patient is receiving care
under more than one therapy plan of care (OT, PT, or SLP) with different certifying
physicians/NPPs, the second certifying physicians/NPP and their NPI are reported in the
Referring Physician fields on institutional claim formats.
10.3.6 - MSN Messages Regarding the Therapy Cap

Existing MSN messages 17.13, 17.18 and 17.19 shall be issued on all claims containing
outpatient rehabilitation services. Contractors add the applied amount for individual
beneficiaries and the generic limit amount to all MSNs that require them. For details of
these MSNs, see: http://www.cms.gov/MSN/02_MSN%20Messages.asp.
10.4 - Claims Processing Requirements for Financial Limitations

(Rev. 3995, Issued: 03-09-18, Effective: 06-11- 18, Implementation: 06-11-18)
A. Requirements – Institutional Claims
Regardless of financial limits on therapy services, CMS requires modifiers (See section
20.1 of this chapter) on specific codes for the purpose of data analysis. Beneficiaries may
not be simultaneously covered by Medicare as an outpatient of a hospital and as a patient
in another facility. When outpatient hospital therapy services are excluded from the
limitation, the beneficiary must be discharged from the other setting and registered as a
hospital outpatient in order to receive payment for outpatient rehabilitation services in a
hospital outpatient setting after the limitation has been reached.
A hospital may bill for services of a facility as hospital outpatient services if that facility
meets the requirements of a department of the provider (hospital) under 42 CFR 413.65.
Facilities that do not meet those requirements are not considered to be part of the hospital
and may not bill under the hospital’s provider number, even if they are owned by the
hospital. For example, services of a Comprehensive Outpatient Rehabilitation Facility
(CORF) must be billed as CORF services and not as hospital outpatient services, even if
the CORF is owned by the hospital.
The CWF applies the financial limitation to the following bill types 12X (with Critical
Access Hospital CMS Certification Numbers), 22X, 23X, 34X, 74X, 75X and 85X using
the lesser of the MPFS allowed amount (before adjustment for beneficiary liability) or
the amount charged.
For SNFs, the financial limitation does apply to rehabilitation services furnished to those
SNF residents in noncovered stays (bill type 22X) who are in a Medicare-certified section
of the facility, i.e., one that is either certified by Medicare alone, or is dually certified by
Medicare as a SNF and by Medicaid as a nursing facility (NF). For SNF residents,
consolidated billing requires all outpatient rehabilitation services be billed to Part B by
the SNF. If a resident has reached the financial limitation, and remains in the Medicare-
certified section of the SNF, no further payment will be made to the SNF or any other
entity. Therefore, SNF residents who are subject to consolidated billing may not obtain
services from an outpatient hospital after the cap has been exceeded.
Once the financial limitation has been reached, services furnished to SNF residents who
are in a non-Medicare certified section of the facility, i.e., one that is certified only by
Medicaid as a NF or that is not certified at all by either program, use bill type 23X. For
SNF residents in non-Medicare certified portions of the facility and SNF nonresidents
who go to the SNF for outpatient treatment (bill type 23X), medically necessary
outpatient therapy may be covered at an outpatient hospital facility after the financial
limitation has been exceeded when outpatient hospital therapy services are excluded from
the limitation.
B. Requirements - Professional Claims
Claims containing any of the “always therapy” codes must have one of the therapy
modifiers appended (GN, GO, GP). Contractors shall return claims for “always therapy”
codes when they do not contain appropriate therapy modifiers for the applicable HCPCS
codes. In addition, when any code on the list of therapy codes is submitted with specialty
codes “65” (physical therapist in private practice), “67” (occupational therapist in private
practice), or “15” (speech-language pathologist in private practice) they always represent
therapy services, because they are provided by therapists. Contractors shall return claims
for these services when they do not contain therapy modifiers for the applicable HCPCS
codes.
compliant with CAQH CORE Business Scenario 2.
Group Code: CO
CARC: 4
RARC: N/A
MSN: N/A
The CMS identifies certain codes listed at:

as “sometimes therapy” services, regardless of the presence of a financial limitation.
Claims from physicians (all specialty codes) and nonphysician practitioners, including
specialty codes “50” (Nurse Practitioner), “89,” (Clinical Nurse Specialist), and “97,”
(Physician Assistant) may be processed without therapy modifiers when they are not
therapy services. On review of these claims, “sometimes therapy” services that are not
accompanied by a therapy modifier must be documented, reasonable and necessary, and
payable as physician or nonphysician practitioner services, and not services that the
contractor interprets as therapy services.
The CWF will capture the amount and apply it to the limitation whenever a service is
billed using the GN, GO, or GP modifier.
C. Contractor Action Based on CWF Trailer
Upon receipt of the CWF error code/trailer, contractors are responsible for assuring that
payment does not exceed the financial limitations, when the limits are in effect, except as
noted below.
In cases where a claim line partially exceeds the limit, the contractor must adjust the line
based on information contained in the CWF trailer. For example, where the MPFS
allowed amount is greater than the financial limitation available, always report the MPFS
allowed amount in the “Financial Limitation” field of the CWF record and include the
CWF override code. See example below for situations where the claim contains multiple
lines that exceed the limit.
EXAMPLE:
Services received to date are $15 under the limit. There is a $15 allowed amount
remaining that Medicare will cover before the cap is reached.
Incoming claim: Line 1 MPFS allowed amount is $50.

Line 2 MPFS allowed amount is $25.
Line 3, MPFS allowed amount is $30.
Based on this example, lines 1 and 3 are denied and line 2 is paid. The contractor reports
in the “Financial Limitation" field of the CWF record “$25.00 along with the CWF
override code. The contractor always applies the amount that would least exceed the
limit. Since institutional claims systems cannot split the payment on a line, CWF will
allow payment on the line that least exceeds the limit and deny other lines.
D. Additional Information for Contractors During the Time Financial Limits Are
in Effect With or Without Exceptions
Once the limit is reached, if a claim is submitted, CWF returns an error code stating the
financial limitation has been met. Over applied lines will be identified at the line level.
The outpatient rehabilitation therapy services that exceed the limit should be denied.
Group Code: CO or PR (as defined by section 10.5)

CARC: 119
RARC: N/A
MSN: 20.5
In situations where a beneficiary is close to reaching the financial limitation and a

particular claim might exceed the limitation, the provider/supplier should bill the usual
and customary charges for the services furnished even though such charges might exceed
the limit. The CWF will return an error code/trailer that will identify the line that
exceeds the limitation.
Because CWF applies the financial limitation according to the date when the claim was
received (when the date of service is within the effective date range for the limitation), it
is possible that the financial limitation will have been met before the date of service of a
given claim. Such claims will prompt the CWF error code and subsequent contractor
denial.
When the provider/supplier knows that the limit has been reached, and exceptions are
either not appropriate or not available, further billing should not occur. The
provider/supplier should inform the beneficiary of the limit and their option of receiving
further covered services from an outpatient hospital when outpatient hospital therapy
services are excluded from the limitation (unless consolidated billing rules prevent the
use of the outpatient hospital setting). If the beneficiary chooses to continue treatment at
a setting other than the outpatient hospital where medically necessary services may be
covered, the services may be billed at the rate the provider/supplier determines. Services
provided in a capped setting after the limitation has been reached are not Medicare
benefits and are not governed by Medicare policies.
If a beneficiary elects to receive services that exceed the cap limitation and a claim is
submitted for such services, the resulting determination is subject to the administrative
appeals process as described in subsection C. of section 10.3 and Pub. 100-04, Chapter
29.
10.5 - Notification for Beneficiaries Exceeding Financial Limitations

A. Notice to Beneficiaries
Contractors will advise providers/suppliers to notify beneficiaries of the therapy financial

limitations at their first therapy encounter with the beneficiary. Prior to 2013, Medicare
instructed providers/suppliers to inform beneficiaries that beneficiaries were responsible
for 100 percent of the costs of therapy services above each respective therapy limit (cap),
unless this outpatient care was furnished directly or under arrangements by a hospital
when outpatient hospital therapy services were excluded from the limitation. The
American Taxpayer Relief Act (ATRA) of 2012 amended §1833(g)(5) of the Social
Security Act (the Act) providing limitation of liability protections (under §1879 of the
Act) to beneficiaries with respect to outpatient therapy services that exceed therapy cap
amounts, furnished on or after January 1, 2013. Thus, effective January 1, 2013,
assignment of liability has changed for therapy services exceeding the cap that don’t
qualify for a coverage exception. The provider/supplier is financially responsible when
Medicare denies payment for therapy services above the cap that don’t qualify for a
coverage exception unless a valid Advance Beneficiary Notice of Noncoverage (ABN),
Form CMS-R-131, was issued per CMS guidelines.
Providers were previously encouraged to use either a form of their own design or a
voluntary ABN when providing therapy above the cap where no exception was applied;
however, this instruction is no longer valid. When providing therapy services above the
cap that don’t qualify for the exceptions process, the provider/supplier must now issue a
mandatory ABN in order to transfer financial responsibility to the beneficiary. When the
ABN is used as a mandatory notice, providers must adhere to the ABN form instructions
and guidance published in Chapter 30, Section 50 of this manual. The ABN and
instructions can be found at: http://www.cms.gov/Medicare/Medicare-General-
Information/BNI/ABN.html.
When issuing the ABN for therapy in excess of therapy caps, the following language is
suggested for the “Reason Medicare May Not Pay” section: “Medicare won’t pay for
physical therapy and speech-language pathology services over (add the dollar amount of
the cap) in (add the year or the dates of service to which it applies) unless you qualify for
an exception to this cap amount. Your services don’t qualify for an exception. ” Providers
should use similar language for occupational therapy services when appropriate. A cost
estimate for the services should be included per the ABN form instructions. Therapy cost
estimates can be listed as a cost per service or as a projected total cost for a certain
amount of therapy provided over a specified time period.
ABN issuance remains mandatory before the cap is exceeded when services aren’t
expected to be covered by Medicare because they are not medically reasonable and
necessary. When the clinician determines that skilled services are not medically
necessary, the clinical goals have been met, or there is no longer potential for the
rehabilitation of health and/or function in a reasonable time, the beneficiary should be
informed. If the beneficiary will be getting services that don’t meet the medical necessity
requirements for Medicare payment, the ABN must be issued prior to delivering these
services. The ABN informs the beneficiary of his/her potential financial obligation to the
provider, allows him/her to choose whether or not to get the services, and provides
information regarding appeal rights.
When a provider/supplier expects that Medicare will deny payment on a claim for
therapy services because they are not medically reasonable and necessary, regardless of
whether or not therapy limits are met, the ABN must be issued before providing the
services in order to transfer financial responsibility to the beneficiary.
10.6 - Functional Reporting

A. General
Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA)
amended Section 1833(g) of the Act to require a claims-based data collection system for
outpatient therapy services, including physical therapy (PT), occupational therapy (OT)
and speech-language pathology (SLP) services. 42 CFR 410.59, 410.60, 410.61, 410.62
and 410.105 implement this requirement. The system will collect data on beneficiary
function during the course of therapy services in order to better understand beneficiary
conditions, outcomes, and expenditures.
Beneficiary unction information is reported using 42 nonpayable functional G-codes and

seven severity/complexity modifiers on claims for PT, OT, and SLP services. Functional
reporting on one functional limitation at a time is required periodically throughout an
entire PT, OT, or SLP therapy episode of care.
The nonpayable G-codes and severity modifiers provide information about the
beneficiary’s functional status at the outset of the therapy episode of care, including
projected goal status, at specified points during treatment, and at the time of discharge.
These G-codes, along with the associated modifiers, are required at specified intervals on
all claims for outpatient therapy services – not just those over the cap.
B. Application of New Coding Requirements
This functional data reporting and collection system is effective for therapy services with
dates of service on and after January 1, 2013. A testing period will be in effect from
January 1, 2013, until July 1, 2013, to allow providers and practitioners to use the new
coding requirements to assure that systems work. Claims for therapy services furnished
on and after July 1, 2013, that do not contain the required functional G-code/modifier
information will be returned or rejected, as applicable.
C. Services Affected
These requirements apply to all claims for services furnished under the Medicare Part B
outpatient therapy benefit and the PT, OT, and SLP services furnished under the CORF
benefit. They also apply to the therapy services furnished personally by and incident to
the service of a physician or a nonphysician practitioner (NPP), including a nurse
practitioner (NP), a certified nurse specialist (CNS), or a physician assistant (PA), as
applicable.
D. Providers and Practitioners Affected.
The functional reporting requirements apply to the therapy services furnished by the
following providers: hospitals, CAHs, SNFs, CORFs, rehabilitation agencies, and HHAs
(when the beneficiary is not under a home health plan of care). It applies to the following
practitioners: physical therapists, occupational therapists, and speech-language
pathologists in private practice (TPPs), physicians, and NPPs as noted above. The term
“clinician” is applied to these practitioners throughout this manual section. (See
definition section of Pub. 100-02, Chapter 15, section 220.)
E. Function-related G-codes
There are 42 functional G-codes, 14 sets of three codes each. Six of the G-code sets are
generally for PT and OT functional limitations and eight sets of G-codes are for SLP
functional limitations.
The following G-codes are for functional limitations typically seen in beneficiaries
receiving PT or OT services. The first four of these sets describe categories of functional
limitations and the final two sets describe “other” functional limitations, which are to be
used for functional limitations not described by one of the four categories.
NONPAYABLE G-CODES FOR FUNCTIONAL LIMITATIONS
Code Long Descriptor Short Descriptor

Mobility G-code Set
G8978 Mobility: walking & moving around functional Mobility current status
limitation, current status, at therapy episode
outset and at reporting intervals
G8979 Mobility: walking & moving around functional Mobility goal status
limitation, projected goal status, at therapy
episode outset, at reporting intervals, and at
discharge or to end reporting
G8980 Mobility: walking & moving around functional Mobility D/C status
limitation, discharge status, at discharge from
therapy or to end reporting
Changing & Maintaining Body Position G-code Set
G8981 Changing & maintaining body position functional Body pos current
limitation, current status, at therapy episode status
G8982 Changing & maintaining body position functional Body pos goal status
G8983 Changing & maintaining body position functional Body pos D/C status
Carrying, Moving & Handling Objects G-code Set
G8984 Carrying, moving & handling objects functional Carry current status
limitation, current status, at therapy episode
G8985 Carrying, moving & handling objects functional Carry goal status
G8986 Carrying, moving & handling objects functional Carry D/C status
Self Care G-code Set
G8987 Self care functional limitation, current status, at Self care current status
therapy episode outset and at reporting intervals
G8988 Self care functional limitation, projected goal Self care goal status
status, at therapy episode outset, at reporting
intervals, and at discharge or to end reporting
G8989 Self care functional limitation, discharge status, at Self care D/C status
discharge from therapy or to end reporting
The following “other PT/OT” functional G-codes are used to report:
• a beneficiary’s functional limitation that is not defined by one of the above four
categories;
• a beneficiary whose therapy services are not intended to treat a functional

limitation;
• or a beneficiary’s functional limitation when an overall, composite or other score

from a functional assessment too is used and it does not clearly represent a
functional limitation defined by one of the above four code sets.
Other PT/OT Primary G-code Set
G8990 Other physical or occupational therapy primary Other PT/OT current
functional limitation, current status, at therapy status
episode outset and at reporting intervals
G8991 Other physical or occupational therapy primary Other PT/OT goal
functional limitation, projected goal status, at status
therapy episode outset, at reporting intervals, and
at discharge or to end reporting
G8992 Other physical or occupational therapy primary Other PT/OT D/C
functional limitation, discharge status, at status
Other PT/OT Subsequent G-code Set
G8993 Other physical or occupational therapy Sub PT/OT current
subsequent functional limitation, current status, at status
G8994 Other physical or occupational therapy Sub PT/OT goal status
subsequent functional limitation, projected goal
G8995 Other physical or occupational subsequent Sub PT/OT D/C status
functional limitation, discharge from therapy or
end reporting.
The following G-codes are for functional limitations typically seen in beneficiaries
receiving SLP services. Seven are for specific functional communication measures,
which are modeled after the National Outcomes Measurement System (NOMS), and one
is for any “other” measure not described by one of the other seven.

Swallowing G-code Set
G8996 Swallowing functional limitation, current status, Swallow current status
at therapy episode outset and at reporting
intervals
G8997 Swallowing functional limitation, projected goal Swallow goal status
G8998 Swallowing functional limitation, discharge Swallow D/C status
status, at discharge from therapy or to end
reporting
Motor Speech G-code Set
(Note: These codes are not sequentially numbered)
G8999 Motor speech functional limitation, current status, Motor speech current
at therapy episode outset and at reporting status
intervals
G9186 Motor speech functional limitation, projected goal Motor speech goal
status at therapy episode outset, at reporting status
G9158 Motor speech functional limitation, discharge Motor speech D/C
status, at discharge from therapy or to end status
reporting
Spoken Language Comprehension G-code Set
G9159 Spoken language comprehension functional Lang comp current
G9160 Spoken language comprehension functional Lang comp goal status
G9161 Spoken language comprehension functional Lang comp D/C status
Spoken Language Expressive G-code Set
G9162 Spoken language expression functional limitation, Lang express current
current status, at therapy episode outset and at status
reporting intervals
G9163 Spoken language expression functional limitation, Lang press goal status
projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end
reporting
G9164 Spoken language expression functional limitation, Lang express D/C
discharge status, at discharge from therapy or to status
end reporting
Attention G-code Set
G9165 Attention functional limitation, current status, at Atten current status
G9166 Attention functional limitation, projected goal Atten goal status
G9167 Attention functional limitation, discharge status, Atten D/C status
at discharge from therapy or to end reporting
Memory G-code Set
G9168 Memory functional limitation, current status, at Memory current status
G9169 Memory functional limitation, projected goal Memory goal status
G9170 Memory functional limitation, discharge status, at Memory D/C status
Voice G-code Set
G9171 Voice functional limitation, current status, at Voice current status
G9172 Voice functional limitation, projected goal status, Voice goal status
at therapy episode outset, at reporting intervals,
and at discharge or to end reporting
G9173 Voice functional limitation, discharge status, at Voice D/C status
The following “other SLP” G-code set is used to report:
• on one of the other eight NOMS-defined functional measures not described by the
above code sets; or
• to report an overall, composite or other score from assessment tool that does not
clearly represent one of the above seven categorical SLP functional measures.

Other Speech Language Pathology G-code Set
G9174 Other speech language pathology functional Speech lang current
G9175 Other speech language pathology functional Speech lang goal
limitation, projected goal status, at therapy status
G9176 Other speech language pathology functional Speech lang D/C
limitation, discharge status, at discharge from status
F. Severity/Complexity Modifiers
For each nonpayable functional G-code, one of the modifiers listed below must be used
to report the severity/complexity for that functional limitation.
Modifier Impairment Limitation Restriction

CH 0 percent impaired, limited or restricted
CI At least 1 percent but less than 20 percent impaired, limited or restricted
CJ At least 20 percent but less than 40 percent impaired, limited or restricted
CK At least 40 percent but less than 60 percent impaired, limited or restricted
CL At least 60 percent but less than 80 percent impaired, limited or restricted
CM At least 80 percent but less than 100 percent impaired, limited or restricted
CN 100 percent impaired, limited or restricted
The severity modifiers reflect the beneficiary’s percentage of functional impairment as

determined by the clinician furnishing the therapy services.
G. Required Reporting of Functional G-codes and Severity Modifiers
The functional G-codes and severity modifiers listed above are used in the required
reporting on therapy claims at certain specified points during therapy episodes of care.
Claims containing these functional G-codes must also contain another billable and
separately payable (non-bundled) service. Only one functional limitation shall be
reported at a given time for each related therapy plan of care (POC).
Functional reporting using the G-codes and corresponding severity modifiers is required
reporting on specified therapy claims. Specifically, they are required on claims:
• At the outset of a therapy episode of care (i.e., on the claim for the date of service
(DOS) of the initial therapy service);
• At least once every 10 treatment days, which corresponds with the progress
reporting period;
• When an evaluative procedure, including a re-evaluative one, ( HCPCS/CPT

codes 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92610, 92611, 92612,
92614, 92616, 96105, 96125, 97161, 97162 ,97163, 97164, 97165, 97166, 97167,
97168) is furnished and billed;
• At the time of discharge from the therapy episode of care–(i.e., on the date
services related to the discharge [progress] report are furnished); and
• At the time reporting of a particular functional limitation is ended in cases where

the need for further therapy is necessary.
• At the time reporting is begun for a new or different functional limitation within
the same episode of care (i.e., after the reporting of the prior functional limitation
is ended)
Functional reporting is required on claims throughout the entire episode of care. When
the beneficiary has reached his or her goal or progress has been maximized on the
initially selected functional limitation, but the need for treatment continues, reporting is
required for a second functional limitation using another set of G-codes. In these
situations two or more functional limitations will be reported for a beneficiary during the
therapy episode of care. Thus, reporting on more than one functional limitation may be
required for some beneficiaries but not simultaneously.
When the beneficiary stops coming to therapy prior to discharge, the clinician should
report the functional information on the last claim. If the clinician is unaware that the
beneficiary is not returning for therapy until after the last claim is submitted, the clinician
cannot report the discharge status.
When functional reporting is required on a claim for therapy services, two G-codes will
generally be required.
Two exceptions exist:
1. Therapy services under more than one therapy POC-- Claims may contain more
than two nonpayable functional G-codes when in cases where a beneficiary
receives therapy services under multiple POCs (PT, OT, and/or SLP) from the
same therapy provider.
2. One-Time Therapy Visit-- When a beneficiary is seen and future therapy services
are either not medically indicated or are going to be furnished by another
provider, the clinician reports on the claim for the DOS of the visit, all three G-
codes in the appropriate code set (current status, goal status and discharge status),
along with corresponding severity modifiers.
Each reported functional G-code must also contain the following line of service
information:
• Functional severity modifier
• Therapy modifier indicating the related discipline/POC -- GP, GO or GN -- for

