The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services is updated annually. The new guidance becomes effective Jan. 1 of each year. NCCI edits are updated quarterly and are effective Jan. 1, April 1, July 1, and Oct. 1 of each year.

ICD-10-CM breaks down carpal tunnel syndrome based on laterality. The codes are in Chapter 6, Diseases of the Nervous System: G56.00 Carpal tunnel syndrome, unspecified upper limb G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, left upper limb G56.03 Carpal tunnel syndrome, bilateral upper limb

Modifier 79 Unrelated procedure by the same physician during the postoperative period is not a payment modifier. Level I payment modifiers include: 26 Professional component 50 Bilateral procedure 53 Discontinued procedure 54 Surgical care only 55 Postoperative management only 56 Preoperative management only 62 Two surgeons 66 Surgical team 78 Unplanned return to operating/procedure room by the same physician or other qualified health care professional following an initial procedure for a related procedure during postoperative period 80 Assistant surgeon 81 Minimum assistant surgeon 82 Assistant surgeon (when qualified resident surgeon not available) 91 Repeat clinical diagnostic laboratory test

CPT® states paired structures include true vocal cords, arytenoids, false vocal cords, ventricles, pyriform sinuses, and aryepiglottic folds.

Codes 31551-31554 reflect procedures for resection of laryngeal stenosis. These codes are differentiated by the age of the patient and whether an indwelling stent was placed. The graft harvest and placement is included and is not separately reported, even when performed through a separate incision.

To bill 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family, more than 50 percent of the time must be spent counseling or care. Per the code descriptor, typically, 45 minutes are spent face-to-face with the patient. This means that 23 minutes or more are needed to exceed the 50 percent threshold.

To bill 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Typically, 15 minutes are spent face-to-face with the patient and/or family, more than 50 percent of the time must be spent counseling or coordinating care. Per the code descriptor, typically, 15 minutes are spent face-to-face with the patient. This means that eight minutes or more are needed to exceed the 50 percent threshold. The next-higher code (99214) has a 25-minute reference time, meaning at least 13 minutes would have to be spent on counseling and coordination of care to report based on time.

The most common code that spine surgeons will use is +22853 Insertion of interbody biomechanical device(s) (e.g., synthetic cage, mesh) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure). This code may be used for anterior or posterior procedures; it is not limited to only anterior spine procedures. Code +22853 includes the placement of any anterior integral instrumentation (meaning the anterior plate is attached to the intervertebral device), when performed. The intervertebral device with an integrated anterior plate, also called a “low profile” or “stand-alone” device, is accurately reported using only +22853.

HIPAA rules apply specifically to “covered entities” and their “business associates.” Covered entities are defined as healthcare providers, health plans, and healthcare clearinghouses. Business associates are any third party a covered entity engages to help carry out its healthcare activities and functions (for example, a third-party billing service).

According to the Medicare Advance Beneficiary Notice (ABN) booklet, an ABN must be issued “when you believe Medicare may not pay for an item or service; Medicare usually covers the item or service; and Medicare is expected to deny payment for the item and or service because it is not medically reasonable and necessary for this beneficiary in this case.

When coding surgeries, review the header of the operative report and then turn to the CPT® Index to identify code options. In reviewing these codes, look for the differences between them and the documentation required to support one service over another.

Code 90682 Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use will be payable by Medicare, but not until July 1. Medicare administrative contractors (MACs) have until Aug. 1 to implement the code, but will pay (at their discretion) claims for 90682 with dates of service between July 1 and July 31. Contact your local MAC to verify their policy.

The sibling acted as an informant and there was no focus on family dynamics — meaning neither 90846 Family psychotherapy (without the patient present), 50 minutes nor 90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes is correct. Code 90836 Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) is an add-on code and cannot be reported by itself. The only remaining code is 90834 Psychotherapy, 45 minutes with patient. The 50-minute individual psychotherapy session most accurately supports 90834.