PT, OT, and SLP services, respectively
• Date of the related therapy service
• Nominal charge, e.g., a penny, for institutional claims submitted to the A/B
MACs (A). For professional claims, a zero charge is acceptable for the service
line. If provider billing software requires an amount for professional claims, a
nominal charge, e.g., a penny, may be included.
NOTE: The KX modifier is not required on the claim line for nonpayable G-codes, but
would be required with the procedure code for medically necessary therapy services
furnished once the beneficiary’s annual cap has been reached.
The following example demonstrates how the G-codes and modifiers are used. In this
example, the clinician determines that the beneficiary’s mobility restriction is the most
clinically relevant functional limitation and selects the Mobility G-code set (G8978 –
G8980) to represent the beneficiary’s functional limitation. The clinician also determines
the severity/complexity of the beneficiary’s functional limitation and selects the
appropriate modifier. In this example, the clinician determines that the beneficiary has a
75 percent mobility restriction for which the CL modifier is applicable. The clinician
expects that at the end of therapy the beneficiaries will have only a 15 percent mobility
restriction for which the CI modifier is applicable. When the beneficiary attains the
mobility goal, therapy continues to be medically necessary to address a functional
limitation for which there is no categorical G-code. The clinician reports this using
(G8990 – G8992).
At the outset of therapy-- On the DOS for which the initial evaluative procedure is
furnished or the initial treatment day of a therapy POC, the claim for the service will also
include two G-codes as shown below.
• G8978-CL to report the functional limitation (Mobility with current mobility

limitation of “at least 60 percent but less than 80 percent impaired, limited or
restricted”)
• G8979-CI to report the projected goal for a mobility restriction of “at least 1
percent but less than 20 percent impaired, limited or restricted.”
At the end of each progress reporting period-- On the claim for the DOS when the
services related to the progress report (which must be done at least once each 10
treatment days) are furnished, the clinician will report the same two G-codes but the
modifier for the current status may be different.
• G8978 with the appropriate modifier are reported to show the beneficiary’s
current status as of this DOS. So if the beneficiary has made no progress, this
claim will include G8978-CL. If the beneficiary made progress and now has a
mobility restriction of 65 percent CL would still be the appropriate modifier for
65 percent, and G8978-CL would be reported in this case. If the beneficiary now
has a mobility restriction of 45 percent, G8978-CK would be reported.
• G8979-CI would be reported to show the projected goal. This severity modifier
would not change unless the clinician adjusts the beneficiary’s goal.
This step is repeated as necessary and clinically appropriate, adjusting the current status
modifier used as the beneficiary progresses through therapy.
At the time the beneficiary is discharged from the therapy episode. The final claim for
therapy episode will include two G-codes.
• G8979-CI would be reported to show the projected goal. G8980-CI would be

reported if the beneficiary attained the 15 percent mobility goal. Alternatively, if
the beneficiary’s mobility restriction only reached 25 percent; G8980-CJ would
be reported.
To end reporting of one functional limitation-- As noted above, functional reporting is

required to continue throughout the entire episode of care. Accordingly, when further
therapy is medically necessary after the beneficiary attains the goal for the first reported
functional limitation, the clinician would end reporting of the first functional limitation
by using the same G-codes and modifiers that would be used at the time of discharge.
Using the mobility example, to end reporting of the mobility functional limitation,
G8979-CI and G8980-CI would be reported on the same DOS that coincides with end of
that progress reporting period.
To begin reporting of a second functional limitation. At the time reporting is begun for a
new and different functional limitation, within the same episode of care (i.e., after the
reporting of the prior functional limitation is ended). Reporting on the second functional
limitation, however, is not begun until the DOS of the next treatment day -- which is day
one of the new progress reporting period. When the next functional limitation to be
reported is NOT defined by one of the other three PT/OT categorical codes, the G-code
set (G8990 - G8992) for the “other PT/OT primary” functional limitation is used, rather
than the G-code set for the “other PT/OT subsequent” because it is the first reported
“other PT/OT” functional limitation. This reporting begins on the DOS of the first
treatment day following the mobility “discharge” reporting, which is counted as the
initial service for the “other PT/OT primary” functional limitation and the first treatment
day of the new progress reporting period. In this case, G8990 and G8991, along with the
corresponding modifiers, are reported on the claim for therapy services.
The table below illustrates when reporting is required using this example and what G-
codes would be used.
Example of Required Reporting

Begin RP #1 for Mobility
D/C or End Reporting for

End RP#1for Mobility at
Key: Reporting Period (RP)

End RP #2 for Mobility
Mobility RP #2 Begins
Mobility RP #3 Begins
Begin RP #1 for Other

Next Treatment Day
Next Treatment Day

at Progress Report
at Episode Outset
Progress Report
PT/OT Primary
Mobility
Mobility: Walking & Moving
Around
G8978 – Current Status X X X
G 8979– Goal Status X X X X
G8980 – Discharge Status X
Other PT/OT Primary
G8990 – Current Status X
G8991 – Goal Status X
G8992 – Discharge Status
No Functional Reporting
X X
Required
H. Required Tracking and Documentation of Functional G-codes and Severity

Modifiers
The clinician who furnishes the services must not only report the functional information
on the therapy claim, but, he/she must track and document the G-codes and severity
modifiers used for this reporting in the beneficiary’s medical record of therapy services.
For details related to the documentation requirements, refer to, Medicare Benefit Policy
Manual, Pub. 100-02, Chapter 15, section 220.4 - Functional Reporting. For coverage
rules related to MCTRJCA and therapy goals, refer to Pub. 100-02: a) for outpatient
therapy services, see Chapter 15, section 220.1.2 B and b) for instructions specific to PT,
OT, and SLP services in the CORF, see Chapter 12, section 10.
10.7 - Multiple Procedure Payment Reductions for Outpatient

Rehabilitation Services
Medicare applies a multiple procedure payment reduction (MPPR) to the practice

expense (PE) payment of select therapy services. The reduction applies to the HCPCS
codes contained on the list of “always therapy” services (see section 20), excluding A/B
MAC (B)-priced, bundled and add-on codes, regardless of the type of provider or
supplier that furnishes the services.
Medicare applies an MPPR to the PE payment when more than one unit or procedure is
provided to the same patient on the same day, i.e., the MPPR applies to multiple units as
well as multiple procedures. Many therapy services are time-based codes, i.e., multiple
units may be billed for a single procedure. The MPPR applies to all therapy services
furnished to a patient on the same day, regardless of whether the services are provided in
one therapy discipline or multiple disciplines, for example, physical therapy,
occupational therapy, or speech-language pathology.
Full payment is made for the unit or procedure with the highest PE payment.
For subsequent units and procedures with dates of service prior to April 1, 2013,
furnished to the same patient on the same day, full payment is made for work and
malpractice and 80 percent payment is made for the PE for services submitted on
professional claims (any claim submitted using the ASC X12 837 professional claim
format or the CMS-1500 paper claim form) and 75 percent payment is made for the PE
for services submitted on institutional claims (ASC X12 837 institutional claim format or
Form CMS-1450).
For subsequent units and procedures with dates of service on or after April 1, 2013,
furnished to the same patient on the same day, full payment is made for work and
malpractice and 50 percent payment is made for the PE for services submitted on either
professional or institutional claims.
To determine which services will receive the MPPR, contractors shall rank services
according to the applicable PE relative value units (RVU) and price the service with the
highest PE RVU at 100% and apply the appropriate MPPR to the remaining services.
When the highest PE RVU applies to more than one of the identified services, contractors
shall additionally sort and rank these services according to highest total fee schedule
amount, and price the service with the highest total fee schedule amount at 100% and
apply the appropriate MPPR to the remaining services.
The therapy payment amount that has been reduced by the MPPR is applied toward the
therapy caps described in section 10.2. As a result, the MPPR may increase the amount
of medically necessary therapy services a beneficiary may receive before exceeding the
caps. The reduced amount is also used to calculate the beneficiary’s coinsurance and
deductible amounts.
when adjusting payment under this policy. The CARC below is not included in the
CAQH CORE Business Scenarios.
Group Code: CO
CARC: 59
RARC: N/A
MSN: 30.1
20 - HCPCS Coding Requirement

A. Uniform Coding
Section 1834(k)(5) of the Act requires that all claims for outpatient rehabilitation therapy
services and all comprehensive outpatient rehabilitation facility (CORF) services be
reported using a uniform coding system. The current Healthcare Common Procedure
Coding System/Current Procedural Terminology is used for the reporting of these
services. The uniform coding requirement in the Act is specific to payment for all CORF
services and outpatient rehabilitation therapy services - including physical therapy,
occupational therapy, and speech-language pathology - that is provided and billed to
Medicare contractors. The Medicare physician fee schedule (MPFS) is used to make
payment for these therapy services at the non facility rate.
Effective for claims submitted on or after April 1, 1998, providers that had not previously
reported HCPCS/CPT for outpatient rehabilitation and CORF services began using
HCPCS to report these services. This requirement does not apply to outpatient
rehabilitation services provided by:
• Critical access hospitals, which are paid on a cost basis, not MPFS;
• RHCs, and FQHCs for which therapy is included in the all-inclusive rate; or
• Providers that do not furnish therapy services.

The following “providers of services” must bill the A/B MAC (A) for outpatient
rehabilitation services using HCPCS codes:
• Hospitals (to outpatients and inpatients who are not in a covered Part A stay);
• Skilled nursing facilities (SNFs) (to residents not in a covered Part A stay and to
nonresidents who receive outpatient rehabilitation services from the SNF);
• Home health agencies (HHAs) (to individuals who are not homebound or
otherwise are not receiving services under a home health plan of care (POC).
• Comprehensive outpatient rehabilitation facilities (CORFs); and
• Providers of outpatient physical therapy and speech-language pathology services

(OPTs), also known as rehabilitation agencies (previously termed outpatient
physical therapy facilities in this instruction).
Note 1. The requirements for hospitals and SNFs apply to inpatient Part B and outpatient
services only. Inpatient Part A services are bundled into the respective prospective
payment system payment; no separate payment is made.
Note 2. For HHAs, HCPCS/CPT coding for outpatient rehabilitation services is required
only when the HHA provides such service to individuals that are not homebound and,
therefore, not under a home health plan of care.
The following practitioners must bill the A/B MAC (B) for outpatient rehabilitation
therapy services using HCPCS/CPT codes:
• Physical therapists in private practice (PTPPs),
• Occupational therapists in private practice (OTPPs),
• Speech-language pathologists in private practice (SLPPs),
• Physicians, including MDs, DOs, podiatrists and optometrists, and
• Certain nonphysician practitioners (NPPs), acting within their State scope of

practice, e.g., nurse practitioners and clinical nurse specialists.
Providers billing to intermediaries shall report:
• The date the therapy plan of care was either established or last reviewed (see
§220.1.3B) in Occurrence Code 17, 29, or 30.
• The first day of treatment in Occurrence Code 35, 44, or 45.

B. Applicable Outpatient Rehabilitation HCPCS Codes
The CMS identifies the codes listed at:

as therapy services, regardless of the presence of a financial limitation. Therapy services
include only physical therapy, occupational therapy and speech-language pathology
services. Therapist means only a physical therapist, occupational therapist or speech-
language pathologist. Therapy modifiers are GP for physical therapy, GO for
occupational therapy, and GN for speech-language pathology.
When in effect, any financial limitation will also apply to services represented unless
otherwise noted on the therapy page on the CMS Web site.
C. Additional HCPCS Codes
Some HCPCS/CPT codes that are not on the list of therapy services should not be billed
with a modifier. For example, outpatient non-rehabilitation HCPCS codes G0237,
G0238, and G0239 should be billed without therapy modifiers. These HCPCS codes
describe services for the improvement of respiratory function and may represent either
“incident to” services or respiratory therapy services that may be appropriately billed in
the CORF setting. When the services described by these G-codes are provided by
physical therapists (PTs) or occupational therapists (OTs) treating respiratory conditions,
they are considered therapy services and must meet the other conditions for physical and
occupational therapy. The PT or OT would use the appropriate HCPCS/CPT code(s) in
the 97000 - 97799 series and the corresponding therapy modifier, GP or GO, must be
used.
Another example of codes that are not on the list of therapy services and should not be
billed with a therapy modifier includes the following HCPCS codes: 95860, 95861,
95863, 95864, 95867, 95869, 95870, 95900, 95903, 95904, and 95934. These services
represent diagnostic services - not therapy services; they must be appropriately billed and
shall not include therapy modifiers.
Other codes not on the therapy code list, and not paid under another fee schedule, are
appropriately billed with therapy modifiers when the services are furnished by therapists
or provided under a therapy plan of care and where the services are covered and
appropriately delivered (e.g., the therapist is qualified to provide the service). One
example of non-listed codes where a therapy modifier is indicated regards the provision
of services described in the CPT code series, 29000 through 29590, for the application of
casts and strapping. Some of these codes previously appeared on the therapy code list,
but were deleted because we determined that they represented services that are most often
performed outside a therapy plan of care. However, when these services are provided by
therapists or as an integral part of a therapy plan of care, the CPT code must be
accompanied with the appropriate therapy modifier.
NOTE: The above lists of HCPCS/CPT codes are intended to facilitate the contractor’s
ability to pay claims under the MPFS. It is not intended to be an exhaustive list of
covered services, imply applicability to provider settings, and does not assure coverage of
these services.
20.1 - Discipline Specific Outpatient Rehabilitation Modifiers - All

Claims
Modifiers are used to identify therapy services whether or not financial limitations are in
effect. When limitations are in effect, the CWF tracks the financial limitation based on
the presence of therapy modifiers. Providers/suppliers must continue to report one of
these modifiers for any therapy code on the list of applicable therapy codes except as
noted in §20 of this chapter. Consult §20 for the list of codes to which modifiers must be
applied. These modifiers do not allow a provider to deliver services that they are not
qualified and recognized by Medicare to perform.
The claim must include one of the following modifiers to distinguish the discipline of the
plan of care under which the service is delivered:
• GN Services delivered under an outpatient speech-language pathology plan of

care;
• GO Services delivered under an outpatient occupational therapy plan of care; or,
• GP Services delivered under an outpatient physical therapy plan of care.
This is applicable to all claims from physicians, nonphysician practitioners (NPPs),

PTPPs, OTPPs, SLPPs, CORFs, OPTs, hospitals, SNFs, and any others billing for
physical therapy, speech-language pathology or occupational therapy services as noted on
the applicable code list in §20 of this chapter.
Modifiers GN, GO, and GP refer only to services provided under plans of care for
physical therapy, occupational therapy and speech-language pathology services. They
should never be used with codes that are not on the list of applicable therapy services.
For example, respiratory therapy services, or nutrition therapy services shall not be
represented by therapy codes which require GN, GO, and GP modifiers.
Contractors edit institutional claims to ensure the following:
• that a GN, GO or GP modifier is present for all lines reporting revenue codes
042X, 043X, or 044X.
• that no more than one GN, GO or GP modifier is reported on the same service
line.
• that revenue codes and modifiers are reported only in the following combinations:
o Revenue code 42x (physical therapy) lines may only contain modifier GP
o Revenue code 43x (occupational therapy) lines may only contain modifier GO
o Revenue code 44x (speech-language pathology) lines may only contain
modifier GN.
• that discipline-specific evaluation and re-evaluation HCPCS codes are always

reported with the modifier for the associated discipline (e.g. modifier GP with a
HCPCS code for a physical therapy evaluation).
Contractors return to the provider institutional claims that do not meet one or more of
these conditions.
20.2 - Reporting of Service Units With HCPCS

A. General
Effective with claims submitted on or after April 1, 1998, providers billing on the ASC
X12 837 institutional claim format or Form CMS-1450 were required to report the
number of units for outpatient rehabilitation services based on the procedure or service,
e.g., based on the HCPCS code reported instead of the revenue code. This was already in
effect for billing on the Form CMS-1500, and CORFs were required to report their full
range of CORF services on the institutional claim. These unit-reporting requirements
continue with the standards required for electronically submitting health care claims
under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) - the
currently adopted version of the ASC X12 837 transaction standards and implementation
guides. The Administrative Simplification Compliance Act mandates that claims be sent
to Medicare electronically unless certain exceptions are met.
B. Timed and Untimed Codes
When reporting service units for HCPCS codes where the procedure is not defined by a
specific timeframe (“untimed” HCPCS), the provider enters “1” in the field labeled units.
For timed codes, units are reported based on the number of times the procedure is
performed, as described in the HCPCS code definition.
EXAMPLE: A beneficiary received a speech-language pathology evaluation

represented by HCPCS “untimed” code 92521. Regardless of the number of minutes
spent providing this service only one unit of service is appropriately billed on the same
day.
Several CPT codes used for therapy modalities, procedures, and tests and measurements
specify that the direct (one on one) time spent in patient contact is 15 minutes. Providers
report these “timed” procedure codes for services delivered on any single calendar day
using CPT codes and the appropriate number of 15 minute units of service.
EXAMPLE: A beneficiary received a total of 60 minutes of occupational therapy, e.g.,
HCPCS “timed” code 97530 which is defined in 15 minute units, on a given date of
service. The provider would then report 4 units of 97530.
C. Counting Minutes for Timed Codes in 15 Minute Units
When only one service is provided in a day, providers should not bill for services
performed for less than 8 minutes. For any single timed CPT code in the same day
measured in 15 minute units, providers bill a single 15-minute unit for treatment greater
than or equal to 8 minutes through and including 22 minutes. If the duration of a single
modality or procedure in a day is greater than or equal to 23 minutes, through and
including 37 minutes, then 2 units should be billed. Time intervals for 1 through 8 units
are as follows:
Units Number of Minutes
1 unit: ≥ 8 minutes through 22 minutes
2 units:≥ 23 minutes through 37 minutes
The pattern remains the same for treatment times in excess of 2 hours.
If a service represented by a 15 minute timed code is performed in a single day for at

least 15 minutes, that service shall be billed for at least one unit. If the service is
performed for at least 30 minutes, that service shall be billed for at least two units, etc. It
is not appropriate to count all minutes of treatment in a day toward the units for one code
if other services were performed for more than 15 minutes. See examples 2 and 3 below.
When more than one service represented by 15 minute timed codes is performed in a
single day, the total number of minutes of service (as noted on the chart above)
determines the number of timed units billed. See example 1 below.
If any 15 minute timed service that is performed for 7 minutes or less than 7 minutes on
the same day as another 15 minute timed service that was also performed for 7 minutes or
less and the total time of the two is 8 minutes or greater than 8 minutes, then bill one unit
for the service performed for the most minutes. This is correct because the total time is
greater than the minimum time for one unit. The same logic is applied when three or
more different services are provided for 7 minutes or less than 7 minutes. See example 5
below.
The expectation (based on the work values for these codes) is that a provider’s direct
patient contact time for each unit will average 15 minutes in length. If a provider has a
consistent practice of billing less than 15 minutes for a unit, these situations should be
highlighted for review.
If more than one 15 minute timed CPT code is billed during a single calendar day, then
the total number of timed units that can be billed is constrained by the total treatment
minutes for that day. See all examples below.
Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3B,
Documentation Requirements for Therapy Services, indicates that the amount of time for
each specific intervention/modality provided to the patient is not required to be
documented in the Treatment Note. However, the total number of timed minutes must be
documented. These examples indicate how to count the appropriate number of units for
the total therapy minutes provided.
Example 1 –
24 minutes of neuromuscular reeducation, code 97112,
23 minutes of therapeutic exercise, code 97110,
Total timed code treatment time was 47 minutes.
See the chart above. The 47 minutes falls within the range for 3 units = 38 to 52 minutes.
Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed
for more than 15 minutes, so each shall be billed for at least 1 unit. The correct coding is
2 units of code 97112 and one unit of code 97110, assigning more timed units to the
service that took the most time.
Example 2 –
20 minutes of neuromuscular reeducation (97112)
20 minutes therapeutic exercise (97110),
40 Total timed code minutes.
Appropriate billing for 40 minutes is 3 units. Each service was done at least 15 minutes
and should be billed for at least one unit, but the total allows 3 units. Since the time for
each service is the same, choose either code for 2 units and bill the other for 1 unit. Do
not bill 3 units for either one of the codes.
Example 3 –
33 minutes of therapeutic exercise (97110),
7 minutes of manual therapy (97140),
40 Total timed minutes
Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of
97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining
time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the
larger, which is 97140.
Example 4 –
18 minutes of therapeutic exercise (97110),
13 minutes of manual therapy (97140),
10 minutes of gait training (97116),
8 minutes of ultrasound (97035),
Appropriate billing is for 3 units. Bill the procedures you spent the most time providing.
Bill 1 unit each of 97110, 97116, and 97140. You are unable to bill for the ultrasound
because the total time of timed units that can be billed is constrained by the total timed
code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless
of how many services were performed). You would still document the ultrasound in the
treatment notes.
Example 5 –
7 minutes of neuromuscular reeducation (97112)
7 minutes therapeutic exercise (97110)
7 minutes manual therapy (97140)
Appropriate billing is for one unit. The qualified professional (See definition in Pub.
100-02, chapter 15, section 220) shall select one appropriate CPT code (97112, 97110,
97140) to bill since each unit was performed for the same amount of time and only one
unit is allowed.
NOTE: The above schedule of times is intended to provide assistance in rounding time
into 15-minute increments. It does not imply that any minute until the eighth should be
excluded from the total count. The total minutes of active treatment counted for all 15
minute timed codes includes all direct treatment time for the timed codes. Total
treatment minutes - including minutes spent providing services represented by untimed
codes - are also documented. For documentation in the medical record of the services
provided see Pub. 100-02, chapter 15, section 220.3.
D. Specific Limits for HCPCS

The Deficit Reduction Act of 2005, section 5107 requires the implementation of
clinically appropriate code edits to eliminate improper payments for outpatient therapy
services. The following codes may be billed, when covered, only at or below the number
of units indicated on the chart per treatment day. When higher amounts of units are
billed than those indicated in the table below, the units on the claim line that exceed the
limit shall be denied as medically unnecessary (according to 1862(a)(1)(A)). Denied
claims may be appealed and an ABN is appropriate to notify the beneficiary of liability.
This chart does not include all of the codes identified as therapy codes; refer to section 20
of this chapter for further detail on these and other therapy codes. For example, therapy
codes called “always therapy” must always be accompanied by therapy modifiers
identifying the type of therapy plan of care under which the service is provided.
Use the chart in the following manner:
The codes that are allowed one unit for “Allowed Units” in the chart below may be billed
no more than once per provider, per discipline, per date of service, per patient.
The codes allowed 0 units in the column for “Allowed Units”, may not be billed under a
plan of care indicated by the discipline in that column. Some codes may be billed by one
discipline (e.g., PT) and not by others (e.g., OT or SLP).
When physicians/NPPs bill “always therapy” codes they must follow the policies of the
type of therapy they are providing e.g., utilize a plan of care, bill with the appropriate
therapy modifier (GP, GO, GN), bill the allowed units on the chart below for PT, OT or
SLP depending on the plan. A physician/NPP shall not bill an “always therapy” code
unless the service is provided under a therapy plan of care. Therefore, NA stands for
“Not Applicable” in the chart below.
When a “sometimes therapy” code is billed by a physician/NPP, but as a medical service,

and not under a therapy plan of care, the therapy modifier shall not be used, but the
number of units billed must not exceed the number of units indicated in the chart below
per patient, per provider/supplier, per day.
NOTE: As of April 1, 2017, the chart below uses the CPT Consumer Friendly Code
Descriptions which are intended only to assist the reader in identifying the service related
to the CPT/HCPCS code. The reader is reminded that these descriptions cannot be used
in place of the CPT long descriptions which officially define each of the services. The
table below no longer contains a column noting whether a code is “timed” or “untimed”
as this notation is not relevant to the number of units allowed per code on claims for the
listed therapy services. We note that the official long descriptors for the CPT codes can
be found in the latest CPT code book.
CPT/ CPT Consumer Friendly PT OT SLP Physician/

HCPCS Code Descriptions and Allowed Allowed Allowed NPP Not
Code Units Units Units
Claim Line Outlier/Edit Under
Details Therapy
POC
92521 Evaluation of speech 0 0 1 NA
fluency
sound production
sound production with
evaluation of language
comprehension and
expression
92524 Behavioral and qualitative 0 0 1 NA
analysis of voice and
resonance
92597 Evaluation for use and/or 0 0 1 NA
fitting of voice prosthetic
device to supplement oral
speech
92607 Evaluation of patient with 0 0 1 NA
prescription of speech-
generating and alternative
communication device
92611 Fluoroscopic and video 0 1 1 1
recorded motion
evaluation of swallowing
function
92612 Evaluation and recording 0 1 1 1
of swallowing using an
endoscope Evaluation and
recording of swallowing
using an endoscope
of voice box sensory
function using an
endoscope
of swallowing and voice
box sensory function using
an endoscope
95833 Manual muscle testing of 1 1 0 1
whole body
95834 Manual muscle testing of 1 1 0 1
whole body including
hands
96110 Developmental screening 1 1 1 1
96111 Developmental testing 1 1 1 1
97161 Evaluation of physical 1 0 0 NA
therapy, typically 20
minutes
minutes
minutes
97164 Re-evaluation of physical 1 0 0 NA

minutes
97165 Evaluation of occupational 0 1 0 NA
minutes
minutes
minutes
97168 Re-evaluation of 0 1 0 NA
occupational therapy
established plan of care,
typically 30 minutes
20.3 - Determining What Time Counts Towards 15-Minute Timed

Codes - All Claims
(Rev. 1, 10-01-03)
Providers report the code for the time actually spent in the delivery of the modality
requiring constant attendance and therapy services. Pre- and post-delivery services are
not to be counted in determining the treatment service time. In other words, the time
counted as “intra-service care” begins when the therapist or physician (or an assistant
under the supervision of a physician or therapist) is directly working with the patient to
deliver treatment services. The patient should already be in the treatment area (e.g., on
the treatment table or mat or in the gym) and prepared to begin treatment.
The time counted is the time the patient is treated. For example, if gait training in a
patient with a recent stroke requires both a therapist and an assistant, or even two
therapists, to manage in the parallel bars, each 15 minutes the patient is being treated can
count as only one unit of code 97116. The time the patient spends not being treated
because of the need for toileting or resting should not be billed. In addition, the time
spent waiting to use a piece of equipment or for other treatment to begin is not considered
treatment time.
20.4 - Coding Guidance for Certain CPT Codes - All Claims

The following provides guidance about the use of codes 96105, 97026, 97150, 97545,
97546, and G0128.
• CPT Codes 96105, 97545, and 97546.
Providers report code 96105, assessment of aphasia with interpretation and report in 1-
hour units. This code represents formal evaluation of aphasia with an instrument such as
the Boston Diagnostic Aphasia Examination. If this formal assessment is performed
during treatment, it is typically performed only once during treatment and its medical
necessity should be documented. If the test is repeated during treatment, the medical
necessity of the repeat administration of the test must also be documented. It is common
practice for regular assessment of a patient’s progress in therapy to be documented in the
chart, and this may be done using test items taken from the formal examinations. This is
considered to be part of the treatment and should not be billed as 96105 unless a full,
formal assessment is completed.
Other timed physical medicine codes are 97545 and 97546. The interval for code 97545
is 2 hours and for code 97546, 1 hour. These are specialized codes to be used in the
context of rehabilitating a worker to return to a job. The expectation is that the entire
time period specified in the codes 97545 or 97546 would be the treatment period, since a
shorter period of treatment could be coded with another code such as codes 97110,
97112, or 97537. (Codes 97545 and 97546 were developed for reporting services to
persons in the worker’s compensation program, thus CMS does not expect to see them
reported for Medicare patients except under very unusual circumstances. Further, CMS
would not expect to see code 97546 without also seeing code 97545 on the same claim.
Code 97546, when used, is used in conjunction with 97545.)
• CPT Code 97026
Effective for services performed on or after October 24, 2006, the Centers for Medicare
& Medicaid Services announce a NCD stating the use of infrared and/or near-infrared
light and/or heat, including monochromatic infrared energy (MIRE), is non-covered for
the treatment, including symptoms such as pain arising from these conditions, of diabetic
and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin
and/or subcutaneous tissues in Medicare beneficiaries. Further coverage guidelines can
be found in the National Coverage Determination Manual (Pub. 100-03), section 270.6.
Contractors shall deny claims with CPT 97026 (infrared therapy incident to or as a
PT/OT benefit) and HCPCS E0221 or A4639, if the claim contains any of the following
diagnosis codes:
ICD-9-CM
250.60 - 250.63
354.4, 354.5, 354.9
355.1 - 355.4
355.6 - 355.9
356.0, 356.2-356.4, 356.8-356.9
357.0 - 357.7
674.10, 674.12, 674.14, 674.20, 674.22, 674.24
707.00 -707.07, 707.09-707.15, 707.19
870.0 - 879.9
880.00 - 887.7
890.0 - 897.7
998.31 - 998.32
ICD-10-CM
See Addendum A Chapter 5, Section 20.4 (at end of this chapter) for the list of ICD 10-
CM diagnosis codes that require denial with the above HCPCD codes.
Group Code: CO
CARC: 50
RARC: N/A
MSN: 21.11
Advanced Beneficiary Notice (ABN):
Physicians, physical therapists, occupational therapists, outpatient rehabilitation facilities

(ORFs), comprehensive outpatient rehabilitation facilities (CORFs), home health
agencies (HHA), and hospital outpatient departments are liable if the service is
performed, unless the beneficiary signs an ABN.
Similarly, DME suppliers and HHA are liable for the devices when they are supplied,
unless the beneficiary signs an ABN.
20.5 - CORF/OPT Edit for Billing Inappropriate Supplies

Supplies furnished by CORFs/OPTs are considered part of the practice expense. Under
the Medicare Physician Fee Schedule (MPFS) these expenses are already taken into
account in the practice expense relative values. Therefore, CORFs/OPTs should not bill
for the supplies they furnish except for the splint and cast, level II HCPCS Q codes
associated with the level I HCPCS in the 29000 series.
The shared system maintainer will return to CORFs/OPTs any claims that they receive
that contain a supply revenue code 270 without the splint and cast Level II HCPCS Q
codes and the related Level I applicable HCPCS codes in the 29000 series.
The appropriate Level II HCPCS “Q” codes to be used are Q4001 thru Q4049.
The appropriate Level I HCPCS codes associated with the Level II HCPCS “Q” codes are
29000 thru 29085; 29105 thru 29131; and 29305 thru 29515.
30 - Special Claims Processing Rules for Outpatient Rehabilitation

Claims - Form CMS-1500
(Rev. 1, 10-01-03)
Rules for completing a Form CMS-1500 and electronic formats are in Chapter 26.
Instructions in §§10.1, 20.1, 20.2, 20.3 and 20.4 above also apply.
30.1 - Determining Payment Amounts

(Rev. 1, 10-01-03)
A/B MACs (B) use the MPFS to determine payment for outpatient rehabilitation services.
Payment rules are the same as those for other services paid on the MPFS.
Assignment is mandatory.
See chapter 23, for a description of the MPFS.
30.2 - Applicable A/B MAC (B) CWF Type of Service Codes

(Rev. 1, 10-01-03)
The A/B MAC (B) assigns the type of service code before submitting the claim record to
CWF.
U = Occupational therapy
W= Physical therapy
40 - Special Claims Processing Rules for Institutional Outpatient

Rehabilitation Claims
40.1 - Determining Payment Amounts – Institutional Claims

Institutional outpatient rehabilitation claims are paid under the Medicare Physician Fee
Schedule (MPFS), except for claims from CAHs and hospitals in Maryland. Medicare
contractors should see §100.2 for details on obtaining the correct fee amounts.
40.2 - Applicable Types of Bill

The appropriate types of bill for submitting outpatient rehabilitation services are: 12X,
13X, 22X, 23X, 34X, 74X, 75X, and 85X.
40.3 - Applicable Revenue Codes

The appropriate revenue codes for reporting outpatient rehabilitation services are
0420 - Physical Therapy Services

0430 - Occupational Therapy Services
0440 – Speech-language pathology services
The general classification of revenue codes is all that is needed for billing. If, however,
providers choose to use more specific revenue code classifications, the A/B MAC (A)
should accept them. Reporting of services is not limited to specific revenue codes; e.g.,
services other than therapy may be included on the same claim.
Many therapy services may be provided by both physical and occupational therapists.
Other services may be delivered by either occupational therapists or speech-language
pathologists. Therefore, providers report outpatient rehabilitation HCPCS codes in
conjunction with the appropriate outpatient rehabilitation revenue code based on the type
of therapist who delivered the service, or, if a therapist does not deliver the service, then
on the type of therapy under the plan of care (POC) for which the service is delivered.
40.4 - Edit Requirements for Revenue Codes

Medicare contractors edit to assure the presence of a HCPCS code when revenue codes
0420, 0430, 0440, or 0470 are reported. However, Medicare contractors do not edit the
matching of revenue code to certain HCPCS codes or edit to limit provider reporting to
only those HCPCS listed in section 20.
40.5 - Line Item Date of Service Reporting

Providers are required to report line item dates of service per revenue code line for
outpatient rehabilitation services. CORFs are also required to report their full range of
CORF services by line item date of service. This means each service (revenue code)
provided must be repeated on a separate line item along with the specific date the service
was provided for every occurrence.
Contractors will return claims that span two or more dates if a line item date of service is
not entered for each HCPCS reported. Line item date of service reporting became
effective for claims with dates of service on or after October 1, 1998.
Services that do not require line item date of service reporting may be reported before or
after those services that require line item reporting.
40.6 - Non-covered Charge Reporting

Institutional outpatient therapy claims may report non-covered charges when appropriate
according to the instructions provided in of this manual. Outpatient therapies billed as
non-covered charges are not counted toward the financial limitation described above,
when that limitation is in effect, unless the charges are subject to review after they are
submitted and found to be covered by Medicare. Modifiers associated with non-covered
charges that are presented in Chapter 1, section 60 can be used on claim lines for therapy
services, in addition to the use of modifiers -GN, -GO and -GP.
40.7 - Billing for Biofeedback Training for the Treatment of Urinary

Incontinence
Medicare covered biofeedback training for the treatment of urinary incontinence may be
provided by physical therapists in facility settings. For information regarding the
coverage of this service, see the Medicare National Coverage Determinations Manual,
Chapter 1, Section 30.1.1. Medicare pays for this service under the Medicare Physician
Fee Schedule.
Providers bill this service on one of the types of bill listed in section 40.2 using revenue
code 042X and one of the following HCPCS codes:
• 90901 - Biofeedback training by any modality

• 90911 - Biofeedback training, perineal muscles, anorectal or urethral sphincter,
including EMG and/or manometry
40.8 – Rebilling Therapy Services for Hospital Inpatients

If a beneficiary receives therapy services during an inpatient hospital stay which was
denied because the stay was not medically necessary, the therapy services may be rebilled
under Medicare Part B coverage. If the therapy would have been reasonable and
necessary as hospital outpatient services, and provided the beneficiary has Part B
entitlement, the services can be billed using Type of Bill 012x. All payment and billing
requirements for outpatient therapy (including therapy caps, functional reporting and
other instructions in this chapter) apply to these claims.
50 - CWF and PS&R Requirements - A/B MAC (A)

The A/B MAC (A) reports the procedure codes in the financial data section (field 65a-
65j) of the PS&R record. It includes revenue code, HCPCS, units, and covered charges
in the record. Where more than one HCPCS procedure is applicable to a single revenue
code, the provider reports each HCPCS and related charge on a separate line. The A/B
MAC (A) reports the payment amount before adjustment for beneficiary liability in field
65g “Rate” and the actual charge in field 65h “Covered Charges.” The PS&R system
includes outpatient rehabilitation, and CORF services listed in subsections E and F on a
separate report from cost based payments. See the PS&R guidelines for specific
information.
100 - Special Rules for Comprehensive Outpatient Rehabilitation

Facilities (CORFs)
(Rev. 1, 10-01-03)
100.1 - General
(Rev. 3220, Issued: 03-16-15, Effective: ICD-10: Upon Implementation of ICD-10,
ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of
ICD-10 ASC X12: 09-16-14)
The Omnibus Reconciliation Act of 1980 (Public Law 96-499, Section 933) defines
CORFs (Comprehensive Outpatient Rehabilitation Facilities) as a distinct type of
Medicare provider and adds CORF services as a benefit under Medicare Part B. The
Balance Budget Act (P.L.105-33) requires payment under a prospective system for all
CORF services.
See Chapter 1, for the policy on A/B MAC (A) designations governing CORFs.
See the Medicare Benefit Policy Manual, Chapter 12, for a description of covered CORF
services.
Physicians’ diagnostic and therapeutic services furnished to a CORF patient are not
considered CORF physician’s services. The physician must bill the area A/B MAC (B)
for these services. If they are covered, the A/B MAC (B) reimburses them via the MPFS.
However, other services are considered CORF services to be billed by the CORF to the
A/B MAC (A), and are also considered included in the fee amount under the MPFS.
These services include such services as administrative services provided by the physician
associated with the CORF, examinations for the purpose of establishing and reviewing
the plan of care, consultation with and medical supervision of nonphysician staff, team
conferences, case reviews, and other facility staff medical and facility administration
activities relating to the services described in Medicare Benefit Policy Manual, chapter
12. Related supplies are also included in the MPFS fee amount.
The CORFs bill Medicare with the ASC X12 837 institutional claim or Form CMS-1450
using HCPCS codes and Revenue Codes. Usually the zero level revenue code is used.
Payment is based on the HCPCS code and related MPFS amount.
Requirements in §§10 - 50 apply to CORF billing. In addition the following

requirements apply.
100.1.1 - Allowable Revenue Codes on CORF 75X Bill Types

Effective October 1, 2012, the following revenue codes are allowable for reporting CORF
services on 75X bill types:
0270 0274 0279 029X

0412 0419 042X 0410
044X 0550 0559 043X
0636 0771 0911 0569
0942
NOTE: Billed revenue codes not listed in the above list will be returned to the provider
by Medicare systems. See Chapter 25, Completing and Processing the CMS-1450 Data
Set, for revenue code descriptions.
100.2 - Obtaining Fee Schedule Amounts

(Rev. 1, 10-01-03)
The CMS furnishes A/B MACs (A) with an annual therapy abstract file and a CORF
supplemental file through the Medicare Telecommunications System. The CMS notifies
A/B MACs (A) when new files are available. A/B MACs (A) are responsible for
informing CORFs of new fee schedule amounts.
Payment is calculated at 80 percent of the allowed charge after deductible is met. The
allowed charge is the lower of billed charges or the fee schedule amount. Unmet
deductible is subtracted from the allowed charge, and payment is calculated at 80 percent
of the result.
EXAMPLE:
$120 Provider charge;

$100 MPFS amount.
Payment is 80 percent of the lower of the actual charge or fee schedule amount,
which in this case is $80.00. ($100.00 (MPFS) X 80 percent.)
The remaining 20 percent or $20 is the patient s coinsurance liability.
These codes are updated as needed by CMS.
If the A/B MAC (A) receives a claim for a Medicare covered CORF service with dates of
service on or after July 1, 2000, that does not appear on its fee schedule abstract file, it
has two options for obtaining pricing information:
1. It is provided with a therapy abstract file or CORF supplemental file that contains
all therapy services and their related prices. This supplemental file contains
approximately a million records, and may be used as a resource to extract pricing
data as needed. The data in the supplemental file is in the same format as the
MPFS abstract file in exhibit 1, but the fields defining the fee and outpatient
hospital indicators are not populated, instead they are space-filled.
2. It can contact the local A/B MAC (B) to obtain the price. When requesting the
pricing data, it advises the A/B MAC (B) to provide the nonfacility fee from the
MPFS. The MPFS supplemental file of physician fee schedule services is
available for retrieval through CMS’ Mainframe Telecommunications System.
The A/B MAC (A) is notified yearly of the file retrieval names and dates by a
program memorandum or other communication.
100.3 - Proper Reporting of Nursing Services by CORFs - A/B MAC (A)

(Rev. 1459; Issued: 02-22-08; Effective: 07-01-08; Implementation: 07-07-08)
Nursing services performed in the CORF shall be billed utilizing the following HCPCS
code:
G0128 – Direct (Face to Face w/ patient) skilled nursing services of a registered nurse
provided in a CORF, each 10 minutes beyond the first 5 minutes.
In addition, HCPCS G0128 is billable with revenue codes 0550 and 0559 only.
100.4 - Outpatient Mental Health Treatment Limitation
The Outpatient Mental Health Treatment Limitation (the limitation) is not applicable to
CORF services because CORFs do not provide services to treat mental, psychoneurotic
and personality disorders that are subject to the limitation in section 1833(c) of the Act.
For dates of service on or after October 1, 2012, HCPCS code G0409 is the only code
allowed for social work and psychological services furnished in a CORF. This service is
not subject to the limitation because it is not a psychiatric mental health treatment
service.
For additional information on the limitation, see Publication 100-01, Chapter 3, section
30 and Publication 100-02, Chapter 12, sections 50-50.5.
100.5 - Off-Site CORF Services

ICD-10 ASC X12: 09-16-14)
The CORFs may provide physical therapy, speech-language pathology and occupational
therapy off the CORF’s premises in addition to the home evaluation. Services provided
offsite are billed separately and identified as “offsite” on the claim in remarks. The
charges for offsite visits include any additional charge for providing the services at a
place other than the CORF premises. There is no change in the payment method for
offsite services.
100.6 - Notifying Patient of Service Denial

ICD-10 ASC X12: 09-16-14)
Services may be noncovered because they are statutorily excluded from coverage under
Medicare, or because they are not medically reasonable and necessary.
If a service is excluded by statute, the CORF may submit a claim for them to Medicare to
obtain a denial prior to billing another insurance carrier. It shows the charges as
noncovered, and includes Condition Code 21. It may bill the beneficiary for the excluded
services, and need not issue an advance beneficiary notice (ABN). However, when
providing therapy services under the financial limitations, the CORF should provide the
beneficiary with the Notice of Exclusion of Medicare Benefits (NEMB). The Medicare
Claims Processing Manual, Chapter 30, “Limitation on Liability,” discusses ABNs for
A/B MAC (A) processed claims for Part B services.
If, after reviewing the plan of care, the CORF determines that the services to be furnished
to the patient are not medically reasonable or necessary, it immediately provides the
beneficiary with an ABN. If the patient signs an ABN, the claim includes occurrence
code 32 “Date Beneficiary Notified of Intent to Bill (Procedures or Treatments)” along
with the date the ABN was signed.
If the beneficiary insists that a claim be submitted for payment, the CORF must indicate
on the bill (billed separately from bills with covered charges) that it is being submitted at
the beneficiary’s request. This is done by using condition code 20.
If during the course of the patient’s treatment the A/B MAC (A) advises the CORF that
covered care has ceased, the CORF must notify the beneficiary (or the beneficiary’s
representative) immediately.
NOTE: Information regarding the form locator numbers that correspond to these data
element names is found in Chapter 25.
100.7 - Payment of Drugs, Biologicals, and Supplies in a CORF

Drugs
Drugs and biologicals generally do not apply in a CORF setting. Therefore, contractors
are to advise their CORFs not to bill for them.
Supplies
The CORFs should not bill for the supplies they furnish when such supplies are part of
the practice expense for that service. Under the MPFS, nearly all of these expenses are
already taken into account in the practice expense relative values. However, CORFs may
bill separately for certain splint and cast supplies, represented by HCPCS codes Q4001
through Q4051, when furnishing a cast/strapping application service in the CPT code
series 29000 through 29750.
Vaccines
The CORFs should refer to Chapter 18, Preventive and Screening Services, for billing
guidance on influenza, pneumococcal pneumonia, and Hepatitis B vaccines and their
administration.
100.8 - Billing for DME, Prosthetic and Orthotic Devices, and Surgical
Dressings
ICD-10 ASC X12: 09-16-14)
The CORFs bill DME to the DME MAC with the ASC X12 professional claim format or
Form CMS-1500 except for claims for implanted DME, which are billed to the local A/B
MAC (B). If the CORF does not have a supplier billing number from the National
Supplier Clearinghouse (NSC), it may contact the NSC to secure one. If the local A/B
MAC (B) has issued the CORF a provider number for billing physician services, the
CORF may not use the same number when billing for DME.
100.10 - Group Therapy Services (Code 97150)

(Rev. 1145, Issued: 12-29-06, Effective: 01-01-07, Implementation: on or before 01-
29-07)
Policies for group therapy services for CORF are the same as group therapy services for
other Part B outpatient services. See Pub 100-02, chapter 15, section 230.
100.10.1 - Therapy Students

(Rev. 1145, Issued: 12-29-06, Effective: 01-01-07, Implementation: on or before 01-
29-07)
Policies for therapy students for CORF are the same as policies for therapy students for
other Part B outpatient services. See Pub. 100-02, chapter 15, section 230.
100.11 - Billing for Social Work and Psychological Services in a CORF

The CORF providers shall only bill social work and psychological services with the
following HCPCS code:
G0409 – Social work and psychological services, directly relating to and/or the patient's
rehabilitation goals, each 15 minutes, face-to-face; individual (services provided
by a CORF-qualified social worker or psychologist in a CORF)
In addition, HCPCS code G0409 shall only be billed with revenue code 0569 or 0911.
100.12 - Billing for Respiratory Therapy Services in a CORF

The CORF providers shall only bill respiratory therapy services with revenue codes 0410,
0412 and 0419. See Chapter 25, Completing and Processing the CMS-1450 Data Set, for
revenue code descriptions.
Exhibit 1 - Physician Fee Schedule Abstract File

This file contains nonfacility fee schedule payment amounts for the outpatient
rehabilitation, and CORF HCPCS codes listed in §20. These codes are identified in the
abstract file by a value of “R” in the fee indicator field. The file includes fee schedule
payment amounts by locality and is available via the CMS Mainframe
Telecommunications System (formerly referred to as the Network Data Mover).
Record Length: 60
Record Format: FB
Block size: 6000
Character Code: EBCDIC
Sort Sequence: A/B MAC (B), Locality HCPCS Code, Modifier
Data Element Name COBOL Picture Value

Location
1 – HCPCS 1-5 X(05)
2 – Modifier 6-7 X(02)
3 – Filler 8-9 X(02)
4 -- Non-Facility Fee 10-16 9(05)V99
5 – Filler 17-23 X(07)
6 – Filler 24-30 X(07)
7 -- A/B MAC (B) 31-35 X(05)

Number
8 – Locality 36-37 X(02) Identical to the

radiology/diagnostic fees
9 – Filler 38-40 X(03)
10 -- Fee Indicator 41-41 X(1) “R” - Rehab/Audiology/CORF

services
11 -- Outpatient 42-42 X(1) “0” - Fee applicable in hospital

Hospital outpatient setting
indicator “1” - Fee not applicable in hospital
outpatient setting
12 – Filler 43-60 X(18)
Upon CMS notification, the contractor is responsible for retrieving this file and making
payment based on 80 percent of the lower of the actual charge or fee schedule amount
indicated on the file after the Part B deductible has been met. The CMS will notify
contractors of updates to the MPFS, file names and when the updated files will be
available for retrieval. Upon retrieval, contractors disseminate the fee schedules to their
providers. The file is also available on the CMS Web site in the Public Use Files (PUF)
area.
Addendum A - Chapter 5, Section 20.4 – Coding Guidance for Certain CPT