The 1995 guidelines define a detailed exam as an “extended exam of the affected area(s) and other symptomatic or related organ system(s).” Neither CPT® nor CMS defines the term “extended,” which is a qualitative, not quantitative, term. By contrast, 1997 guidelines define a detailed exam by counting bullet items (e.g., the definition is quantitative).

Carpal tunnel is pressure on the nerve and is coded in Chapter 6, Diseases of the Nervous System.

The physician usually will inject to relieve symptoms, then perform either an endoscopic or open surgery. Therefore, all three options are correct.

Although Medicare is for those aged 65 and over (and therefore not necessarily comparable to all patients in a practice), the “bell curve” that Medicare’s data illustrates for established and new patient visits is an industry-norm.

For 2017 professional (practitioner’s) claims to Medicare, mammography services should be reported using the G codes (G0202, G0204, G0206, G0279) or 77063. Be sure the service ordered and performed matches the description of the code. Medicare codes the diagnostic mammogram as either G0204 Screening mammography bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed or G0206 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral. If a tomosynthesis is also ordered, add +G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206) to either G0204 or G0206, as appropriate.

In 2017, commercial payers will likely use the new CPT® codes for breast mammography, A screening mammogram is coded as 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed. If tomosynthesis is also ordered, add +77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure).

 In practice, call on modifier 99 Multiple modifiers only if a single line item requires five or more modifiers. The reason is the standard 1500 Health Insurance Claim Form (or electronic equivalent) field 24D accommodates the entry of up to four modifiers

Where the patient is seen doesn’t matter. If the provider treats a patient for a face-to-face service within the previous three years (in any location), that patient is established (in all locations). If another provider within the group practice has seen the patient within the past three years, but that provider was of a different specialty/subspecialty, report a new patient service.

Solely within the context of evaluation and management (E/M) code selection, CPT® defines a professional service as “those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s).” Medicare policy (the Centers for Medicare & Medicaid Services (CMS) Transmittal R731CP, Change Request 4032) confirms, “An interpretation of a diagnostic test, reading an X-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”

In general, non-physician practitioners (NPPs) are not permitted to supervise the technical component of a diagnostic test: Only physicians may do this unless an exception applies

Although the Medicare Claims Processing Manual clearly states that critical care cannot be billed as a shared service (99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), it’s best to check with your local Medicare administrative contractor about other time-based services. Local policies vary on whether a hospital discharge service (a time-based code) may be billed as a shared visit.

Per the American Medical Association (AMA), place of service code 32 indicates a non-skilled nursing facility.

The column 2 code is the service that would be denied when the code pair is reported together for the same patient on the same date of service, making it necessary to add the modifier to this code to explain the circumstance for which it should be paid.

Both the procedure and the separate, same-day E/M service must be linked to a diagnosis substantiated in the medical record. The diagnoses supporting each service may be the same or different. Per CMS Transmittal R954CP, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date” [emphasis added].

A minor procedure is any procedure/CPT® code with a zero- or 10-day global period, as defined by the Medicare Physician Fee Schedule Relative Value File. Turn to modifier 57 Decision for surgery to report a separately identifiable E/M service that occurs on the same day, or on the day before, a major surgical procedure (a procedure or service with a 90-day global period), and that results in the physician’s decision to perform the surgery.

CPT® parenthetical instructions direct, “For application of an intervertebral bone device/graft, see 20930-20938.” Threaded bone dowel falls within this category, and is reported as a structural bone allograft (+20931 Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure).

Nursing facility service codes are: • 99304-99306 for the initial visit • 99307-99310 for any subsequent visits • 99315-99316 for the discharge • 99318 for an annual nursing facility assessment

To report an E/M service using time as the key component, time must be references in the code descriptor by the statement “Typically, X minutes are spent face-to-face with the patient and/or family.” Emergency department visits do not specify a reference time, and therefore must be reported using the three key components of history, time, and medical decision-making.

Either A49.02 or B95.62 usually is the first-listed code when a patient is treated for an MRSA infection. Exceptions include a patient with MRSA sepsis (A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus) or MRSA pneumonia (J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureus), which have specific codes.