Codes – All Claims
ICD-10 ASC X12: 09-16-14)
ICD-10-CM - Code and Description

A52.15 Late syphilitic neuropathy
E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy,
unspecified
E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy
E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E09.40 Drug or chemical induced diabetes mellitus with neurological complications
with diabetic neuropathy, unspecified
with diabetic mononeuropathy
with diabetic polyneuropathy
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E10.49 Type 1 diabetes mellitus with other diabetic neurological complication
E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E11.49 Type 2 diabetes mellitus with other diabetic neurological complication
E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.41 Other specified diabetes mellitus with diabetic mononeuropathy
E13.42 Other specified diabetes mellitus with diabetic polyneuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.44 Other specified diabetes mellitus with diabetic amyotrophy
E13.49 Other specified diabetes mellitus with other diabetic neurological complication
E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy
G13.0 Paraneoplastic neuromyopathy and neuropathy
G13.1 Other systemic atrophy primarily affecting central nervous system in neoplastic
disease
G56.40 Causalgia of unspecified upper limb
G56.41 Causalgia of right upper limb
G56.42 Causalgia of left upper limb
G56.90 Unspecified mononeuropathy of unspecified upper limb
G56.91 Unspecified mononeuropathy of right upper limb
G56.92 Unspecified mononeuropathy of left upper limb
G57.10 Meralgia paresthetica, unspecified lower limb
G57.11 Meralgia paresthetica, right lower limb
G57.12 Meralgia paresthetica, left lower limb
G57.20 Lesion of femoral nerve, unspecified lower limb
G57.21 Lesion of femoral nerve, right lower limb
G57.22 Lesion of femoral nerve, left lower limb
G57.30 Lesion of lateral popliteal nerve, unspecified lower limb
G57.31 Lesion of lateral popliteal nerve, right lower limb
G57.32 Lesion of lateral popliteal nerve, left lower limb
G57.40 Lesion of medial popliteal nerve, unspecified lower limb
G57.41 Lesion of medial popliteal nerve, right lower limb
G57.42 Lesion of medial popliteal nerve, left lower limb
G57.60 Lesion of plantar nerve, unspecified lower limb
G57.61 Lesion of plantar nerve, right lower limb
G57.62 Lesion of plantar nerve, left lower limb
G57.70 Causalgia of unspecified lower limb
G57.71 Causalgia of right lower limb
G57.72 Causalgia of left lower limb
G57.80 Other specified mononeuropathies of unspecified lower limb
G57.81 Other specified mononeuropathies of right lower limb
G57.82 Other specified mononeuropathies of left lower limb
G57.90 Unspecified mononeuropathy of unspecified lower limb
G57.91 Unspecified mononeuropathy of right lower limb
G57.92 Unspecified mononeuropathy of left lower limb
G58.7 Mononeuritis multiplex
G58.8 Other specified mononeuropathies
G58.9 Mononeuropathy, unspecified
G59 Mononeuropathy in diseases classified elsewhere
G60.0 Hereditary motor and sensory neuropathy
G60.1 Refsum's disease
G60.2 Neuropathy in association with hereditary ataxia
G60.3 Idiopathic progressive neuropathy
G60.8 Other hereditary and idiopathic neuropathies
G60.9 Hereditary and idiopathic neuropathy, unspecified
G61.0 Guillain-Barre syndrome
G61.1 Serum neuropathy
G62.0 Drug-induced polyneuropathy
G62.1 Alcoholic polyneuropathy
G62.2 Polyneuropathy due to other toxic agents
G62.82 Radiation-induced polyneuropathy
G63 Polyneuropathy in diseases classified elsewhere
G65.0 Sequelae of Guillain-Barré syndrome
G65.1 Sequelae of other inflammatory polyneuropathy
G65.2 Sequelae of toxic polyneuropathy
I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle
I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of
lower right leg
I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf
I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle
I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot
I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of
lower left leg
I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site
I70.331 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with
ulceration of thigh
ulceration of calf
ulceration of ankle
ulceration of heel and midfoot
ulceration of other part of foot
ulceration of other part of lower leg
ulceration of unspecified site
I70.341 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with
ulceration of thigh
ulceration of calf
ulceration of ankle
I70.431 Atherosclerosis of autologous vein bypass graft(s) of the right leg with
ulceration of thigh
ulceration of calf
ulceration of ankle
I70.441 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration
of thigh
of calf
of ankle
of heel and midfoot
of other part of foot
of other part of lower leg
of unspecified site
I70.531 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with
ulceration of thigh
ulceration of calf
ulceration of ankle
I70.541 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with
ulceration of thigh
ulceration of calf
ulceration of ankle
I70.631 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration
of thigh
of calf
of ankle
of heel and midfoot
of unspecified site
I70.641 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of
thigh
calf
ankle
heel and midfoot
other part of foot
other part of lower leg
unspecified site
I70.731 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration
of thigh
of calf
of ankle
of heel and midfoot
of unspecified site
I70.741 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of
thigh
calf
ankle
heel and midfoot
other part of foot
other part of lower leg
unspecified site
L89.000 Pressure ulcer of unspecified elbow, unstageable
L89.001 Pressure ulcer of unspecified elbow, stage 1
L89.009 Pressure ulcer of unspecified elbow, unspecified stage
L89.010 Pressure ulcer of right elbow, unstageable
L89.011 Pressure ulcer of right elbow, stage 1
L89.019 Pressure ulcer of right elbow, unspecified stage
L89.020 Pressure ulcer of left elbow, unstageable
L89.021 Pressure ulcer of left elbow, stage 1
L89.029 Pressure ulcer of left elbow, unspecified stage
L89.100 Pressure ulcer of unspecified part of back, unstageable
L89.101 Pressure ulcer of unspecified part of back, stage 1
L89.109 Pressure ulcer of unspecified part of back, unspecified stage
L89.110 Pressure ulcer of right upper back, unstageable
L89.111 Pressure ulcer of right upper back, stage 1
L89.119 Pressure ulcer of right upper back, unspecified stage
L89.120 Pressure ulcer of left upper back, unstageable
L89.121 Pressure ulcer of left upper back, stage 1
L89.129 Pressure ulcer of left upper back, unspecified stage
L89.130 Pressure ulcer of right lower back, unstageable
L89.131 Pressure ulcer of right lower back, stage 1
L89.139 Pressure ulcer of right lower back, unspecified stage
L89.140 Pressure ulcer of left lower back, unstageable
L89.141 Pressure ulcer of left lower back, stage 1
L89.149 Pressure ulcer of left lower back, unspecified stage
L89.150 Pressure ulcer of sacral region, unstageable
L89.151 Pressure ulcer of sacral region, stage 1
L89.159 Pressure ulcer of sacral region, unspecified stage
L89.200 Pressure ulcer of unspecified hip, unstageable
L89.201 Pressure ulcer of unspecified hip, stage 1
L89.209 Pressure ulcer of unspecified hip, unspecified stage
L89.210 Pressure ulcer of right hip, unstageable
L89.211 Pressure ulcer of right hip, stage 1
L89.219 Pressure ulcer of right hip, unspecified stage
L89.220 Pressure ulcer of left hip, unstageable
L89.221 Pressure ulcer of left hip, stage 1
L89.229 Pressure ulcer of left hip, unspecified stage
L89.300 Pressure ulcer of unspecified buttock, unstageable
L89.301 Pressure ulcer of unspecified buttock, stage 1
L89.309 Pressure ulcer of unspecified buttock, unspecified stage
L89.310 Pressure ulcer of right buttock, unstageable
L89.311 Pressure ulcer of right buttock, stage 1
L89.319 Pressure ulcer of right buttock, unspecified stage
L89.320 Pressure ulcer of left buttock, unstageable
L89.321 Pressure ulcer of left buttock, stage 1
L89.329 Pressure ulcer of left buttock, unspecified stage
L89.40 Pressure ulcer of contiguous site of back, buttock and hip, unspecified stage
L89.41 Pressure ulcer of contiguous site of back, buttock and hip, stage 1
L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unstageable
L89.500 Pressure ulcer of unspecified ankle, unstageable
L89.501 Pressure ulcer of unspecified ankle, stage 1
L89.509 Pressure ulcer of unspecified ankle, unspecified stage
L89.510 Pressure ulcer of right ankle, unstageable
L89.511 Pressure ulcer of right ankle, stage 1
L89.519 Pressure ulcer of right ankle, unspecified stage
L89.520 Pressure ulcer of left ankle, unstageable
L89.521 Pressure ulcer of left ankle, stage 1
L89.529 Pressure ulcer of left ankle, unspecified stage
L89.600 Pressure ulcer of unspecified heel, unstageable
L89.601 Pressure ulcer of unspecified heel, stage 1
L89.609 Pressure ulcer of unspecified heel, unspecified stage
L89.610 Pressure ulcer of right heel, unstageable
L89.611 Pressure ulcer of right heel, stage 1
L89.619 Pressure ulcer of right heel, unspecified stage
L89.620 Pressure ulcer of left heel, unstageable
L89.621 Pressure ulcer of left heel, stage 1
L89.629 Pressure ulcer of left heel, unspecified stage
L89.810 Pressure ulcer of head, unstageable
L89.811 Pressure ulcer of head, stage 1
L89.819 Pressure ulcer of head, unspecified stage
L89.890 Pressure ulcer of other site, unstageable
L89.891 Pressure ulcer of other site, stage 1
L89.899 Pressure ulcer of other site, unspecified stage
L89.90 Pressure ulcer of unspecified site, unspecified stage
L89.91 Pressure ulcer of unspecified site, stage 1
L89.95 Pressure ulcer of unspecified site, unstageable
L97.101 Non-pressure chronic ulcer of unspecified thigh limited to breakdown of skin
L97.102 Non-pressure chronic ulcer of unspecified thigh with fat layer exposed
L97.103 Non-pressure chronic ulcer of unspecified thigh with necrosis of muscle
L97.104 Non-pressure chronic ulcer of unspecified thigh with necrosis of bone
L97.109 Non-pressure chronic ulcer of unspecified thigh with unspecified severity
L97.111 Non-pressure chronic ulcer of right thigh limited to breakdown of skin
L97.112 Non-pressure chronic ulcer of right thigh with fat layer exposed
L97.113 Non-pressure chronic ulcer of right thigh with necrosis of muscle
L97.114 Non-pressure chronic ulcer of right thigh with necrosis of bone
L97.119 Non-pressure chronic ulcer of right thigh with unspecified severity
L97.121 Non-pressure chronic ulcer of left thigh limited to breakdown of skin
L97.122 Non-pressure chronic ulcer of left thigh with fat layer exposed
L97.123 Non-pressure chronic ulcer of left thigh with necrosis of muscle
L97.124 Non-pressure chronic ulcer of left thigh with necrosis of bone
L97.129 Non-pressure chronic ulcer of left thigh with unspecified severity
L97.201 Non-pressure chronic ulcer of unspecified calf limited to breakdown of skin
L97.202 Non-pressure chronic ulcer of unspecified calf with fat layer exposed
L97.203 Non-pressure chronic ulcer of unspecified calf with necrosis of muscle
L97.204 Non-pressure chronic ulcer of unspecified calf with necrosis of bone
L97.209 Non-pressure chronic ulcer of unspecified calf with unspecified severity
L97.211 Non-pressure chronic ulcer of right calf limited to breakdown of skin
L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed
L97.213 Non-pressure chronic ulcer of right calf with necrosis of muscle
L97.214 Non-pressure chronic ulcer of right calf with necrosis of bone
L97.219 Non-pressure chronic ulcer of right calf with unspecified severity
L97.221 Non-pressure chronic ulcer of left calf limited to breakdown of skin
L97.222 Non-pressure chronic ulcer of left calf with fat layer exposed
L97.223 Non-pressure chronic ulcer of left calf with necrosis of muscle
L97.224 Non-pressure chronic ulcer of left calf with necrosis of bone
L97.229 Non-pressure chronic ulcer of left calf with unspecified severity
L97.301 Non-pressure chronic ulcer of unspecified ankle limited to breakdown of skin
L97.302 Non-pressure chronic ulcer of unspecified ankle with fat layer exposed
L97.303 Non-pressure chronic ulcer of unspecified ankle with necrosis of muscle
L97.304 Non-pressure chronic ulcer of unspecified ankle with necrosis of bone
L97.309 Non-pressure chronic ulcer of unspecified ankle with unspecified severity
L97.311 Non-pressure chronic ulcer of right ankle limited to breakdown of skin
L97.312 Non-pressure chronic ulcer of right ankle with fat layer exposed
L97.313 Non-pressure chronic ulcer of right ankle with necrosis of muscle
L97.314 Non-pressure chronic ulcer of right ankle with necrosis of bone
L97.319 Non-pressure chronic ulcer of right ankle with unspecified severity
L97.321 Non-pressure chronic ulcer of left ankle limited to breakdown of skin
L97.322 Non-pressure chronic ulcer of left ankle with fat layer exposed
L97.323 Non-pressure chronic ulcer of left ankle with necrosis of muscle
L97.324 Non-pressure chronic ulcer of left ankle with necrosis of bone
L97.329 Non-pressure chronic ulcer of left ankle with unspecified severity
L97.401 Non-pressure chronic ulcer of unspecified heel and midfoot limited to
breakdown of skin
L97.402 Non-pressure chronic ulcer of unspecified heel and midfoot with fat layer
exposed
L97.403 Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of
muscle
L97.404 Non-pressure chronic ulcer of unspecified heel and midfoot with necrosis of
bone
L97.409 Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified
severity
L97.411 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of
skin
L97.412 Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed
L97.413 Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle
L97.414 Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone
L97.419 Non-pressure chronic ulcer of right heel and midfoot with unspecified severity
L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of
skin
L97.422 Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed
L97.423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle
L97.424 Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone
L97.429 Non-pressure chronic ulcer of left heel and midfoot with unspecified severity
L97.501 Non-pressure chronic ulcer of other part of unspecified foot limited to
breakdown of skin
L97.502 Non-pressure chronic ulcer of other part of unspecified foot with fat layer
exposed
L97.503 Non-pressure chronic ulcer of other part of unspecified foot with necrosis of
muscle
L97.504 Non-pressure chronic ulcer of other part of unspecified foot with necrosis of
bone
L97.509 Non-pressure chronic ulcer of other part of unspecified foot with unspecified
severity
L97.511 Non-pressure chronic ulcer of other part of right foot limited to breakdown of
skin
L97.512 Non-pressure chronic ulcer of other part of right foot with fat layer exposed
L97.513 Non-pressure chronic ulcer of other part of right foot with necrosis of muscle
L97.514 Non-pressure chronic ulcer of other part of right foot with necrosis of bone
L97.519 Non-pressure chronic ulcer of other part of right foot with unspecified severity
L97.521 Non-pressure chronic ulcer of other part of left foot limited to breakdown of
skin
L97.522 Non-pressure chronic ulcer of other part of left foot with fat layer exposed
L97.523 Non-pressure chronic ulcer of other part of left foot with necrosis of muscle
L97.524 Non-pressure chronic ulcer of other part of left foot with necrosis of bone
L97.529 Non-pressure chronic ulcer of other part of left foot with unspecified severity
L97.801 Non-pressure chronic ulcer of other part of unspecified lower leg limited to
breakdown of skin
L97.802 Non-pressure chronic ulcer of other part of unspecified lower leg with fat layer
exposed
L97.803 Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis
of muscle
L97.804 Non-pressure chronic ulcer of other part of unspecified lower leg with necrosis
of bone
L97.809 Non-pressure chronic ulcer of other part of unspecified lower leg with
unspecified severity
L97.811 Non-pressure chronic ulcer of other part of right lower leg limited to
breakdown of skin
L97.812 Non-pressure chronic ulcer of other part of right lower leg with fat layer
exposed
L97.813 Non-pressure chronic ulcer of other part of right lower leg with necrosis of
muscle
L97.814 Non-pressure chronic ulcer of other part of right lower leg with necrosis of
bone
L97.819 Non-pressure chronic ulcer of other part of right lower leg with unspecified
severity
L97.821 Non-pressure chronic ulcer of other part of left lower leg limited to breakdown
of skin
L97.822 Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed
L97.823 Non-pressure chronic ulcer of other part of left lower leg with necrosis of
muscle
L97.824 Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone
L97.829 Non-pressure chronic ulcer of other part of left lower leg with unspecified
severity
L97.901 Non-pressure chronic ulcer of unspecified part of unspecified lower leg limited
to breakdown of skin
L97.902 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with fat
layer exposed
L97.903 Non-pressure chronic ulcer of unspecified part of unspecified lower leg with
necrosis of muscle
necrosis of bone
L97.911 Non-pressure chronic ulcer of unspecified part of right lower leg limited to
breakdown of skin
L97.912 Non-pressure chronic ulcer of unspecified part of right lower leg with fat layer
exposed
L97.913 Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis
of muscle
L97.914 Non-pressure chronic ulcer of unspecified part of right lower leg with necrosis
of bone
L97.919 Non-pressure chronic ulcer of unspecified part of right lower leg with
L97.921 Non-pressure chronic ulcer of unspecified part of left lower leg limited to
breakdown of skin
L97.922 Non-pressure chronic ulcer of unspecified part of left lower leg with fat layer
exposed
L97.923 Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of
muscle
L97.924 Non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of
bone
L97.929 Non-pressure chronic ulcer of unspecified part of left lower leg with
M05.50 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site
M05.511 Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder
M05.512 Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
M05.519 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder
M05.521 Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow
M05.522 Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
M05.529 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow
M05.531 Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist
M05.532 Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
M05.539 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist
M05.541 Rheumatoid polyneuropathy with rheumatoid arthritis of right hand
M05.542 Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
M05.549 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand
M05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
M05.559 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip
M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
M05.569 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee
M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
M05.579 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and
foot
M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
M34.83 Systemic sclerosis with polyneuropathy
O90.0 Disruption of cesarean delivery wound
O90.1 Disruption of perineal obstetric wound
S01.00XA Unspecified open wound of scalp, initial encounter
S01.01XA Laceration without foreign body of scalp, initial encounter
S01.02XA Laceration with foreign body of scalp, initial encounter
S01.03XA Puncture wound without foreign body of scalp, initial encounter
S01.04XA Puncture wound with foreign body of scalp, initial encounter
S01.05XA Open bite of scalp, initial encounter
S01.101A Unspecified open wound of right eyelid and periocular area, initial encounter
S01.102A Unspecified open wound of left eyelid and periocular area, initial encounter
S01.109A Unspecified open wound of unspecified eyelid and periocular area, initial
encounter
S01.111A Laceration without foreign body of right eyelid and periocular area, initial
encounter
S01.112A Laceration without foreign body of left eyelid and periocular area, initial
encounter
S01.119A Laceration without foreign body of unspecified eyelid and periocular area,
initial encounter
S01.119A Laceration without foreign body of unspecified eyelid and periocular area,
initial encounter
S01.121A Laceration with foreign body of right eyelid and periocular area, initial
encounter
S01.122A Laceration with foreign body of left eyelid and periocular area, initial
encounter
S01.129A Laceration with foreign body of unspecified eyelid and periocular area, initial
encounter
S01.129A Laceration with foreign body of unspecified eyelid and periocular area, initial
encounter
S01.131A Puncture wound without foreign body of right eyelid and periocular area,
initial encounter
S01.132A Puncture wound without foreign body of left eyelid and periocular area, initial
encounter
S01.139A Puncture wound without foreign body of unspecified eyelid and periocular
area, initial encounter
S01.141A Puncture wound with foreign body of right eyelid and periocular area, initial
encounter
S01.142A Puncture wound with foreign body of left eyelid and periocular area, initial
encounter
S01.149A Puncture wound with foreign body of unspecified eyelid and periocular area,
initial encounter
S01.151A Open bite of right eyelid and periocular area, initial encounter
S01.152A Open bite of left eyelid and periocular area, initial encounter
S01.159A Open bite of unspecified eyelid and periocular area, initial encounter
S01.20XA Unspecified open wound of nose, initial encounter
S01.21XA Laceration without foreign body of nose, initial encounter
S01.22XA Laceration with foreign body of nose, initial encounter
S01.23XA Puncture wound without foreign body of nose, initial encounter
S01.24XA Puncture wound with foreign body of nose, initial encounter
S01.25XA Open bite of nose, initial encounter
S01.301A Unspecified open wound of right ear, initial encounter
S01.302A Unspecified open wound of left ear, initial encounter
S01.309A Unspecified open wound of unspecified ear, initial encounter
S01.311A Laceration without foreign body of right ear, initial encounter
S01.312A Laceration without foreign body of left ear, initial encounter
S01.319A Laceration without foreign body of unspecified ear, initial encounter
S01.321A Laceration with foreign body of right ear, initial encounter
S01.322A Laceration with foreign body of left ear, initial encounter
S01.329A Laceration with foreign body of unspecified ear, initial encounter
S01.331A Puncture wound without foreign body of right ear, initial encounter
S01.332A Puncture wound without foreign body of left ear, initial encounter
S01.339A Puncture wound without foreign body of unspecified ear, initial encounter
S01.341A Puncture wound with foreign body of right ear, initial encounter
S01.342A Puncture wound with foreign body of left ear, initial encounter
S01.349A Puncture wound with foreign body of unspecified ear, initial encounter
S01.351A Open bite of right ear, initial encounter
S01.352A Open bite of left ear, initial encounter
S01.359A Open bite of unspecified ear, initial encounter
S01.401A Unspecified open wound of right cheek and temporomandibular area, initial
encounter
S01.402A Unspecified open wound of left cheek and temporomandibular area, initial
encounter
S01.409A Unspecified open wound of unspecified cheek and temporomandibular area,
initial encounter
S01.411A Laceration without foreign body of right cheek and temporomandibular area,
initial encounter
S01.412A Laceration without foreign body of left cheek and temporomandibular area,
initial encounter
S01.419A Laceration without foreign body of unspecified cheek and temporomandibular
S01.421A Laceration with foreign body of right cheek and temporomandibular area,
initial encounter
S01.422A Laceration with foreign body of left cheek and temporomandibular area,
initial encounter
S01.429A Laceration with foreign body of unspecified cheek and temporomandibular
S01.431A Puncture wound without foreign body of right cheek and temporomandibular
S01.432A Puncture wound without foreign body of left cheek and temporomandibular
S01.439A Puncture wound without foreign body of unspecified cheek and
temporomandibular area, initial encounter
S01.441A Puncture wound with foreign body of right cheek and temporomandibular
S01.442A Puncture wound with foreign body of left cheek and temporomandibular area,
initial encounter
S01.449A Puncture wound with foreign body of unspecified cheek and
temporomandibular area, initial encounter
S01.451A Open bite of right cheek and temporomandibular area, initial encounter
S01.452A Open bite of left cheek and temporomandibular area, initial encounter
S01.459A Open bite of unspecified cheek and temporomandibular area, initial encounter
S01.501A Unspecified open wound of lip, initial encounter
S01.502A Unspecified open wound of oral cavity, initial encounter
S01.511A Laceration without foreign body of lip, initial encounter
S01.512A Laceration without foreign body of oral cavity, initial encounter
S01.521A Laceration with foreign body of lip, initial encounter
S01.522A Laceration with foreign body of oral cavity, initial encounter
S01.531A Puncture wound without foreign body of lip, initial encounter
S01.532A Puncture wound without foreign body of oral cavity, initial encounter
S01.541A Puncture wound with foreign body of lip, initial encounter
S01.542A Puncture wound with foreign body of oral cavity, initial encounter
S01.551A Open bite of lip, initial encounter
S01.552A Open bite of oral cavity, initial encounter
S01.80XA Unspecified open wound of other part of head, initial encounter
S01.81XA Laceration without foreign body of other part of head, initial encounter
S01.82XA Laceration with foreign body of other part of head, initial encounter
S01.83XA Puncture wound without foreign body of other part of head, initial encounter
S01.84XA Puncture wound with foreign body of other part of head, initial encounter
S01.85XA Open bite of other part of head, initial encounter
S01.90XA Unspecified open wound of unspecified part of head, initial encounter
S01.91XA Laceration without foreign body of unspecified part of head, initial encounter
S01.92XA Laceration with foreign body of unspecified part of head, initial encounter
S01.93XA Puncture wound without foreign body of unspecified part of head, initial
encounter
S01.94XA Puncture wound with foreign body of unspecified part of head, initial
encounter
S01.95XA Open bite of unspecified part of head, initial encounter
S02.5XXA Fracture of tooth (traumatic), initial encounter for closed fracture
S02.5XXB Fracture of tooth (traumatic), initial encounter for open fracture
S03.2XXA Dislocation of tooth, initial encounter
S05.20XA Ocular laceration and rupture with prolapse or loss of intraocular tissue,
unspecified eye, initial encounter
S05.21XA Ocular laceration and rupture with prolapse or loss of intraocular tissue, right
eye, initial encounter
S05.22XA Ocular laceration and rupture with prolapse or loss of intraocular tissue, left
S05.30XA Ocular laceration without prolapse or loss of intraocular tissue, unspecified
S05.31XA Ocular laceration without prolapse or loss of intraocular tissue, right eye,
initial encounter
S05.32XA Ocular laceration without prolapse or loss of intraocular tissue, left eye,
initial encounter
S05.40XA Penetrating wound of orbit with or without foreign body, unspecified eye,
initial encounter
S05.41XA Penetrating wound of orbit with or without foreign body, right eye, initial
encounter
S05.42XA Penetrating wound of orbit with or without foreign body, left eye, initial
encounter
S05.50XA Penetrating wound with foreign body of unspecified eyeball, initial encounter
S05.51XA Penetrating wound with foreign body of right eyeball, initial encounter
S05.52XA Penetrating wound with foreign body of left eyeball, initial encounter
S05.60XA Penetrating wound without foreign body of unspecified eyeball, initial
encounter
S05.61XA Penetrating wound without foreign body of right eyeball, initial encounter
S05.62XA Penetrating wound without foreign body of left eyeball, initial encounter
S05.70XA Avulsion of unspecified eye, initial encounter
S05.71XA Avulsion of right eye, initial encounter
S05.72XA Avulsion of left eye, initial encounter
S05.8X1A Other injuries of right eye and orbit, initial encounter
S05.8X2A Other injuries of left eye and orbit, initial encounter
S05.8X9A Other injuries of unspecified eye and orbit, initial encounter
S05.90XA Unspecified injury of unspecified eye and orbit, initial encounter
S05.91XA Unspecified injury of right eye and orbit, initial encounter
S05.92XA Unspecified injury of left eye and orbit, initial encounter
S08.0XXA Avulsion of scalp, initial encounter
S08.111A Complete traumatic amputation of right ear, initial encounter
S08.112A Complete traumatic amputation of left ear, initial encounter
S08.119A Complete traumatic amputation of unspecified ear, initial encounter
S08.121A Partial traumatic amputation of right ear, initial encounter
S08.122A Partial traumatic amputation of left ear, initial encounter
S08.129A Partial traumatic amputation of unspecified ear, initial encounter
S08.811A Complete traumatic amputation of nose, initial encounter
S08.812A Partial traumatic amputation of nose, initial encounter
S08.89XA Traumatic amputation of other parts of head, initial encounter
S09.12XA Laceration of muscle and tendon of head, initial encounter
S09.20XA Traumatic rupture of unspecified ear drum, initial encounter
S09.21XA Traumatic rupture of right ear drum, initial encounter
S09.22XA Traumatic rupture of left ear drum, initial encounter
S09.301A Unspecified injury of right middle and inner ear, initial encounter
S09.302A Unspecified injury of left middle and inner ear, initial encounter
S09.309A Unspecified injury of unspecified middle and inner ear, initial encounter
S09.311A Primary blast injury of right ear, initial encounter
S09.312A Primary blast injury of left ear, initial encounter
S09.313A Primary blast injury of ear, bilateral, initial encounter
S09.319A Primary blast injury of unspecified ear, initial encounter
S09.391A Other specified injury of right middle and inner ear, initial encounter
S09.392A Other specified injury of left middle and inner ear, initial encounter
S09.399A Other specified injury of unspecified middle and inner ear, initial encounter
S09.8XXA Other specified injuries of head, initial encounter
S09.90XA Unspecified injury of head, initial encounter
S09.91XA Unspecified injury of ear, initial encounter
S09.93XA Unspecified injury of face, initial encounter
S11.011A Laceration without foreign body of larynx, initial encounter
S11.012A Laceration with foreign body of larynx, initial encounter
S11.013A Puncture wound without foreign body of larynx, initial encounter
S11.014A Puncture wound with foreign body of larynx, initial encounter
S11.015A Open bite of larynx, initial encounter
S11.019A Unspecified open wound of larynx, initial encounter
S11.021A Laceration without foreign body of trachea, initial encounter
S11.022A Laceration with foreign body of trachea, initial encounter
S11.023A Puncture wound without foreign body of trachea, initial encounter
S11.024A Puncture wound with foreign body of trachea, initial encounter
S11.025A Open bite of trachea, initial encounter
S11.029A Unspecified open wound of trachea, initial encounter
S11.031A Laceration without foreign body of vocal cord, initial encounter
S11.032A Laceration with foreign body of vocal cord, initial encounter
S11.033A Puncture wound without foreign body of vocal cord, initial encounter
S11.034A Puncture wound with foreign body of vocal cord, initial encounter
S11.035A Open bite of vocal cord, initial encounter
S11.039A Unspecified open wound of vocal cord, initial encounter
S11.10XA Unspecified open wound of thyroid gland, initial encounter
S11.11XA Laceration without foreign body of thyroid gland, initial encounter
S11.12XA Laceration with foreign body of thyroid gland, initial encounter
S11.13XA Puncture wound without foreign body of thyroid gland, initial encounter
S11.14XA Puncture wound with foreign body of thyroid gland, initial encounter
S11.15XA Open bite of thyroid gland, initial encounter
S11.20XA Unspecified open wound of pharynx and cervical esophagus, initial encounter
S11.21XA Laceration without foreign body of pharynx and cervical esophagus, initial
encounter
S11.22XA Laceration with foreign body of pharynx and cervical esophagus, initial
encounter
S11.23XA Puncture wound without foreign body of pharynx and cervical esophagus,
initial encounter
S11.24XA Puncture wound with foreign body of pharynx and cervical esophagus, initial
encounter
S11.25XA Open bite of pharynx and cervical esophagus, initial encounter
S11.80XA Unspecified open wound of other specified part of neck, initial encounter
S11.81XA Laceration without foreign body of other specified part of neck, initial
encounter
S11.82XA Laceration with foreign body of other specified part of neck, initial encounter
S11.83XA Puncture wound without foreign body of other specified part of neck, initial
encounter
S11.84XA Puncture wound with foreign body of other specified part of neck, initial
encounter
S11.85XA Open bite of other specified part of neck, initial encounter
S11.89XA Other open wound of other specified part of neck, initial encounter
S11.90XA Unspecified open wound of unspecified part of neck, initial encounter
S11.91XA Laceration without foreign body of unspecified part of neck, initial encounter
S11.92XA Laceration with foreign body of unspecified part of neck, initial encounter
S11.93XA Puncture wound without foreign body of unspecified part of neck, initial
encounter
S11.94XA Puncture wound with foreign body of unspecified part of neck, initial
encounter
S11.95XA Open bite of unspecified part of neck, initial encounter
S16.2XXA Laceration of muscle, fascia and tendon at neck level, initial encounter
S21.001A Unspecified open wound of right breast, initial encounter
S21.002A Unspecified open wound of left breast, initial encounter
S21.009A Unspecified open wound of unspecified breast, initial encounter
S21.011A Laceration without foreign body of right breast, initial encounter
S21.012A Laceration without foreign body of left breast, initial encounter
S21.019A Laceration without foreign body of unspecified breast, initial encounter
S21.021A Laceration with foreign body of right breast, initial encounter
S21.022A Laceration with foreign body of left breast, initial encounter
S21.029A Laceration with foreign body of unspecified breast, initial encounter
S21.031A Puncture wound without foreign body of right breast, initial encounter
S21.032A Puncture wound without foreign body of left breast, initial encounter
S21.039A Puncture wound without foreign body of unspecified breast, initial encounter
S21.041A Puncture wound with foreign body of right breast, initial encounter
S21.042A Puncture wound with foreign body of left breast, initial encounter
S21.049A Puncture wound with foreign body of unspecified breast, initial encounter
S21.051A Open bite of right breast, initial encounter
S21.052A Open bite of left breast, initial encounter
S21.059A Open bite of unspecified breast, initial encounter
S21.101A Unspecified open wound of right front wall of thorax without penetration into
thoracic cavity, initial encounter
S21.102A Unspecified open wound of left front wall of thorax without penetration into
S21.109A Unspecified open wound of unspecified front wall of thorax without
penetration into thoracic cavity, initial encounter
S21.111A Laceration without foreign body of right front wall of thorax without
S21.112A Laceration without foreign body of left front wall of thorax without
S21.119A Laceration without foreign body of unspecified front wall of thorax without
S21.121A Laceration with foreign body of right front wall of thorax without penetration
into thoracic cavity, initial encounter
S21.122A Laceration with foreign body of left front wall of thorax without penetration
S21.129A Laceration with foreign body of unspecified front wall of thorax without
S21.131A Puncture wound without foreign body of right front wall of thorax without
S21.132A Puncture wound without foreign body of left front wall of thorax without
S21.139A Puncture wound without foreign body of unspecified front wall of thorax
without penetration into thoracic cavity, initial encounter
S21.141A Puncture wound with foreign body of right front wall of thorax without
S21.142A Puncture wound with foreign body of left front wall of thorax without
S21.149A Puncture wound with foreign body of unspecified front wall of thorax without
S21.151A Open bite of right front wall of thorax without penetration into thoracic
cavity, initial encounter
S21.152A Open bite of left front wall of thorax without penetration into thoracic cavity,
initial encounter
S21.159A Open bite of unspecified front wall of thorax without penetration into thoracic
S21.201A Unspecified open wound of right back wall of thorax without penetration into
S21.202A Unspecified open wound of left back wall of thorax without penetration into
S21.209A Unspecified open wound of unspecified back wall of thorax without
S21.211A Laceration without foreign body of right back wall of thorax without
S21.212A Laceration without foreign body of left back wall of thorax without
S21.219A Laceration without foreign body of unspecified back wall of thorax without
S21.221A Laceration with foreign body of right back wall of thorax without penetration
S21.222A Laceration with foreign body of left back wall of thorax without penetration
S21.229A Laceration with foreign body of unspecified back wall of thorax without
S21.231A Puncture wound without foreign body of right back wall of thorax without
S21.232A Puncture wound without foreign body of left back wall of thorax without
S21.239A Puncture wound without foreign body of unspecified back wall of thorax
without penetration into thoracic cavity, initial encounter
S21.241A Puncture wound with foreign body of right back wall of thorax without
S21.242A Puncture wound with foreign body of left back wall of thorax without
S21.249A Puncture wound with foreign body of unspecified back wall of thorax without
S21.251A Open bite of right back wall of thorax without penetration into thoracic
S21.252A Open bite of left back wall of thorax without penetration into thoracic cavity,
initial encounter
S21.259A Open bite of unspecified back wall of thorax without penetration into thoracic
S21.90XA Unspecified open wound of unspecified part of thorax, initial encounter
S21.91XA Laceration without foreign body of unspecified part of thorax, initial
encounter
S21.92XA Laceration with foreign body of unspecified part of thorax, initial encounter
S21.93XA Puncture wound without foreign body of unspecified part of thorax, initial
encounter
S21.94XA Puncture wound with foreign body of unspecified part of thorax, initial
encounter
S21.95XA Open bite of unspecified part of thorax, initial encounter
S28.1XXA Traumatic amputation (partial) of part of thorax, except breast, initial
encounter
S28.211A Complete traumatic amputation of right breast, initial encounter
S28.212A Complete traumatic amputation of left breast, initial encounter
S28.219A Complete traumatic amputation of unspecified breast, initial encounter
S28.221A Partial traumatic amputation of right breast, initial encounter
S28.222A Partial traumatic amputation of left breast, initial encounter
S28.229A Partial traumatic amputation of unspecified breast, initial encounter
S29.021A Laceration of muscle and tendon of front wall of thorax, initial encounter
S29.022A Laceration of muscle and tendon of back wall of thorax, initial encounter
S29.029A Laceration of muscle and tendon of unspecified wall of thorax, initial
encounter
S31.000A Unspecified open wound of lower back and pelvis without penetration into
retroperitoneum, initial encounter
S31.010A Laceration without foreign body of lower back and pelvis without penetration
into retroperitoneum, initial encounter
S31.020A Laceration with foreign body of lower back and pelvis without penetration
into retroperitoneum, initial encounter
S31.030A Puncture wound without foreign body of lower back and pelvis without
penetration into retroperitoneum, initial encounter
S31.040A Puncture wound with foreign body of lower back and pelvis without
penetration into retroperitoneum, initial encounter
S31.050A Open bite of lower back and pelvis without penetration into retroperitoneum,
initial encounter
S31.100A Unspecified open wound of abdominal wall, right upper quadrant without
penetration into peritoneal cavity, initial encounter
S31.101A Unspecified open wound of abdominal wall, left upper quadrant without
S31.102A Unspecified open wound of abdominal wall, epigastric region without
S31.103A Unspecified open wound of abdominal wall, right lower quadrant without
S31.104A Unspecified open wound of abdominal wall, left lower quadrant without
S31.105A Unspecified open wound of abdominal wall, periumbilic region without
S31.109A Unspecified open wound of abdominal wall, unspecified quadrant without
S31.110A Laceration without foreign body of abdominal wall, right upper quadrant
without penetration into peritoneal cavity, initial encounter
S31.111A Laceration without foreign body of abdominal wall, left upper quadrant
S31.112A Laceration without foreign body of abdominal wall, epigastric region without
S31.113A Laceration without foreign body of abdominal wall, right lower quadrant
S31.114A Laceration without foreign body of abdominal wall, left lower quadrant
S31.115A Laceration without foreign body of abdominal wall, periumbilic region
S31.119A Laceration without foreign body of abdominal wall, unspecified quadrant
S31.120A Laceration of abdominal wall with foreign body, right upper quadrant without
S31.121A Laceration of abdominal wall with foreign body, left upper quadrant without
S31.122A Laceration of abdominal wall with foreign body, epigastric region without
S31.123A Laceration of abdominal wall with foreign body, right lower quadrant without
S31.124A Laceration of abdominal wall with foreign body, left lower quadrant without
S31.125A Laceration of abdominal wall with foreign body, periumbilic region without
S31.129A Laceration of abdominal wall with foreign body, unspecified quadrant without
S31.130A Puncture wound of abdominal wall without foreign body, right upper
quadrant without penetration into peritoneal cavity, initial encounter
S31.131A Puncture wound of abdominal wall without foreign body, left upper quadrant
S31.132A Puncture wound of abdominal wall without foreign body, epigastric region
S31.133A Puncture wound of abdominal wall without foreign body, right lower
S31.134A Puncture wound of abdominal wall without foreign body, left lower quadrant
S31.135A Puncture wound of abdominal wall without foreign body, periumbilic region
S31.139A Puncture wound of abdominal wall without foreign body, unspecified
S31.140A Puncture wound of abdominal wall with foreign body, right upper quadrant
S31.141A Puncture wound of abdominal wall with foreign body, left upper quadrant
S31.142A Puncture wound of abdominal wall with foreign body, epigastric region
S31.143A Puncture wound of abdominal wall with foreign body, right lower quadrant
S31.144A Puncture wound of abdominal wall with foreign body, left lower quadrant
S31.145A Puncture wound of abdominal wall with foreign body, periumbilic region
S31.149A Puncture wound of abdominal wall with foreign body, unspecified quadrant
S31.150A Open bite of abdominal wall, right upper quadrant without penetration into
peritoneal cavity, initial encounter
S31.151A Open bite of abdominal wall, left upper quadrant without penetration into
S31.152A Open bite of abdominal wall, epigastric region without penetration into
S31.153A Open bite of abdominal wall, right lower quadrant without penetration into
S31.154A Open bite of abdominal wall, left lower quadrant without penetration into
S31.155A Open bite of abdominal wall, periumbilic region without penetration into
S31.159A Open bite of abdominal wall, unspecified quadrant without penetration into
S31.20XA Unspecified open wound of penis, initial encounter
S31.21XA Laceration without foreign body of penis, initial encounter
S31.22XA Laceration with foreign body of penis, initial encounter
S31.23XA Puncture wound without foreign body of penis, initial encounter
S31.24XA Puncture wound with foreign body of penis, initial encounter
S31.25XA Open bite of penis, initial encounter
S31.30XA Unspecified open wound of scrotum and testes, initial encounter
S31.31XA Laceration without foreign body of scrotum and testes, initial encounter
S31.32XA Laceration with foreign body of scrotum and testes, initial encounter
S31.33XA Puncture wound without foreign body of scrotum and testes, initial encounter
S31.34XA Puncture wound with foreign body of scrotum and testes, initial encounter
S31.35XA Open bite of scrotum and testes, initial encounter
S31.40XA Unspecified open wound of vagina and vulva, initial encounter
S31.41XA Laceration without foreign body of vagina and vulva, initial encounter
S31.42XA Laceration with foreign body of vagina and vulva, initial encounter
S31.43XA Puncture wound without foreign body of vagina and vulva, initial encounter
S31.44XA Puncture wound with foreign body of vagina and vulva, initial encounter
S31.45XA Open bite of vagina and vulva, initial encounter
S31.501A Unspecified open wound of unspecified external genital organs, male, initial
encounter
S31.502A Unspecified open wound of unspecified external genital organs, female, initial
encounter
S31.511A Laceration without foreign body of unspecified external genital organs, male,
initial encounter
S31.512A Laceration without foreign body of unspecified external genital organs,
female, initial encounter
S31.521A Laceration with foreign body of unspecified external genital organs, male,
initial encounter
S31.522A Laceration with foreign body of unspecified external genital organs, female,
initial encounter
S31.531A Puncture wound without foreign body of unspecified external genital organs,
male, initial encounter
S31.532A Puncture wound without foreign body of unspecified external genital organs,
S31.541A Puncture wound with foreign body of unspecified external genital organs,
male, initial encounter
S31.542A Puncture wound with foreign body of unspecified external genital organs,
S31.551A Open bite of unspecified external genital organs, male, initial encounter
S31.552A Open bite of unspecified external genital organs, female, initial encounter
S31.801A Laceration without foreign body of unspecified buttock, initial encounter
S31.802A Laceration with foreign body of unspecified buttock, initial encounter
S31.803A Puncture wound without foreign body of unspecified buttock, initial
encounter
S31.804A Puncture wound with foreign body of unspecified buttock, initial encounter
S31.805A Open bite of unspecified buttock, initial encounter
S31.809A Unspecified open wound of unspecified buttock, initial encounter
S31.811A Laceration without foreign body of right buttock, initial encounter
S31.812A Laceration with foreign body of right buttock, initial encounter
S31.813A Puncture wound without foreign body of right buttock, initial encounter
S31.814A Puncture wound with foreign body of right buttock, initial encounter
S31.815A Open bite of right buttock, initial encounter
S31.819A Unspecified open wound of right buttock, initial encounter
S31.821A Laceration without foreign body of left buttock, initial encounter
S31.822A Laceration with foreign body of left buttock, initial encounter
S31.823A Puncture wound without foreign body of left buttock, initial encounter
S31.824A Puncture wound with foreign body of left buttock, initial encounter
S31.825A Open bite of left buttock, initial encounter
S31.829A Unspecified open wound of left buttock, initial encounter
S31.831A Laceration without foreign body of anus, initial encounter
S31.832A Laceration with foreign body of anus, initial encounter
S31.833A Puncture wound without foreign body of anus, initial encounter
S31.834A Puncture wound with foreign body of anus, initial encounter
S31.835A Open bite of anus, initial encounter
S31.839A Unspecified open wound of anus, initial encounter
S38.211A Complete traumatic amputation of female external genital organs, initial
encounter
S38.212A Partial traumatic amputation of female external genital organs, initial
encounter
S38.221A Complete traumatic amputation of penis, initial encounter
S38.222A Partial traumatic amputation of penis, initial encounter
S38.231A Complete traumatic amputation of scrotum and testis, initial encounter
S38.232A Partial traumatic amputation of scrotum and testis, initial encounter
S38.3XXA Transection (partial) of abdomen, initial encounter
S39.021A Laceration of muscle, fascia and tendon of abdomen, initial encounter
S39.022A Laceration of muscle, fascia and tendon of lower back, initial encounter
S39.023A Laceration of muscle, fascia and tendon of pelvis, initial encounter
S41.001A Unspecified open wound of right shoulder, initial encounter
S41.002A Unspecified open wound of left shoulder, initial encounter
S41.009A Unspecified open wound of unspecified shoulder, initial encounter
S41.011A Laceration without foreign body of right shoulder, initial encounter
S41.012A Laceration without foreign body of left shoulder, initial encounter
S41.019A Laceration without foreign body of unspecified shoulder, initial encounter
S41.021A Laceration with foreign body of right shoulder, initial encounter
S41.022A Laceration with foreign body of left shoulder, initial encounter
S41.029A Laceration with foreign body of unspecified shoulder, initial encounter
S41.031A Puncture wound without foreign body of right shoulder, initial encounter
S41.032A Puncture wound without foreign body of left shoulder, initial encounter
S41.039A Puncture wound without foreign body of unspecified shoulder, initial
encounter
S41.041A Puncture wound with foreign body of right shoulder, initial encounter
S41.042A Puncture wound with foreign body of left shoulder, initial encounter
S41.049A Puncture wound with foreign body of unspecified shoulder, initial encounter
S41.051A Open bite of right shoulder, initial encounter
S41.052A Open bite of left shoulder, initial encounter
S41.059A Open bite of unspecified shoulder, initial encounter
S41.101A Unspecified open wound of right upper arm, initial encounter
S41.102A Unspecified open wound of left upper arm, initial encounter
S41.109A Unspecified open wound of unspecified upper arm, initial encounter
S41.111A Laceration without foreign body of right upper arm, initial encounter
S41.112A Laceration without foreign body of left upper arm, initial encounter
S41.119A Laceration without foreign body of unspecified upper arm, initial encounter
S41.121A Laceration with foreign body of right upper arm, initial encounter
S41.122A Laceration with foreign body of left upper arm, initial encounter
S41.129A Laceration with foreign body of unspecified upper arm, initial encounter
S41.131A Puncture wound without foreign body of right upper arm, initial encounter
S41.132A Puncture wound without foreign body of left upper arm, initial encounter
S41.139A Puncture wound without foreign body of unspecified upper arm, initial
encounter
S41.141A Puncture wound with foreign body of right upper arm, initial encounter
S41.142A Puncture wound with foreign body of left upper arm, initial encounter
S41.149A Puncture wound with foreign body of unspecified upper arm, initial encounter
S41.151A Open bite of right upper arm, initial encounter
S41.152A Open bite of left upper arm, initial encounter
S41.159A Open bite of unspecified upper arm, initial encounter
S46.021A Laceration of muscle(s) and tendon(s) of the rotator cuff of right shoulder,
initial encounter
S46.022A Laceration of muscle(s) and tendon(s) of the rotator cuff of left shoulder,
initial encounter
S46.029A Laceration of muscle(s) and tendon(s) of the rotator cuff of unspecified
shoulder, initial encounter
S46.121A Laceration of muscle, fascia and tendon of long head of biceps, right arm,
initial encounter
S46.122A Laceration of muscle, fascia and tendon of long head of biceps, left arm,
initial encounter
S46.129A Laceration of muscle, fascia and tendon of long head of biceps, unspecified
arm, initial encounter
S46.221A Laceration of muscle, fascia and tendon of other parts of biceps, right arm,
initial encounter
S46.222A Laceration of muscle, fascia and tendon of other parts of biceps, left arm,
initial encounter
S46.229A Laceration of muscle, fascia and tendon of other parts of biceps, unspecified
S46.321A Laceration of muscle, fascia and tendon of triceps, right arm, initial encounter
S46.322A Laceration of muscle, fascia and tendon of triceps, left arm, initial encounter
S46.329A Laceration of muscle, fascia and tendon of triceps, unspecified arm, initial
encounter
S46.821A Laceration of other muscles, fascia and tendons at shoulder and upper arm
level, right arm, initial encounter
level, left arm, initial encounter
level, unspecified arm, initial encounter
S46.921A Laceration of unspecified muscle, fascia and tendon at shoulder and upper
arm level, right arm, initial encounter
arm level, left arm, initial encounter
arm level, unspecified arm, initial encounter
S48.011A Complete traumatic amputation at right shoulder joint, initial encounter
S48.012A Complete traumatic amputation at left shoulder joint, initial encounter
S48.019A Complete traumatic amputation at unspecified shoulder joint, initial encounter
S48.021A Partial traumatic amputation at right shoulder joint, initial encounter
S48.022A Partial traumatic amputation at left shoulder joint, initial encounter
S48.029A Partial traumatic amputation at unspecified shoulder joint, initial encounter
S48.111A Complete traumatic amputation at level between right shoulder and elbow,
initial encounter
S48.112A Complete traumatic amputation at level between left shoulder and elbow,
initial encounter
S48.119A Complete traumatic amputation at level between unspecified shoulder and
elbow, initial encounter
S48.121A Partial traumatic amputation at level between right shoulder and elbow, initial
encounter
S48.122A Partial traumatic amputation at level between left shoulder and elbow, initial
encounter
S48.129A Partial traumatic amputation at level between unspecified shoulder and elbow,
initial encounter
S48.911A Complete traumatic amputation of right shoulder and upper arm, level
unspecified, initial encounter
S48.912A Complete traumatic amputation of left shoulder and upper arm, level
S48.919A Complete traumatic amputation of unspecified shoulder and upper arm, level
S48.921A Partial traumatic amputation of right shoulder and upper arm, level
S48.922A Partial traumatic amputation of left shoulder and upper arm, level unspecified,
initial encounter
S48.929A Partial traumatic amputation of unspecified shoulder and upper arm, level
S51.001A Unspecified open wound of right elbow, initial encounter
S51.002A Unspecified open wound of left elbow, initial encounter
S51.009A Unspecified open wound of unspecified elbow, initial encounter
S51.011A Laceration without foreign body of right elbow, initial encounter
S51.012A Laceration without foreign body of left elbow, initial encounter
S51.019A Laceration without foreign body of unspecified elbow, initial encounter
S51.021A Laceration with foreign body of right elbow, initial encounter
S51.022A Laceration with foreign body of left elbow, initial encounter
S51.029A Laceration with foreign body of unspecified elbow, initial encounter
S51.031A Puncture wound without foreign body of right elbow, initial encounter
S51.032A Puncture wound without foreign body of left elbow, initial encounter
S51.039A Puncture wound without foreign body of unspecified elbow, initial encounter
S51.041A Puncture wound with foreign body of right elbow, initial encounter
S51.042A Puncture wound with foreign body of left elbow, initial encounter
S51.049A Puncture wound with foreign body of unspecified elbow, initial encounter
S51.051A Open bite, right elbow, initial encounter
S51.052A Open bite, left elbow, initial encounter
S51.059A Open bite, unspecified elbow, initial encounter
S51.801A Unspecified open wound of right forearm, initial encounter
S51.802A Unspecified open wound of left forearm, initial encounter
S51.809A Unspecified open wound of unspecified forearm, initial encounter
S51.811A Laceration without foreign body of right forearm, initial encounter
S51.812A Laceration without foreign body of left forearm, initial encounter
S51.819A Laceration without foreign body of unspecified forearm, initial encounter
S51.821A Laceration with foreign body of right forearm, initial encounter
S51.822A Laceration with foreign body of left forearm, initial encounter
S51.829A Laceration with foreign body of unspecified forearm, initial encounter
S51.831A Puncture wound without foreign body of right forearm, initial encounter
S51.832A Puncture wound without foreign body of left forearm, initial encounter
S51.839A Puncture wound without foreign body of unspecified forearm, initial
encounter