Essentially, a whistleblower files a case on the government’s behalf, claiming fraud against the government. These cases, also called qui tam cases, often involve Medicare billing fraud (e.g., upcoding, double billing, and similar bad acts).

Encryption is not a HIPAA requirement; however, HIPAA (and state data breach laws) exempt encrypted data loss from data breach reporting (as long as the encryption keys were not taken with the data).

The Watson scaphoid shift test, which evaluates four progressive stages of carpal arthritis, is a popular test to detect scapholunate advanced collapse (SLAC).

The two main codes for Methicillin-resistant Staphylococcus aureus (MRSA) infections are A49.02 Methicillin resistant Staphylococcus aureus infection, site unspecified (the infection site has not yet been determined) and B95.62 Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere (the infection site is known, and reported secondarily (e.g., skin of the groin)). One of the above two codes usually is the first-listed code when a patient is treated for a MRSA infection.

The reported E/M service must have a “reference time,” identified in the code descriptor by the statement, “Typically, X minutes are spent face-to-face with the patient and/or family.” The reference time provides an objective standard for determining whether “more than 50 percent” of the visit is spent in counseling and/or coordination of care.

As outlined in the CPT® Evaluation and Management (E/M) Service Guidelines, in the context of office and other outpatient visits, “time” refers specifically to time spent face to face with the patient, as well as “time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members.” Time may include floor/unit time in the hospital or nursing facility.

The wrist, or carpus, contains eight carpal bones. There are three bones in the proximal row (scaphoid, lunate, and triquetrum) and five bones in the distal row (trapezium, trapezoid, capitate, hamate, and pisiform).

The wrist is classified as an “intermediate” joint, but consists of many intricate structures and bones of various shapes and sizes.

Yes: present on admission. This condition was not diagnosed prior to the admission, but clear signs/symptoms of the condition were present on admission (POA).

The patient did suffer a fall after arriving at the hospital, but it was in the emergency department (ED). The ED is considered an outpatient hospital; therefore, the hip fracture occurred prior to inpatient admission.

Because the service was performed under fluoroscopic guidance, and fluoroscopy is an inclusive component of the service, neither A nor B is correct. In addition, 62322 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance is without imaging guidance, meaning it is not logical to report fluoroscopy with a code that indicates without imaging guidance. The two are mutually exclusive and contradictory. Although 62323 is under imaging guidance, fluoroscopy is included in the code, per instructions, and 62323 is not approved for use in conjunction with fluoroscopy code +77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). Finally, 62327 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) is for continuous infusion or indwelling catheter, but the documentation indicates this was a single injection, which does not support a continuous infusion.

Neither A nor B comply with the instructions for appropriate use of CPT® +77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure) under the fluoroscopy guidelines. Answer A is also against the instructions for the spinal injection services. Answer C is not a reportable code combination per the fluoroscopy guidance instructions for CPT® +77002. CPT® 62321 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) is a spinal injection and CPT® 77003 is for fluoroscopic guidance of needle placement for spinal injections, but the codes can’t be reported together per instructions for both codes. This means only answer D is correct; this is a proper coding combination per the instructions for CPT® +77002.

CPT® states paired structures include true vocal cords, arytenoids, false vocal cords, ventricles, pyriform sinuses, and aryepiglottic folds.

Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency for ablation (destruction) of uterine fibroids using radiofrequency. The procedure includes ultrasound guidance. Code 58674 replaces Category III code 0336T.

The proximal row of carpal bones consists of the scaphoid, lunate, and triquetral bones, which articulate with the radius and the articular disk of the ulna. The distal row of carpal bones is made up of the trapezium, trapezoid, capitate, and hamate bones.