S51.841A Puncture wound with foreign body of right forearm, initial encounter
S51.842A Puncture wound with foreign body of left forearm, initial encounter
S51.849A Puncture wound with foreign body of unspecified forearm, initial encounter
S51.851A Open bite of right forearm, initial encounter
S51.852A Open bite of left forearm, initial encounter
S51.859A Open bite of unspecified forearm, initial encounter
S56.021A Laceration of flexor muscle, fascia and tendon of right thumb at forearm
level, initial encounter
S56.022A Laceration of flexor muscle, fascia and tendon of left thumb at forearm level,
initial encounter
S56.029A Laceration of flexor muscle, fascia and tendon of unspecified thumb at
forearm level, initial encounter
S56.121A Laceration of flexor muscle, fascia and tendon of right index finger at forearm
S56.122A Laceration of flexor muscle, fascia and tendon of left index finger at forearm
S56.123A Laceration of flexor muscle, fascia and tendon of right middle finger at
S56.124A Laceration of flexor muscle, fascia and tendon of left middle finger at forearm
S56.125A Laceration of flexor muscle, fascia and tendon of right ring finger at forearm
S56.126A Laceration of flexor muscle, fascia and tendon of left ring finger at forearm
S56.127A Laceration of flexor muscle, fascia and tendon of right little finger at forearm
S56.128A Laceration of flexor muscle, fascia and tendon of left little finger at forearm
S56.129A Laceration of flexor muscle, fascia and tendon of unspecified finger at
S56.221A Laceration of other flexor muscle, fascia and tendon at forearm level, right
S56.222A Laceration of other flexor muscle, fascia and tendon at forearm level, left arm,
initial encounter
S56.229A Laceration of other flexor muscle, fascia and tendon at forearm level,
unspecified arm, initial encounter
S56.321A Laceration of extensor or abductor muscles, fascia and tendons of right thumb
at forearm level, initial encounter
S56.322A Laceration of extensor or abductor muscles, fascia and tendons of left thumb
at forearm level, initial encounter
S56.329A Laceration of extensor or abductor muscles, fascia and tendons of unspecified
thumb at forearm level, initial encounter
S56.421A Laceration of extensor muscle, fascia and tendon of right index finger at
S56.422A Laceration of extensor muscle, fascia and tendon of left index finger at
S56.423A Laceration of extensor muscle, fascia and tendon of right middle finger at
S56.424A Laceration of extensor muscle, fascia and tendon of left middle finger at
S56.425A Laceration of extensor muscle, fascia and tendon of right ring finger at
S56.426A Laceration of extensor muscle, fascia and tendon of left ring finger at forearm
S56.427A Laceration of extensor muscle, fascia and tendon of right little finger at
S56.428A Laceration of extensor muscle, fascia and tendon of left little finger at forearm
S56.429A Laceration of extensor muscle, fascia and tendon of unspecified finger at
S56.521A Laceration of other extensor muscle, fascia and tendon at forearm level, right
S56.522A Laceration of other extensor muscle, fascia and tendon at forearm level, left
S56.529A Laceration of other extensor muscle, fascia and tendon at forearm level,
S56.821A Laceration of other muscles, fascia and tendons at forearm level, right arm,
initial encounter
S56.822A Laceration of other muscles, fascia and tendons at forearm level, left arm,
initial encounter
S56.829A Laceration of other muscles, fascia and tendons at forearm level, unspecified
S56.921A Laceration of unspecified muscles, fascia and tendons at forearm level, right
S56.922A Laceration of unspecified muscles, fascia and tendons at forearm level, left
S56.929A Laceration of unspecified muscles, fascia and tendons at forearm level,
S58.011A Complete traumatic amputation at elbow level, right arm, initial encounter
S58.012A Complete traumatic amputation at elbow level, left arm, initial encounter
S58.019A Complete traumatic amputation at elbow level, unspecified arm, initial
encounter
S58.021A Partial traumatic amputation at elbow level, right arm, initial encounter
S58.022A Partial traumatic amputation at elbow level, left arm, initial encounter
S58.029A Partial traumatic amputation at elbow level, unspecified arm, initial encounter
S58.111A Complete traumatic amputation at level between elbow and wrist, right arm,
initial encounter
S58.112A Complete traumatic amputation at level between elbow and wrist, left arm,
initial encounter
S58.119A Complete traumatic amputation at level between elbow and wrist, unspecified
S58.121A Partial traumatic amputation at level between elbow and wrist, right arm,
initial encounter
S58.122A Partial traumatic amputation at level between elbow and wrist, left arm, initial
encounter
S58.129A Partial traumatic amputation at level between elbow and wrist, unspecified
S58.911A Complete traumatic amputation of right forearm, level unspecified, initial
encounter
S58.912A Complete traumatic amputation of left forearm, level unspecified, initial
encounter
S58.919A Complete traumatic amputation of unspecified forearm, level unspecified,
initial encounter
S58.921A Partial traumatic amputation of right forearm, level unspecified, initial
encounter
S58.922A Partial traumatic amputation of left forearm, level unspecified, initial
encounter
S58.929A Partial traumatic amputation of unspecified forearm, level unspecified, initial
encounter
S61.001A Unspecified open wound of right thumb without damage to nail, initial
encounter
S61.002A Unspecified open wound of left thumb without damage to nail, initial
encounter
S61.009A Unspecified open wound of unspecified thumb without damage to nail, initial
encounter
S61.011A Laceration without foreign body of right thumb without damage to nail, initial
encounter
S61.012A Laceration without foreign body of left thumb without damage to nail, initial
encounter
S61.019A Laceration without foreign body of unspecified thumb without damage to
nail, initial encounter
S61.021A Laceration with foreign body of right thumb without damage to nail, initial
encounter
S61.022A Laceration with foreign body of left thumb without damage to nail, initial
encounter
S61.029A Laceration with foreign body of unspecified thumb without damage to nail,
initial encounter
S61.031A Puncture wound without foreign body of right thumb without damage to nail,
initial encounter
S61.032A Puncture wound without foreign body of left thumb without damage to nail,
initial encounter
S61.039A Puncture wound without foreign body of unspecified thumb without damage
to nail, initial encounter
S61.041A Puncture wound with foreign body of right thumb without damage to nail,
initial encounter
S61.042A Puncture wound with foreign body of left thumb without damage to nail,
initial encounter
S61.049A Puncture wound with foreign body of unspecified thumb without damage to
S61.051A Open bite of right thumb without damage to nail, initial encounter
S61.052A Open bite of left thumb without damage to nail, initial encounter
S61.059A Open bite of unspecified thumb without damage to nail, initial encounter
S61.101A Unspecified open wound of right thumb with damage to nail, initial encounter
S61.102A Unspecified open wound of left thumb with damage to nail, initial encounter
S61.109A Unspecified open wound of unspecified thumb with damage to nail, initial
encounter
S61.109A Unspecified open wound of unspecified thumb with damage to nail, initial
encounter
S61.111A Laceration without foreign body of right thumb with damage to nail, initial
encounter
S61.112A Laceration without foreign body of left thumb with damage to nail, initial
encounter
S61.119A Laceration without foreign body of unspecified thumb with damage to nail,
initial encounter
S61.121A Laceration with foreign body of right thumb with damage to nail, initial
encounter
S61.122A Laceration with foreign body of left thumb with damage to nail, initial
encounter
S61.129A Laceration with foreign body of unspecified thumb with damage to nail,
initial encounter
S61.131A Puncture wound without foreign body of right thumb with damage to nail,
initial encounter
S61.132A Puncture wound without foreign body of left thumb with damage to nail,
initial encounter
S61.139A Puncture wound without foreign body of unspecified thumb with damage to
S61.141A Puncture wound with foreign body of right thumb with damage to nail, initial
encounter
S61.142A Puncture wound with foreign body of left thumb with damage to nail, initial
encounter
S61.149A Puncture wound with foreign body of unspecified thumb with damage to nail,
initial encounter
S61.151A Open bite of right thumb with damage to nail, initial encounter
S61.152A Open bite of left thumb with damage to nail, initial encounter
S61.159A Open bite of unspecified thumb with damage to nail, initial encounter
S61.200A Unspecified open wound of right index finger without damage to nail, initial
encounter
S61.201A Unspecified open wound of left index finger without damage to nail, initial
encounter
S61.202A Unspecified open wound of right middle finger without damage to nail, initial
encounter
S61.203A Unspecified open wound of left middle finger without damage to nail, initial
encounter
S61.204A Unspecified open wound of right ring finger without damage to nail, initial
encounter
S61.205A Unspecified open wound of left ring finger without damage to nail, initial
encounter
S61.206A Unspecified open wound of right little finger without damage to nail, initial
encounter
S61.207A Unspecified open wound of left little finger without damage to nail, initial
encounter
S61.208A Unspecified open wound of other finger without damage to nail, initial
encounter
S61.209A Unspecified open wound of unspecified finger without damage to nail, initial
encounter
S61.209A Unspecified open wound of unspecified finger without damage to nail, initial
encounter
S61.210A Laceration without foreign body of right index finger without damage to nail,
initial encounter
S61.211A Laceration without foreign body of left index finger without damage to nail,
initial encounter
S61.212A Laceration without foreign body of right middle finger without damage to
S61.213A Laceration without foreign body of left middle finger without damage to nail,
initial encounter
S61.214A Laceration without foreign body of right ring finger without damage to nail,
initial encounter
S61.215A Laceration without foreign body of left ring finger without damage to nail,
initial encounter
S61.216A Laceration without foreign body of right little finger without damage to nail,
initial encounter
S61.217A Laceration without foreign body of left little finger without damage to nail,
initial encounter
S61.218A Laceration without foreign body of other finger without damage to nail, initial
encounter
S61.219A Laceration without foreign body of unspecified finger without damage to nail,
initial encounter
S61.220A Laceration with foreign body of right index finger without damage to nail,
initial encounter
S61.221A Laceration with foreign body of left index finger without damage to nail,
initial encounter
S61.222A Laceration with foreign body of right middle finger without damage to nail,
initial encounter
S61.223A Laceration with foreign body of left middle finger without damage to nail,
initial encounter
S61.224A Laceration with foreign body of right ring finger without damage to nail,
initial encounter
S61.225A Laceration with foreign body of left ring finger without damage to nail, initial
encounter
S61.226A Laceration with foreign body of right little finger without damage to nail,
initial encounter
S61.227A Laceration with foreign body of left little finger without damage to nail, initial
encounter
S61.228A Laceration with foreign body of other finger without damage to nail, initial
encounter
S61.229A Laceration with foreign body of unspecified finger without damage to nail,
initial encounter
S61.230A Puncture wound without foreign body of right index finger without damage to
S61.231A Puncture wound without foreign body of left index finger without damage to
S61.232A Puncture wound without foreign body of right middle finger without damage
S61.233A Puncture wound without foreign body of left middle finger without damage to
S61.234A Puncture wound without foreign body of right ring finger without damage to
S61.235A Puncture wound without foreign body of left ring finger without damage to
S61.236A Puncture wound without foreign body of right little finger without damage to
S61.237A Puncture wound without foreign body of left little finger without damage to
S61.238A Puncture wound without foreign body of other finger without damage to nail,
initial encounter
S61.239A Puncture wound without foreign body of unspecified finger without damage
S61.240A Puncture wound with foreign body of right index finger without damage to
S61.241A Puncture wound with foreign body of left index finger without damage to
S61.242A Puncture wound with foreign body of right middle finger without damage to
S61.243A Puncture wound with foreign body of left middle finger without damage to
S61.244A Puncture wound with foreign body of right ring finger without damage to nail,
initial encounter
S61.245A Puncture wound with foreign body of left ring finger without damage to nail,
initial encounter
S61.246A Puncture wound with foreign body of right little finger without damage to
S61.247A Puncture wound with foreign body of left little finger without damage to nail,
initial encounter
S61.248A Puncture wound with foreign body of other finger without damage to nail,
initial encounter
S61.249A Puncture wound with foreign body of unspecified finger without damage to
S61.250A Open bite of right index finger without damage to nail, initial encounter
S61.251A Open bite of left index finger without damage to nail, initial encounter
S61.252A Open bite of right middle finger without damage to nail, initial encounter
S61.253A Open bite of left middle finger without damage to nail, initial encounter
S61.254A Open bite of right ring finger without damage to nail, initial encounter
S61.255A Open bite of left ring finger without damage to nail, initial encounter
S61.256A Open bite of right little finger without damage to nail, initial encounter
S61.257A Open bite of left little finger without damage to nail, initial encounter
S61.258A Open bite of other finger without damage to nail, initial encounter
S61.259A Open bite of unspecified finger without damage to nail, initial encounter
S61.300A Unspecified open wound of right index finger with damage to nail, initial
encounter
S61.301A Unspecified open wound of left index finger with damage to nail, initial
encounter
S61.302A Unspecified open wound of right middle finger with damage to nail, initial
encounter
S61.303A Unspecified open wound of left middle finger with damage to nail, initial
encounter
S61.304A Unspecified open wound of right ring finger with damage to nail, initial
encounter
S61.305A Unspecified open wound of left ring finger with damage to nail, initial
encounter
S61.306A Unspecified open wound of right little finger with damage to nail, initial
encounter
S61.307A Unspecified open wound of left little finger with damage to nail, initial
encounter
S61.308A Unspecified open wound of other finger with damage to nail, initial encounter
S61.309A Unspecified open wound of unspecified finger with damage to nail, initial
encounter
S61.310A Laceration without foreign body of right index finger with damage to nail,
initial encounter
S61.311A Laceration without foreign body of left index finger with damage to nail,
initial encounter
S61.312A Laceration without foreign body of right middle finger with damage to nail,
initial encounter
S61.313A Laceration without foreign body of left middle finger with damage to nail,
initial encounter
S61.314A Laceration without foreign body of right ring finger with damage to nail,
initial encounter
S61.315A Laceration without foreign body of left ring finger with damage to nail, initial
encounter
S61.316A Laceration without foreign body of right little finger with damage to nail,
initial encounter
S61.317A Laceration without foreign body of left little finger with damage to nail, initial
encounter
S61.318A Laceration without foreign body of other finger with damage to nail, initial
encounter
S61.319A Laceration without foreign body of unspecified finger with damage to nail,
initial encounter
S61.320A Laceration with foreign body of right index finger with damage to nail, initial
encounter
S61.321A Laceration with foreign body of left index finger with damage to nail, initial
encounter
S61.322A Laceration with foreign body of right middle finger with damage to nail,
initial encounter
S61.323A Laceration with foreign body of left middle finger with damage to nail, initial
encounter
S61.324A Laceration with foreign body of right ring finger with damage to nail, initial
encounter
S61.325A Laceration with foreign body of left ring finger with damage to nail, initial
encounter
S61.326A Laceration with foreign body of right little finger with damage to nail, initial
encounter
S61.327A Laceration with foreign body of left little finger with damage to nail, initial
encounter
S61.328A Laceration with foreign body of other finger with damage to nail, initial
encounter
S61.329A Laceration with foreign body of unspecified finger with damage to nail, initial
encounter
S61.330A Puncture wound without foreign body of right index finger with damage to
S61.331A Puncture wound without foreign body of left index finger with damage to
S61.340A Puncture wound with foreign body of right index finger with damage to nail,
initial encounter
S61.341A Puncture wound with foreign body of left index finger with damage to nail,
initial encounter
S61.342A Puncture wound with foreign body of right middle finger with damage to nail,
initial encounter
S61.343A Puncture wound with foreign body of left middle finger with damage to nail,
initial encounter
S61.344A Puncture wound with foreign body of right ring finger with damage to nail,
initial encounter
S61.345A Puncture wound with foreign body of left ring finger with damage to nail,
initial encounter
S61.346A Puncture wound with foreign body of right little finger with damage to nail,
initial encounter
S61.347A Puncture wound with foreign body of left little finger with damage to nail,
initial encounter
S61.348A Puncture wound with foreign body of other finger with damage to nail, initial
encounter
S61.349A Puncture wound with foreign body of unspecified finger with damage to nail,
initial encounter
S61.401A Unspecified open wound of right hand, initial encounter
S61.402A Unspecified open wound of left hand, initial encounter
S61.409A Unspecified open wound of unspecified hand, initial encounter
S61.411A Laceration without foreign body of right hand, initial encounter
S61.412A Laceration without foreign body of left hand, initial encounter
S61.419A Laceration without foreign body of unspecified hand, initial encounter
S61.421A Laceration with foreign body of right hand, initial encounter
S61.422A Laceration with foreign body of left hand, initial encounter
S61.429A Laceration with foreign body of unspecified hand, initial encounter
S61.431A Puncture wound without foreign body of right hand, initial encounter
S61.432A Puncture wound without foreign body of left hand, initial encounter
S61.439A Puncture wound without foreign body of unspecified hand, initial encounter
S61.441A Puncture wound with foreign body of right hand, initial encounter
S61.442A Puncture wound with foreign body of left hand, initial encounter
S61.449A Puncture wound with foreign body of unspecified hand, initial encounter
S61.451A Open bite of right hand, initial encounter
S61.452A Open bite of left hand, initial encounter
S61.459A Open bite of unspecified hand, initial encounter
S61.501A Unspecified open wound of right wrist, initial encounter
S61.502A Unspecified open wound of left wrist, initial encounter
S61.509A Unspecified open wound of unspecified wrist, initial encounter
S61.511A Laceration without foreign body of right wrist, initial encounter
S61.512A Laceration without foreign body of left wrist, initial encounter
S61.519A Laceration without foreign body of unspecified wrist, initial encounter
S61.521A Laceration with foreign body of right wrist, initial encounter
S61.522A Laceration with foreign body of left wrist, initial encounter
S61.529A Laceration with foreign body of unspecified wrist, initial encounter
S61.531A Puncture wound without foreign body of right wrist, initial encounter
S61.532A Puncture wound without foreign body of left wrist, initial encounter
S61.539A Puncture wound without foreign body of unspecified wrist, initial encounter
S61.541A Puncture wound with foreign body of right wrist, initial encounter
S61.542A Puncture wound with foreign body of left wrist, initial encounter
S61.549A Puncture wound with foreign body of unspecified wrist, initial encounter
S61.551A Open bite of right wrist, initial encounter
S61.552A Open bite of left wrist, initial encounter
S61.559A Open bite of unspecified wrist, initial encounter
S66.021A Laceration of long flexor muscle, fascia and tendon of right thumb at wrist
and hand level, initial encounter
S66.022A Laceration of long flexor muscle, fascia and tendon of left thumb at wrist and
hand level, initial encounter
S66.029A Laceration of long flexor muscle, fascia and tendon of unspecified thumb at
wrist and hand level, initial encounter
S66.120A Laceration of flexor muscle, fascia and tendon of right index finger at wrist
S66.121A Laceration of flexor muscle, fascia and tendon of left index finger at wrist and
S66.122A Laceration of flexor muscle, fascia and tendon of right middle finger at wrist
S66.123A Laceration of flexor muscle, fascia and tendon of left middle finger at wrist
S66.124A Laceration of flexor muscle, fascia and tendon of right ring finger at wrist and
S66.125A Laceration of flexor muscle, fascia and tendon of left ring finger at wrist and
S66.126A Laceration of flexor muscle, fascia and tendon of right little finger at wrist
S66.127A Laceration of flexor muscle, fascia and tendon of left little finger at wrist and
S66.128A Laceration of flexor muscle, fascia and tendon of other finger at wrist and
S66.129A Laceration of flexor muscle, fascia and tendon of unspecified finger at wrist
S66.221A Laceration of extensor muscle, fascia and tendon of right thumb at wrist and
S66.222A Laceration of extensor muscle, fascia and tendon of left thumb at wrist and
S66.229A Laceration of extensor muscle, fascia and tendon of unspecified thumb at
S66.320A Laceration of extensor muscle, fascia and tendon of right index finger at wrist
S66.321A Laceration of extensor muscle, fascia and tendon of left index finger at wrist
S66.322A Laceration of extensor muscle, fascia and tendon of right middle finger at
S66.323A Laceration of extensor muscle, fascia and tendon of left middle finger at wrist
S66.324A Laceration of extensor muscle, fascia and tendon of right ring finger at wrist
S66.325A Laceration of extensor muscle, fascia and tendon of left ring finger at wrist
S66.326A Laceration of extensor muscle, fascia and tendon of right little finger at wrist
S66.327A Laceration of extensor muscle, fascia and tendon of left little finger at wrist
S66.328A Laceration of extensor muscle, fascia and tendon of other finger at wrist and
S66.329A Laceration of extensor muscle, fascia and tendon of unspecified finger at wrist
S66.421A Laceration of intrinsic muscle, fascia and tendon of right thumb at wrist and
S66.422A Laceration of intrinsic muscle, fascia and tendon of left thumb at wrist and
S66.429A Laceration of intrinsic muscle, fascia and tendon of unspecified thumb at
S66.520A Laceration of intrinsic muscle, fascia and tendon of right index finger at wrist
S66.521A Laceration of intrinsic muscle, fascia and tendon of left index finger at wrist
S66.522A Laceration of intrinsic muscle, fascia and tendon of right middle finger at
S66.523A Laceration of intrinsic muscle, fascia and tendon of left middle finger at wrist
S66.524A Laceration of intrinsic muscle, fascia and tendon of right ring finger at wrist
S66.525A Laceration of intrinsic muscle, fascia and tendon of left ring finger at wrist
S66.526A Laceration of intrinsic muscle, fascia and tendon of right little finger at wrist
S66.527A Laceration of intrinsic muscle, fascia and tendon of left little finger at wrist
S66.528A Laceration of intrinsic muscle, fascia and tendon of other finger at wrist and
S66.529A Laceration of intrinsic muscle, fascia and tendon of unspecified finger at wrist
S66.821A Laceration of other specified muscles, fascia and tendons at wrist and hand
level, right hand, initial encounter
level, left hand, initial encounter
level, unspecified hand, initial encounter
S66.921A Laceration of unspecified muscle, fascia and tendon at wrist and hand level,
right hand, initial encounter
left hand, initial encounter
unspecified hand, initial encounter
S68.011A Complete traumatic metacarpophalangeal amputation of right thumb, initial
encounter
S68.012A Complete traumatic metacarpophalangeal amputation of left thumb, initial
encounter
S68.019A Complete traumatic metacarpophalangeal amputation of unspecified thumb,
initial encounter
S68.021A Partial traumatic metacarpophalangeal amputation of right thumb, initial
encounter
S68.022A Partial traumatic metacarpophalangeal amputation of left thumb, initial
encounter
S68.029A Partial traumatic metacarpophalangeal amputation of unspecified thumb,
initial encounter
S68.110A Complete traumatic metacarpophalangeal amputation of right index finger,
initial encounter
S68.111A Complete traumatic metacarpophalangeal amputation of left index finger,
initial encounter
S68.112A Complete traumatic metacarpophalangeal amputation of right middle finger,
initial encounter
S68.113A Complete traumatic metacarpophalangeal amputation of left middle finger,
initial encounter
S68.114A Complete traumatic metacarpophalangeal amputation of right ring finger,
initial encounter
S68.115A Complete traumatic metacarpophalangeal amputation of left ring finger,
initial encounter
S68.116A Complete traumatic metacarpophalangeal amputation of right little finger,
initial encounter
S68.117A Complete traumatic metacarpophalangeal amputation of left little finger,
initial encounter
S68.118A Complete traumatic metacarpophalangeal amputation of other finger, initial
encounter
S68.119A Complete traumatic metacarpophalangeal amputation of unspecified finger,
initial encounter
S68.120A Partial traumatic metacarpophalangeal amputation of right index finger, initial
encounter
S68.121A Partial traumatic metacarpophalangeal amputation of left index finger, initial
encounter
S68.122A Partial traumatic metacarpophalangeal amputation of right middle finger,
initial encounter
S68.123A Partial traumatic metacarpophalangeal amputation of left middle finger, initial
encounter
S68.124A Partial traumatic metacarpophalangeal amputation of right ring finger, initial
encounter
S68.125A Partial traumatic metacarpophalangeal amputation of left ring finger, initial
encounter
S68.126A Partial traumatic metacarpophalangeal amputation of right little finger, initial
encounter
S68.127A Partial traumatic metacarpophalangeal amputation of left little finger, initial
encounter
S68.128A Partial traumatic metacarpophalangeal amputation of other finger, initial
encounter
S68.129A Partial traumatic metacarpophalangeal amputation of unspecified finger,
initial encounter
S68.411A Complete traumatic amputation of right hand at wrist level, initial encounter
S68.412A Complete traumatic amputation of left hand at wrist level, initial encounter
S68.419A Complete traumatic amputation of unspecified hand at wrist level, initial
encounter
S68.421A Partial traumatic amputation of right hand at wrist level, initial encounter
S68.422A Partial traumatic amputation of left hand at wrist level, initial encounter
S68.429A Partial traumatic amputation of unspecified hand at wrist level, initial
encounter
S68.511A Complete traumatic transphalangeal amputation of right thumb, initial
encounter
S68.512A Complete traumatic transphalangeal amputation of left thumb, initial
encounter
S68.519A Complete traumatic transphalangeal amputation of unspecified thumb, initial
encounter
S68.521A Partial traumatic transphalangeal amputation of right thumb, initial encounter
S68.522A Partial traumatic transphalangeal amputation of left thumb, initial encounter
S68.529A Partial traumatic transphalangeal amputation of unspecified thumb, initial
encounter
S68.610A Complete traumatic transphalangeal amputation of right index finger, initial
encounter
S68.611A Complete traumatic transphalangeal amputation of left index finger, initial
encounter
S68.612A Complete traumatic transphalangeal amputation of right middle finger, initial
encounter
S68.613A Complete traumatic transphalangeal amputation of left middle finger, initial
encounter
S68.614A Complete traumatic transphalangeal amputation of right ring finger, initial
encounter
S68.615A Complete traumatic transphalangeal amputation of left ring finger, initial
encounter
S68.616A Complete traumatic transphalangeal amputation of right little finger, initial
encounter
S68.617A Complete traumatic transphalangeal amputation of left little finger, initial
encounter
S68.618A Complete traumatic transphalangeal amputation of other finger, initial
encounter
S68.619A Complete traumatic transphalangeal amputation of unspecified finger, initial
encounter
S68.620A Partial traumatic transphalangeal amputation of right index finger, initial
encounter
S68.621A Partial traumatic transphalangeal amputation of left index finger, initial
encounter
S68.622A Partial traumatic transphalangeal amputation of right middle finger, initial
encounter
S68.623A Partial traumatic transphalangeal amputation of left middle finger, initial
encounter
S68.624A Partial traumatic transphalangeal amputation of right ring finger, initial
encounter
S68.625A Partial traumatic transphalangeal amputation of left ring finger, initial
encounter
S68.626A Partial traumatic transphalangeal amputation of right little finger, initial
encounter
S68.627A Partial traumatic transphalangeal amputation of left little finger, initial
encounter
S68.628A Partial traumatic transphalangeal amputation of other finger, initial encounter
S68.629A Partial traumatic transphalangeal amputation of unspecified finger, initial
encounter
S68.711A Complete traumatic transmetacarpal amputation of right hand, initial
encounter
S68.712A Complete traumatic transmetacarpal amputation of left hand, initial encounter
S68.719A Complete traumatic transmetacarpal amputation of unspecified hand, initial
encounter
S68.721A Partial traumatic transmetacarpal amputation of right hand, initial encounter
S68.722A Partial traumatic transmetacarpal amputation of left hand, initial encounter
S68.729A Partial traumatic transmetacarpal amputation of unspecified hand, initial
encounter
S71.001A Unspecified open wound, right hip, initial encounter
S71.002A Unspecified open wound, left hip, initial encounter
S71.009A Unspecified open wound, unspecified hip, initial encounter
S71.011A Laceration without foreign body, right hip, initial encounter
S71.012A Laceration without foreign body, left hip, initial encounter
S71.019A Laceration without foreign body, unspecified hip, initial encounter
S71.021A Laceration with foreign body, right hip, initial encounter
S71.022A Laceration with foreign body, left hip, initial encounter
S71.029A Laceration with foreign body, unspecified hip, initial encounter
S71.031A Puncture wound without foreign body, right hip, initial encounter
S71.032A Puncture wound without foreign body, left hip, initial encounter
S71.039A Puncture wound without foreign body, unspecified hip, initial encounter
S71.041A Puncture wound with foreign body, right hip, initial encounter
S71.042A Puncture wound with foreign body, left hip, initial encounter
S71.049A Puncture wound with foreign body, unspecified hip, initial encounter
S71.051A Open bite, right hip, initial encounter
S71.052A Open bite, left hip, initial encounter
S71.059A Open bite, unspecified hip, initial encounter
S71.101A Unspecified open wound, right thigh, initial encounter
S71.102A Unspecified open wound, left thigh, initial encounter
S71.109A Unspecified open wound, unspecified thigh, initial encounter
S71.111A Laceration without foreign body, right thigh, initial encounter
S71.112A Laceration without foreign body, left thigh, initial encounter
S71.119A Laceration without foreign body, unspecified thigh, initial encounter
S71.121A Laceration with foreign body, right thigh, initial encounter
S71.122A Laceration with foreign body, left thigh, initial encounter
S71.129A Laceration with foreign body, unspecified thigh, initial encounter
S71.131A Puncture wound without foreign body, right thigh, initial encounter
S71.132A Puncture wound without foreign body, left thigh, initial encounter
S71.139A Puncture wound without foreign body, unspecified thigh, initial encounter
S71.141A Puncture wound with foreign body, right thigh, initial encounter
S71.142A Puncture wound with foreign body, left thigh, initial encounter
S71.149A Puncture wound with foreign body, unspecified thigh, initial encounter
S71.151A Open bite, right thigh, initial encounter
S71.152A Open bite, left thigh, initial encounter
S71.159A Open bite, unspecified thigh, initial encounter
S76.021A Laceration of muscle, fascia and tendon of right hip, initial encounter
S76.022A Laceration of muscle, fascia and tendon of left hip, initial encounter
S76.029A Laceration of muscle, fascia and tendon of unspecified hip, initial encounter
S76.121A Laceration of right quadriceps muscle, fascia and tendon, initial encounter
S76.122A Laceration of left quadriceps muscle, fascia and tendon, initial encounter
S76.129A Laceration of unspecified quadriceps muscle, fascia and tendon, initial
encounter
S76.221A Laceration of adductor muscle, fascia and tendon of right thigh, initial
encounter
S76.222A Laceration of adductor muscle, fascia and tendon of left thigh, initial
encounter
S76.229A Laceration of adductor muscle, fascia and tendon of unspecified thigh, initial
encounter
S76.321A Laceration of muscle, fascia and tendon of the posterior muscle group at thigh
level, right thigh, initial encounter
level, left thigh, initial encounter
level, unspecified thigh, initial encounter
S76.821A Laceration of other specified muscles, fascia and tendons at thigh level, right
thigh, initial encounter
S76.822A Laceration of other specified muscles, fascia and tendons at thigh level, left
S76.829A Laceration of other specified muscles, fascia and tendons at thigh level,
unspecified thigh, initial encounter
S76.921A Laceration of unspecified muscles, fascia and tendons at thigh level, right
S76.922A Laceration of unspecified muscles, fascia and tendons at thigh level, left
S76.929A Laceration of unspecified muscles, fascia and tendons at thigh level,
unspecified thigh, initial encounter
S78.011A Complete traumatic amputation at right hip joint, initial encounter
S78.012A Complete traumatic amputation at left hip joint, initial encounter
S78.019A Complete traumatic amputation at unspecified hip joint, initial encounter
S78.021A Partial traumatic amputation at right hip joint, initial encounter
S78.022A Partial traumatic amputation at left hip joint, initial encounter
S78.029A Partial traumatic amputation at unspecified hip joint, initial encounter
S78.111A Complete traumatic amputation at level between right hip and knee, initial
encounter
S78.112A Complete traumatic amputation at level between left hip and knee, initial
encounter
S78.119A Complete traumatic amputation at level between unspecified hip and knee,
initial encounter
S78.121A Partial traumatic amputation at level between right hip and knee, initial
encounter
S78.122A Partial traumatic amputation at level between left hip and knee, initial
encounter
S78.129A Partial traumatic amputation at level between unspecified hip and knee, initial
encounter
S78.911A Complete traumatic amputation of right hip and thigh, level unspecified,
initial encounter
S78.912A Complete traumatic amputation of left hip and thigh, level unspecified, initial
encounter
S78.919A Complete traumatic amputation of unspecified hip and thigh, level
S78.921A Partial traumatic amputation of right hip and thigh, level unspecified, initial
encounter
S78.922A Partial traumatic amputation of left hip and thigh, level unspecified, initial
encounter
S78.929A Partial traumatic amputation of unspecified hip and thigh, level unspecified,
initial encounter
S81.001A Unspecified open wound, right knee, initial encounter
S81.002A Unspecified open wound, left knee, initial encounter
S81.009A Unspecified open wound, unspecified knee, initial encounter
S81.011A Laceration without foreign body, right knee, initial encounter
S81.012A Laceration without foreign body, left knee, initial encounter
S81.019A Laceration without foreign body, unspecified knee, initial encounter
S81.021A Laceration with foreign body, right knee, initial encounter
S81.022A Laceration with foreign body, left knee, initial encounter
S81.029A Laceration with foreign body, unspecified knee, initial encounter
S81.031A Puncture wound without foreign body, right knee, initial encounter
S81.032A Puncture wound without foreign body, left knee, initial encounter
S81.039A Puncture wound without foreign body, unspecified knee, initial encounter
S81.041A Puncture wound with foreign body, right knee, initial encounter
S81.042A Puncture wound with foreign body, left knee, initial encounter
S81.049A Puncture wound with foreign body, unspecified knee, initial encounter
S81.051A Open bite, right knee, initial encounter
S81.052A Open bite, left knee, initial encounter
S81.059A Open bite, unspecified knee, initial encounter
S81.801A Unspecified open wound, right lower leg, initial encounter
S81.802A Unspecified open wound, left lower leg, initial encounter
S81.809A Unspecified open wound, unspecified lower leg, initial encounter
S81.811A Laceration without foreign body, right lower leg, initial encounter
S81.812A Laceration without foreign body, left lower leg, initial encounter
S81.819A Laceration without foreign body, unspecified lower leg, initial encounter
S81.821A Laceration with foreign body, right lower leg, initial encounter
S81.822A Laceration with foreign body, left lower leg, initial encounter
S81.829A Laceration with foreign body, unspecified lower leg, initial encounter
S81.831A Puncture wound without foreign body, right lower leg, initial encounter
S81.832A Puncture wound without foreign body, left lower leg, initial encounter
S81.839A Puncture wound without foreign body, unspecified lower leg, initial encounter
S81.841A Puncture wound with foreign body, right lower leg, initial encounter
S81.842A Puncture wound with foreign body, left lower leg, initial encounter
S81.849A Puncture wound with foreign body, unspecified lower leg, initial encounter
S81.851A Open bite, right lower leg, initial encounter
S81.852A Open bite, left lower leg, initial encounter
S81.859A Open bite, unspecified lower leg, initial encounter
S86.021A Laceration of right Achilles tendon, initial encounter
S86.022A Laceration of left Achilles tendon, initial encounter
S86.029A Laceration of unspecified Achilles tendon, initial encounter
S86.121A Laceration of other muscle(s) and tendon(s) of posterior muscle group at
lower leg level, right leg, initial encounter
lower leg level, left leg, initial encounter
lower leg level, unspecified leg, initial encounter
S86.221A Laceration of muscle(s) and tendon(s) of anterior muscle group at lower leg
level, right leg, initial encounter
level, left leg, initial encounter
level, unspecified leg, initial encounter
S86.321A Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg
level, right leg, initial encounter
level, left leg, initial encounter
level, unspecified leg, initial encounter
S86.821A Laceration of other muscle(s) and tendon(s) at lower leg level, right leg, initial
encounter
S86.822A Laceration of other muscle(s) and tendon(s) at lower leg level, left leg, initial
encounter
S86.829A Laceration of other muscle(s) and tendon(s) at lower leg level, unspecified
leg, initial encounter
S86.921A Laceration of unspecified muscle(s) and tendon(s) at lower leg level, right leg,
initial encounter
S86.922A Laceration of unspecified muscle(s) and tendon(s) at lower leg level, left leg,
initial encounter
S86.929A Laceration of unspecified muscle(s) and tendon(s) at lower leg level,
unspecified leg, initial encounter
S88.011A Complete traumatic amputation at knee level, right lower leg, initial encounter
S88.012A Complete traumatic amputation at knee level, left lower leg, initial encounter
S88.019A Complete traumatic amputation at knee level, unspecified lower leg, initial
encounter
S88.021A Partial traumatic amputation at knee level, right lower leg, initial encounter
S88.022A Partial traumatic amputation at knee level, left lower leg, initial encounter
S88.029A Partial traumatic amputation at knee level, unspecified lower leg, initial
encounter
S88.111A Complete traumatic amputation at level between knee and ankle, right lower
S88.112A Complete traumatic amputation at level between knee and ankle, left lower
S88.119A Complete traumatic amputation at level between knee and ankle, unspecified
lower leg, initial encounter
S88.121A Partial traumatic amputation at level between knee and ankle, right lower leg,
initial encounter
S88.122A Partial traumatic amputation at level between knee and ankle, left lower leg,
initial encounter
S88.129A Partial traumatic amputation at level between knee and ankle, unspecified
lower leg, initial encounter
S88.911A Complete traumatic amputation of right lower leg, level unspecified, initial
encounter
S88.912A Complete traumatic amputation of left lower leg, level unspecified, initial
encounter
S88.919A Complete traumatic amputation of unspecified lower leg, level unspecified,
initial encounter
S88.921A Partial traumatic amputation of right lower leg, level unspecified, initial
encounter
S88.922A Partial traumatic amputation of left lower leg, level unspecified, initial
encounter
S88.929A Partial traumatic amputation of unspecified lower leg, level unspecified,
initial encounter
S91.001A Unspecified open wound, right ankle, initial encounter
S91.002A Unspecified open wound, left ankle, initial encounter
S91.009A Unspecified open wound, unspecified ankle, initial encounter
S91.011A Laceration without foreign body, right ankle, initial encounter
S91.012A Laceration without foreign body, left ankle, initial encounter
S91.019A Laceration without foreign body, unspecified ankle, initial encounter
S91.021A Laceration with foreign body, right ankle, initial encounter
S91.022A Laceration with foreign body, left ankle, initial encounter
S91.029A Laceration with foreign body, unspecified ankle, initial encounter
S91.031A Puncture wound without foreign body, right ankle, initial encounter
S91.032A Puncture wound without foreign body, left ankle, initial encounter
S91.039A Puncture wound without foreign body, unspecified ankle, initial encounter
S91.041A Puncture wound with foreign body, right ankle, initial encounter
S91.042A Puncture wound with foreign body, left ankle, initial encounter
S91.049A Puncture wound with foreign body, unspecified ankle, initial encounter
S91.051A Open bite, right ankle, initial encounter
S91.052A Open bite, left ankle, initial encounter
S91.059A Open bite, unspecified ankle, initial encounter
S91.101A Unspecified open wound of right great toe without damage to nail, initial
encounter
S91.102A Unspecified open wound of left great toe without damage to nail, initial
encounter
S91.103A Unspecified open wound of unspecified great toe without damage to nail,
initial encounter
S91.104A Unspecified open wound of right lesser toe(s) without damage to nail, initial
encounter
S91.105A Unspecified open wound of left lesser toe(s) without damage to nail, initial
encounter
S91.106A Unspecified open wound of unspecified lesser toe(s) without damage to nail,
initial encounter
S91.109A Unspecified open wound of unspecified toe(s) without damage to nail, initial
encounter
S91.111A Laceration without foreign body of right great toe without damage to nail,
initial encounter
S91.112A Laceration without foreign body of left great toe without damage to nail,
initial encounter
S91.113A Laceration without foreign body of unspecified great toe without damage to
S91.114A Laceration without foreign body of right lesser toe(s) without damage to nail,
initial encounter
S91.115A Laceration without foreign body of left lesser toe(s) without damage to nail,
initial encounter
S91.116A Laceration without foreign body of unspecified lesser toe(s) without damage
S91.119A Laceration without foreign body of unspecified toe without damage to nail,
initial encounter
S91.121A Laceration with foreign body of right great toe without damage to nail, initial
encounter
S91.122A Laceration with foreign body of left great toe without damage to nail, initial
encounter
S91.123A Laceration with foreign body of unspecified great toe without damage to nail,
initial encounter
S91.124A Laceration with foreign body of right lesser toe(s) without damage to nail,
initial encounter
S91.125A Laceration with foreign body of left lesser toe(s) without damage to nail,
initial encounter
S91.126A Laceration with foreign body of unspecified lesser toe(s) without damage to
S91.129A Laceration with foreign body of unspecified toe(s) without damage to nail,
initial encounter
S91.131A Puncture wound without foreign body of right great toe without damage to
S91.132A Puncture wound without foreign body of left great toe without damage to nail,
initial encounter
S91.133A Puncture wound without foreign body of unspecified great toe without
damage to nail, initial encounter
S91.134A Puncture wound without foreign body of right lesser toe(s) without damage to
S91.135A Puncture wound without foreign body of left lesser toe(s) without damage to
S91.136A Puncture wound without foreign body of unspecified lesser toe(s) without
S91.139A Puncture wound without foreign body of unspecified toe(s) without damage
S91.141A Puncture wound with foreign body of right great toe without damage to nail,
initial encounter
S91.142A Puncture wound with foreign body of left great toe without damage to nail,
initial encounter
S91.143A Puncture wound with foreign body of unspecified great toe without damage to
S91.144A Puncture wound with foreign body of right lesser toe(s) without damage to
S91.145A Puncture wound with foreign body of left lesser toe(s) without damage to nail,
initial encounter
S91.146A Puncture wound with foreign body of unspecified lesser toe(s) without
S91.149A Puncture wound with foreign body of unspecified toe(s) without damage to
S91.151A Open bite of right great toe without damage to nail, initial encounter
S91.152A Open bite of left great toe without damage to nail, initial encounter
S91.153A Open bite of unspecified great toe without damage to nail, initial encounter
S91.154A Open bite of right lesser toe(s) without damage to nail, initial encounter
S91.155A Open bite of left lesser toe(s) without damage to nail, initial encounter
S91.156A Open bite of unspecified lesser toe(s) without damage to nail, initial encounter
S91.159A Open bite of unspecified toe(s) without damage to nail, initial encounter
S91.201A Unspecified open wound of right great toe with damage to nail, initial
encounter
S91.202A Unspecified open wound of left great toe with damage to nail, initial
encounter
S91.203A Unspecified open wound of unspecified great toe with damage to nail, initial
encounter
S91.204A Unspecified open wound of right lesser toe(s) with damage to nail, initial
encounter
S91.205A Unspecified open wound of left lesser toe(s) with damage to nail, initial
encounter
S91.206A Unspecified open wound of unspecified lesser toe(s) with damage to nail,
initial encounter
S91.209A Unspecified open wound of unspecified toe(s) with damage to nail, initial
encounter
S91.211A Laceration without foreign body of right great toe with damage to nail, initial
encounter
S91.212A Laceration without foreign body of left great toe with damage to nail, initial
encounter
S91.213A Laceration without foreign body of unspecified great toe with damage to nail,
initial encounter
S91.214A Laceration without foreign body of right lesser toe(s) with damage to nail,
initial encounter
S91.215A Laceration without foreign body of left lesser toe(s) with damage to nail,
initial encounter
S91.216A Laceration without foreign body of unspecified lesser toe(s) with damage to
S91.219A Laceration without foreign body of unspecified toe(s) with damage to nail,
initial encounter
S91.221A Laceration with foreign body of right great toe with damage to nail, initial
encounter
S91.222A Laceration with foreign body of left great toe with damage to nail, initial
encounter
S91.223A Laceration with foreign body of unspecified great toe with damage to nail,
initial encounter
S91.224A Laceration with foreign body of right lesser toe(s) with damage to nail, initial
encounter
S91.225A Laceration with foreign body of left lesser toe(s) with damage to nail, initial
encounter
S91.226A Laceration with foreign body of unspecified lesser toe(s) with damage to nail,
initial encounter
S91.229A Laceration with foreign body of unspecified toe(s) with damage to nail, initial
encounter
S91.231A Puncture wound without foreign body of right great toe with damage to nail,
initial encounter
S91.232A Puncture wound without foreign body of left great toe with damage to nail,
initial encounter
S91.233A Puncture wound without foreign body of unspecified great toe with damage to
S91.234A Puncture wound without foreign body of right lesser toe(s) with damage to
S91.235A Puncture wound without foreign body of left lesser toe(s) with damage to nail,
initial encounter
S91.236A Puncture wound without foreign body of unspecified lesser toe(s) with
S91.239A Puncture wound without foreign body of unspecified toe(s) with damage to
S91.241A Puncture wound with foreign body of right great toe with damage to nail,
initial encounter
S91.242A Puncture wound with foreign body of left great toe with damage to nail, initial
encounter
S91.243A Puncture wound with foreign body of unspecified great toe with damage to
S91.244A Puncture wound with foreign body of right lesser toe(s) with damage to nail,
initial encounter
S91.245A Puncture wound with foreign body of left lesser toe(s) with damage to nail,
initial encounter
S91.246A Puncture wound with foreign body of unspecified lesser toe(s) with damage to
S91.249A Puncture wound with foreign body of unspecified toe(s) with damage to nail,
initial encounter
S91.251A Open bite of right great toe with damage to nail, initial encounter
S91.252A Open bite of left great toe with damage to nail, initial encounter
S91.253A Open bite of unspecified great toe with damage to nail, initial encounter
S91.254A Open bite of right lesser toe(s) with damage to nail, initial encounter
S91.255A Open bite of left lesser toe(s) with damage to nail, initial encounter
S91.256A Open bite of unspecified lesser toe(s) with damage to nail, initial encounter
S91.259A Open bite of unspecified toe(s) with damage to nail, initial encounter
S91.301A Unspecified open wound, right foot, initial encounter
S91.302A Unspecified open wound, left foot, initial encounter
S91.309A Unspecified open wound, unspecified foot, initial encounter
S91.311A Laceration without foreign body, right foot, initial encounter
S91.312A Laceration without foreign body, left foot, initial encounter
S91.319A Laceration without foreign body, unspecified foot, initial encounter
S91.321A Laceration with foreign body, right foot, initial encounter
S91.322A Laceration with foreign body, left foot, initial encounter
S91.329A Laceration with foreign body, unspecified foot, initial encounter
S91.331A Puncture wound without foreign body, right foot, initial encounter
S91.332A Puncture wound without foreign body, left foot, initial encounter
S91.339A Puncture wound without foreign body, unspecified foot, initial encounter
S91.341A Puncture wound with foreign body, right foot, initial encounter
S91.342A Puncture wound with foreign body, left foot, initial encounter
S91.349A Puncture wound with foreign body, unspecified foot, initial encounter
S91.351A Open bite, right foot, initial encounter
S91.352A Open bite, left foot, initial encounter
S91.359A Open bite, unspecified foot, initial encounter
S96.021A Laceration of muscle and tendon of long flexor muscle of toe at ankle and
foot level, right foot, initial encounter
foot level, left foot, initial encounter
foot level, unspecified foot, initial encounter
S96.121A Laceration of muscle and tendon of long extensor muscle of toe at ankle and
foot level, right foot, initial encounter
foot level, left foot, initial encounter
foot level, unspecified foot, initial encounter
S96.221A Laceration of intrinsic muscle and tendon at ankle and foot level, right foot,
initial encounter
S96.222A Laceration of intrinsic muscle and tendon at ankle and foot level, left foot,
initial encounter
S96.229A Laceration of intrinsic muscle and tendon at ankle and foot level, unspecified
foot, initial encounter
S96.821A Laceration of other specified muscles and tendons at ankle and foot level,
right foot, initial encounter
S96.822A Laceration of other specified muscles and tendons at ankle and foot level, left
S96.829A Laceration of other specified muscles and tendons at ankle and foot level,
unspecified foot, initial encounter
S96.921A Laceration of unspecified muscle and tendon at ankle and foot level, right
S96.922A Laceration of unspecified muscle and tendon at ankle and foot level, left foot,
initial encounter
S96.929A Laceration of unspecified muscle and tendon at ankle and foot level,
unspecified foot, initial encounter
S98.011A Complete traumatic amputation of right foot at ankle level, initial encounter
S98.012A Complete traumatic amputation of left foot at ankle level, initial encounter
S98.019A Complete traumatic amputation of unspecified foot at ankle level, initial
encounter
S98.021A Partial traumatic amputation of right foot at ankle level, initial encounter
S98.022A Partial traumatic amputation of left foot at ankle level, initial encounter
S98.029A Partial traumatic amputation of unspecified foot at ankle level, initial
encounter
S98.111A Complete traumatic amputation of right great toe, initial encounter
S98.112A Complete traumatic amputation of left great toe, initial encounter
S98.119A Complete traumatic amputation of unspecified great toe, initial encounter
S98.121A Partial traumatic amputation of right great toe, initial encounter
S98.122A Partial traumatic amputation of left great toe, initial encounter
S98.129A Partial traumatic amputation of unspecified great toe, initial encounter
S98.131A Complete traumatic amputation of one right lesser toe, initial encounter
S98.132A Complete traumatic amputation of one left lesser toe, initial encounter
S98.139A Complete traumatic amputation of one unspecified lesser toe, initial encounter
S98.141A Partial traumatic amputation of one right lesser toe, initial encounter
S98.142A Partial traumatic amputation of one left lesser toe, initial encounter
S98.149A Partial traumatic amputation of one unspecified lesser toe, initial encounter
S98.211A Complete traumatic amputation of two or more right lesser toes, initial
encounter
S98.212A Complete traumatic amputation of two or more left lesser toes, initial
encounter
S98.219A Complete traumatic amputation of two or more unspecified lesser toes, initial
encounter
S98.221A Partial traumatic amputation of two or more right lesser toes, initial encounter
S98.222A Partial traumatic amputation of two or more left lesser toes, initial encounter
S98.229A Partial traumatic amputation of two or more unspecified lesser toes, initial
encounter
S98.311A Complete traumatic amputation of right midfoot, initial encounter
S98.312A Complete traumatic amputation of left midfoot, initial encounter
S98.319A Complete traumatic amputation of unspecified midfoot, initial encounter
S98.321A Partial traumatic amputation of right midfoot, initial encounter
S98.322A Partial traumatic amputation of left midfoot, initial encounter
S98.329A Partial traumatic amputation of unspecified midfoot, initial encounter
S98.911A Complete traumatic amputation of right foot, level unspecified, initial
encounter
S98.912A Complete traumatic amputation of left foot, level unspecified, initial
encounter
S98.919A Complete traumatic amputation of unspecified foot, level unspecified, initial
encounter
S98.921A Partial traumatic amputation of right foot, level unspecified, initial encounter
S98.922A Partial traumatic amputation of left foot, level unspecified, initial encounter
S98.929A Partial traumatic amputation of unspecified foot, level unspecified, initial
encounter
T81.31XA Disruption of external operation (surgical) wound, not elsewhere classified,
initial encounter
T81.32XA Disruption of internal operation (surgical) wound, not elsewhere classified,
initial encounter
Transmittals Issued for this Chapter
Rev # Issue Date Subject Impl Date CR#
R3995CP 03/09/2018 Correction to Pub. 100-04, Chapter 5 06/11/2018 10509
R3936CP 12/21/2017 Updated Editing of Always Therapy Services - 01/02/2018 10176