CPT® includes average time in the description of home visits, to be used when counseling/coordination of care dominate the visit (e.g., comprises over 50 percent of total face-to-face time between the provider and patient), as follows: Code Description RVU Average Time 99341 Home visit new patient; problem focused 1.55 20 min. 99342 Home visit new patient; expanded 2.23 30 min 99343 Home visit new patient; detailed 3.66 45 min.. 99344 Home visit new patient; moderate 5.13 60 min. 99345 Home visit new patient; high 6.22 75 min. 99324 Domiciliary, rest home visit new patient;  a problem focused 1.56 20 min. 99325 Domiciliary, rest home visit new patient; expanded 2.27 30 min. 99326 Domiciliary, rest home visit new patient; detailed 3.92 45 min. 99327 Domiciliary, rest home visit new patient; moderate 5.23 60 min. 99328 Domiciliary, rest home visit new patient; high 6.11 75 min.

The ICD-10 Code for benign neoplasm of ascending colon is D12.2.

The ICD-10-CM code for rectal polyp is K62.1.

Explanation.The diagnosis (L60.1 Onycholysis) links to both the evaluation and management (E/M) service (99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making.) and the avulsion (11730 Avulsion of nail plate, partial or complete, simple; single). Different diagnoses are not required to report the E/M service on the same date. Modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or another service must be appended to the E/M service to distinguish it as a significant, separately reported service.

Explanation: National Correct Coding Initiative (NCCI) edits bundle 11721 Debridement of a nail(s) by any method(s); 6 or more and 11719 Trimming of nondystrophic nails, any number. Report only 11719.

Explanation: All new, initial, and emergency department codes must meet three of three defined levels for history, exam, and medical decision-making (MDM).

Explanation: As of Jan. 1, 2017, 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed; and radiological supervision and interpretation replaces deleted Category III code 0281T to describes transcatheter placement of an implant (e.g., Watchman™ implant) to close the left atrial appendage, as an alternative to long-term oral anticoagulants to deter emboli formation and prevent stroke.

Explanation: The provider repairs an aortic valve (to treat aortic valve stenosis, or narrowing) via an open approach with the patient on cardiopulmonary bypass. Code 33390 Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; simple (i.e., valvotomy, debridement, debulking, and/or simple commissural resuspension) describes a “simple” procedure. Code 33391 Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; complex (i.e., leaflet extension, leaflet resection, leaflet reconstruction, or annuloplasty) describes a “complex” procedure.

Explanation: For complete exchange transfusions in a neonate, report 36450 Exchange transfusion, blood; newborn. Do not report 36456 Partial exchange transfusion, blood, plasma, or crystalloid necessitating the skill of a physician or other qualified health care professional, newborn with transfusion services 36430, 36440, or 36450.

Explanation: Codes 27193 and 27914 were deleted for 2017 and replaced with two new codes: 27197 Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation and 27198 Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural).

Explanation: For closed treatment of anterior (vs. posterior) pelvic ring fracture and dislocation(s) of the pubic symphysis and superior/inferior rami (unilateral or bilateral), CPT® instructs you to report an appropriate E/M services code.

Explanation: In 2017, eight influenza vaccine codes are reported by dosage, rather than patient age (deleted text is crossed out, new text is underlined): 90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to children 6-35 months of age0.25 mL dosage, for intramuscular use 90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when administered to individuals 3 years and older0.5 mL dosage, for intramuscular use 90657 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to children 6-35 months of age0.25 mL dosage, for intramuscular use 90658 Influenza virus vaccine, trivalent (IIV3), split virus, when administered to individuals 3 years of age and older0.5 mL dosage, for intramuscular use 90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to children 6-35 months of age0.25 mL dosage, for intramuscular use 90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when administered to individuals 3 years of age and older0.5 mL dosage, for intramuscular use 90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to children 6-35 months of age0.25 mL dosage, for intramuscular use 90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, when administered to individuals 3 years of age and older0.5 mL dosage, for intramuscular use In this scenario, there is no mention of preservative- free vaccine.

Explanation: Medicare requires G0008 Administration of influenza virus vaccine for the administration of a flu vaccination. Note also that Medicare pays for a single influenza virus vaccination per influenza season.

The ICD-10 Procedure Coding System (ICD-10-PCS) is an international system of medical classification used for procedural coding. ICD-10-PCS is a replacement for ICD-9-CM, Volume 3.

Applicable To
Coxsackievirus meningitis
Echovirus meningitis