MCS
R3863CP 09/15/2017 Updated Editing of Always Therapy Services – 01/02/2018 10176

MCS- Rescinded and replaced by Transmittal
3936
R3814CP 07/27/2017 Updated Editing of Always Therapy Services – 01/02/2018 10176

MCS - Rescinded and replaced by Transmittal
3863
R3670CP 12/01/2016 Update to Editing of Therapy Services to 04/03/2017 9698

Reflect Coding Changes
R3634CP 10/27/2016 Update to Editing of Therapy Services to 04/03/2017 9698

Reflect Coding Changes – Rescinded and
replaced by Transmittal 3670
R3475CP 03/04/2016 Updates to Pub. 100-04, Chapters 4 and 5 to 06/06/2016 9424

Correct Remittance Advice Messages
R3454CP 02/04/2016 Correction to Applying Therapy Caps to 07/05/2016 9489

Maryland Hospitals and Billing Requirement
for Rehabilitation Agencies and
Comprehensive Outpatient Rehabilitation
Facilities (CORFs)
R3367CP 10/07/2015 Applying Therapy Caps to Maryland Hospitals 01/04/2016 9223
R3309CP 08/06/2015 Applying Therapy Caps to Maryland Hospitals 01/04/2016 9223

– Rescinded and replaced by Transmittal 3367
R3220CP 03/16/2015 Update to Pub. 100-04, Chapters 5 and 6 to 09/16/2014 8524

Provide Language-Only Changes for Updating
ICD-10, ASC X12, and Medicare
Administrative Contractor (MAC)

Implementation
R3028CP 08/15/2014 Update to Pub. 100-04, Chapters 5 and 6 to 09/16/2014 8524

Provide Language-Only Changes for Updating
ICD-10, ASC X12, and Medicare
Administrative Contractor (MAC)
Implementation – Rescinded and replaced by
Transmittal 3220
R2899CP 03/07/2014 Pub 100-04, Language Only Update for 10/01/2014 8524
Chapters Five and Six for Conversion to ICD-
10 - Rescinded and replaced by Transmittal
3028
R2868CP 02/06/2014 Therapy Modifier Consistency Edits 07/07/2014 8556
R2859CP 01/17/2014 Applying the Therapy Caps to Critical Access 01/31/2014 8426
Hospitals
R2844CP 12/27/2013 2014 Annual Update to the Therapy Code List 01/06/2014 8482
– Rescinded and replaced by Transmittal 2844
R2783CP 09/10/2013 Corrections to the Medicare Claims Processing 09/17/2013 8343

Manual
R2736CP 06/28/2013 Billing Social Work and Psychological 10/07/2013 8257

Services in Comprehensive Outpatient
Rehabilitation Facilities (CORFs)
R2725CP 06/14/2013 Corrections to the Medicare Claims Processing 09/17/2013 8343

Manual – Rescinded and replaced by
Transmittal 2783
R2690CP 05/03/2013 Billing Social Work and Psychological 10/07/2013 8257

Services in Comprehensive Outpatient
Rehabilitation Facilities (CORFs) – Rescinded
and replaced by Transmittal 2736
R2622CP 12/21/2012 Implementing the Claims-Based Data 01/07/2013 8005

Collection Requirement for Outpatient
Therapy Services -- Section 3005(g) of the
Middle Class Tax Relief and Jobs Creation Act
(MCTRJCA) of 2012
R2615CP 12/14/2012 Revisions of the Financial Limitation for 10/01/2012 7785

Outpatient Therapy Services-Section 3005 of
the Middle Class Tax Relief and Job Creation
Act of 2012

(MCTRJCA) of 2012 – Rescinded and
R2537CP 08/31/2012 Expiration of 2012 Therapy Cap Revisions and 01/07/2013 7881
User-Controlled Mechanism to Identify
Legislative Effective Dates

(MCTRJCA) of 2012 – Rescinded and
R2457CP 04/27/2012 Revisions of the Financial Limitation for 10/01/2012 7785

Outpatient Therapy Services-Section 3005 of
the Middle Class Tax Relief and Job Creation
Act of 2012 – Rescinded and replaced by
Transmittal 2615
R2328CP 10/27/2011 Claim Adjustment Reason Code (CARC) Used 04/02/2012 7564
for Therapy Claims Subject to the Multiple
Procedure Payment Reduction
R2160CP 02/18/2011 Correction to Manual References in Chapter 5, 05/19/2011 7315

Section 20.2
R2121CP 12/17/2010 Reporting of Service Units With HCPCS 03/21/2011 7247
R2091CP 11/12/2010 Correct Reporting of Modifiers and Revenue 04/04/2011 7170

Codes on Claims for Therapy Services
R2073CP 10/22/2010 Therapy Cap Values for Calendar Year (CY) 01/03/2011 7107
2011
2011 – Rescinded and replaced by Transmittal
2073
R2044CP 09/03/2010 Revisions and Re-issuance of Audiology 09/30/2010 6447

Policies

Policies – Rescinded and replaced by
Transmittal 2044
R1985CP 06/11/2010 Clarifications and Updates of Therapy 07/11/2010 6980

Services Policies

Policies - Rescinded and replaced by
Transmittal 2007
R1951CP 04/27/2010 Removal of the Provider Reporting 10/04/2010 6899

Requirement for Total Number of Therapy
Visits Using Value Codes 50-53
R1921CP 02/19/2010 Billing for Services Related to Voluntary Uses 04/05/2010 6563
of Advanced Beneficiary Notices of
Noncoverage (ABNs)
Noncoverage (ABNs) – Rescinded and
R1876CP 12/18/2009 Coverage of Kidney Disease Patient Education 04/05/2010 6557

Services
2010
2010 – Rescinded and replaced by Transmittal
1860
R1843CP 10/30/2009 Outpatient Mental Health Treatment 01/04/2010 6686

Limitation
Noncoverage (ABNs) – Rescinded and
R1733CP 05/08/2009 Manual Clarification for Skilled Nursing 04/27/2009 6407

Facility (SNF) and Therapy Billing
R1717CP 04/24/2009 Speech-Language Pathology Practice Payment 07/06/2009 6381

Policy
R1706CP 03/27/2009 Manual Clarification for Skilled Nursing 04/27/2009 6407

Facility (SNF) and Therapy Billing –
Rescinded and replaced by Transmittal 1733
R1678CP 02/13/2009 Outpatient Therapy Caps With Exceptions in 04/06/2009 6321

CY 2009
R1631CP 11/07/2008 Extension of Therapy Cap Exception Process 12/08/2008 6222
R1593CP 09/12/2008 Smoking and Tobacco Use Cessation 12/12/2008 6163

Counseling Billing Update for Comprehensive
Outpatient Rehabilitation Facilities (CORFs)
and Outpatient Physical Therapy Providers
(OPTs)
R1472CP 03/06/2008 Update of Institutional Claims References 04/07/2008 5893
R1459CP 02/22/2008 Comprehensive Outpatient Rehabilitation 07/07/2008 5898

Facility (CORF) Billing Requirement Updates
for Fiscal Year (FY) 2008
R1421CP 01/25/2008 Update of Institutional Claims References - 04/07/2008 5893

Rescinded and Replaced by Transmittal 1472
R1414CP 01/17/2008 Outpatient Therapy Caps Without KX 01/07/2008 5871

Modifier Exceptions Start January 1, 2008
R1407CP 01/10/2008 Outpatient Therapy Caps Without KX 01/07/2008 5871

Modifier Exceptions Start January 1, 2008 –
Replaced by Transmittal 1414
R1183CP 02/09/2007 Infrared Therapy Devices 01/16/2007 5421
R1145CP 12/29/2006 Outpatient Therapy Cap Exceptions Process 01/29/2007 5478

for Calendar Year (CY) 2007
R1127CP 12/15/2006 Infrared Therapy Devices – Replaced by 01/16/2007 5421

Transmittal 1183
R1106CP 11/09/2006 Outpatient Therapy Cap Clarifications 12/09/2006 5271
R1019CP 08/03/2006 Outpatient Therapy - Additional DRA 01/02/2007 5253

Mandated Service Edits
R1016CP 07/28/2006 Outpatient Therapy - Additional DRA 01/02/2007 5253

Mandated Service Edit
R1000CP 07/19/2006 Common Working File (CWF) to the Medicare 10/02/2006 4300
Beneficiary Database (MBD) Data Exchange
Changes
R980CP 06/14/2006 Changes Conforming to CR 3648 Instructions 10/02/2006 4014

for Therapy Services - Replaces Rev. 941
R941CP 05/05/2006 Changes Conforming to CR 3648 Instructions 10/02/2006 4014

for Therapy Services
R908CP 04/21/2006 Common Working File (CWF) to the Medicare 10/02/2006 4300
Beneficiary Database (MBD) Data Exchange
Changes
R855CP 02/15/2006 Therapy Caps Exception Process 3/13/2006 4364
R853CP 02/13/2006 Therapy Caps Exception Process 3/13/2006 4364
R805CP 01/06/2006 Annual Update to the Therapy Code List 02/06/2006 4226
R771CP 12/02/2005 Revisions to Pub.100-04, Medicare Claims 01/03/2006 4181

Processing Manual in Preparation for the
National Provider Identifier
R759CP 11/18/2005 Therapy Caps to be Effective January 1, 2006 01/03/2006 4115
R515CP 04/01/2005 Update to 100-04 and Therapy Code Lists 07/05/2005 3647
R463CP 02/04/2005 Update to 100-04 and Therapy Code Lists 07/05/2005 3647
R319CP 10/22/2004 CORF/OPT Edit for Billing Inappropriate 04/04/2005 3468

Supplies
R042CP 12/08/2003 The Financial Limitation on Therapy Services 12/08/2003 3005
R030CP 11/14/2003 The Financial Limitation on Therapy Services 01/05/2004 2973
R001CP 10/01/2003 Initial Publication of Manual NA NA
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Chapter 5 - Part B Outpatient Rehabilitation

Transmittals for Chapter 5

10 - Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation

• Comprehensive outpatient rehabilitation facilities (CORFs);

• Outpatient physical therapy providers (OPTs), also known as rehabilitation

Contractors process outpatient rehabilitation claims from hospitals, including CAHs,

Payment for rehabilitation services provided to Part A inpatients of hospitals or SNFs is

An institutional employer (other than a SNF) of the TPPs, or physician performing

“Provider/Supplier Service” Format Bill Type Comment

Outpatient SNF Institutional 23X SNF must provide and bill or

Comprehensive Outpatient Institutional 75X Paid MPFS for outpatient

NOTE: Payment may be made

Physician/NPP/TPPs office, Professional See Chapter Paid via MPFS.

For a list of the outpatient rehabilitation HCPCS codes see §20.

10.1 - New Payment Requirement for A/B MACs (A)

10.2 - The Financial Limitation Legislation

10.3 - Application of Financial Limitations

Financial limitations on outpatient therapy services, as described above, began for

10.3.2 - Exceptions Process

An exception may be made when the patient’s condition is justified by documentation

No special documentation is submitted to the contractor for exceptions. The clinician is

The patient’s condition, including the diagnosis, complexities, and severity;

1. Exceptions for Evaluation Services

2. Exceptions for Medically Necessary Services

10.3.3 - Use of the KX Modifier for Therapy Cap Exceptions

o Pub.100-04, Medicare Claims Processing Manual, chapter 26, for more

o The ASC X12N 837 Health Care Claim: Professional Implementation

o For claims paid by a carrier or an A/B MAC(B), it is only appropriate to

• For institutional claims, sent to the A/B MAC(A):

Qualify for an exception using the automatic process exception.

If this attestation is determined to be inaccurate, the provider/supplier is subject to

10.3.4 - Therapy Cap Manual Review Threshold

B. Requirements - Professional Claims

The CMS identifies certain codes listed at:

C. Contractor Action Based on CWF Trailer

Incoming claim: Line 1 MPFS allowed amount is $50.

Group Code: CO or PR (as defined by section 10.5)

In situations where a beneficiary is close to reaching the financial limitation and a

10.3.5 - Identifying the Certifying Physician

Therapy plans of care must be certified by a physician or non-physician practitioner

10.3.6 - MSN Messages Regarding the Therapy Cap

10.4 - Claims Processing Requirements for Financial Limitations

A. Requirements – Institutional Claims

B. Requirements - Professional Claims

The CMS identifies certain codes listed at:

C. Contractor Action Based on CWF Trailer

Incoming claim: Line 1 MPFS allowed amount is $50.

Group Code: CO or PR (as defined by section 10.5)

In situations where a beneficiary is close to reaching the financial limitation and a

10.5 - Notification for Beneficiaries Exceeding Financial Limitations

Contractors will advise providers/suppliers to notify beneficiaries of the therapy financial

10.6 - Functional Reporting

Beneficiary unction information is reported using 42 nonpayable functional G-codes and

B. Application of New Coding Requirements

D. Providers and Practitioners Affected.

NONPAYABLE G-CODES FOR FUNCTIONAL LIMITATIONS

Code Long Descriptor Short Descriptor

The following “other PT/OT” functional G-codes are used to report: