Medicare Correct Coding Guide

Contents Getting Started with Medicare Correct Coding Guide .................................................................................................................................. Introduction–1 Introduction ........................................................................................................................................................................................................................ Introduction–3 Resource-Based Relative Value Scale (RBRVS) ..........................................................................................................................................Introduction–3 Correct Coding Initiative (CCI) ......................................................................................................................................................................Introduction–3 Manual Organization ...................................................................................................................................................................................Introduction–3 How to Use This Book .................................................................................................................................................................................Introduction–4 Resource-Based Relative Value Scale (RBRVS) Payment Computation ..........................................................................................Introduction–4 Modifiers ......................................................................................................................................................................................................Introduction–4 Surgery Modifiers ..............................................................................................................................................................................Introduction–4 Modifiers Affecting Correct Coding Edits ..........................................................................................................................................Introduction–5 Other Payment Indicators ............................................................................................................................................................................Introduction–5 Status Indicator ...................................................................................................................................................................................Introduction–5 Global Period ......................................................................................................................................................................................Introduction–5 Physician Supervision Level ..............................................................................................................................................................Introduction–5 Definitions ...........................................................................................................................................................................................Introduction–5 Correct Coding Initiative (CCI) ......................................................................................................................................................................Introduction–6 Step-by-Step Instructions .............................................................................................................................................................................Introduction–7 Code Pair Additions ..................................................................................................................................................................................... Summary of Changes–1 Code Pair Deletions ....................................................................................................................................................................................Summary of Changes–91 Modifier Revisions ..................................................................................................................................................................................Summary of Changes–151 General Correct Coding Policies ..........................................................................................................................................................................................General–1 A. Introduction ...........................................................................................................................................................................................General–1 B. Coding Based on Standard of Medical/Surgical Practice ...................................................................................................................General–1 C. Medical/Surgical Package ....................................................................................................................................................................General–2 D. Evaluation and Management Services ................................................................................................................................................General–3 E. Modifiers and Modifier Indicators .......................................................................................................................................................General–4 F. Standard Preparation/Monitoring Services .........................................................................................................................................General–5 G. Anesthesia Service Included in the Surgical Procedure .....................................................................................................................General–5 H. HCPCS/CPT Procedure Code Definition ...............................................................................................................................................General–5 I. HCPCS/CPT Coding Manual Instruction/Guideline ..............................................................................................................................General–6 J. Separate Procedure ................................................................................................................................................................................General–6 K. Family of Codes ....................................................................................................................................................................................General–6 L. Most Extensive Procedure ....................................................................................................................................................................General–6 M. Sequential Procedure ...........................................................................................................................................................................General–6 N. Laboratory Panel ..................................................................................................................................................................................General–7 O. Misuse of Column 2 Code with Column 1 Code ..............................................................................................................................General–7 P. Mutually Exclusive Procedures ...........................................................................................................................................................General–7 Q. Gender-Specific Procedure (formerly Designation of Sex) ................................................................................................................General–7 R. Add-on Codes ........................................................................................................................................................................................General–7 S. Excluded Service ...................................................................................................................................................................................General–8 T. Unlisted Service or Procedure ..............................................................................................................................................................General–8 U. Modified, Deleted, and Added Code Pairs/Edits ................................................................................................................................General–8 V. Medically Unbelievable Edits (MUEs) ..................................................................................................................................................General–8 Surgery: Integumentary System (CPT Codes 10000–19999) ................................................................................................................ Integumentary–1 Correct Coding Policies ........................................................................................................................................................................... Integumentary–1 A. Introduction ............................................................................................................................................................................... Integumentary–1 B. Evaluation and Management ................................................................................................................................................... Integumentary–1 C. Anesthesia ................................................................................................................................................................................. Integumentary–1 D. Incision and Drainage .............................................................................................................................................................. Integumentary–1 E. Lesion Removal ......................................................................................................................................................................... Integumentary–2 F. Repair and Tissue Transfer ...................................................................................................................................................... Integumentary–3 G. Grafts and Flaps ....................................................................................................................................................................... Integumentary–3 H. Breast (Incision, Excision, Introduction, Repair and Reconstruction) .................................................................................... Integumentary–3 I. Add-on Codes ............................................................................................................................................................................. Integumentary–4 J. General Policy Statements ........................................................................................................................................................ Integumentary–4 © 2005 Ingenix, Inc. CPT only © 2005 American Medical Association. All Rights Reserved.

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Contents-1

Medicare Correct Coding Guide (CCI—Version 12.0)

Integumentary System Code Tables ...................................................................................................................................................... Integumentary–5 Surgery: Musculoskeletal System (CPT Codes 20000–29999) ........................................................................................................... Musculoskeletal–1 Correct Coding Policies .........................................................................................................................................................................Musculoskeletal–1 A. Introduction .............................................................................................................................................................................Musculoskeletal–1 B. Anesthesia ...............................................................................................................................................................................Musculoskeletal–1 C. Biopsy ......................................................................................................................................................................................Musculoskeletal–1 D. Fractures .................................................................................................................................................................................Musculoskeletal–1 E. General Policy Statements ......................................................................................................................................................Musculoskeletal–1 Musculoskeletal System Code Tables .................................................................................................................................................Musculoskeletal–3 Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems, Mediastinum and Diaphragm (CPT Codes 30000–39999) .................................................................................................................................................................................. Respiratory–1 Correct Coding Policies .................................................................................................................................................................................Respiratory–1 A. Introduction .....................................................................................................................................................................................Respiratory–1 B. Respiratory System ........................................................................................................................................................................Respiratory–1 C. Cardiovascular System ...................................................................................................................................................................Respiratory–2 D. Hemic and Lymphatic Systems .....................................................................................................................................................Respiratory–3 E. General Policy Statements ..............................................................................................................................................................Respiratory–3 Respiratory System Code Tables .................................................................................................................................................................Respiratory–5 Cardiovascular System Code Tables ........................................................................................................................................................ Respiratory–39 Hemic and Lymphatic System Code Tables............................................................................................................................................Respiratory–114 Mediastinum and Diaphragm System Code Tables .............................................................................................................................Respiratory–120 Surgery: Digestive System (CPT Codes 40000–49999) ......................................................................................................................................... Digestive–1 Correct Coding Policies .................................................................................................................................................................................... Digestive–1 A. Introduction ........................................................................................................................................................................................ Digestive–1 B. Endoscopic Services .......................................................................................................................................................................... Digestive–1 C. Abdominal Procedures ...................................................................................................................................................................... Digestive–2 D. General Policy Statements ................................................................................................................................................................ Digestive–2 Digestive System Code Tables........................................................................................................................................................................ Digestive–5 Surgery: Urinary, Male Genital and Female Genital Systems, Maternity Care and Delivery (CPT Codes 50000–59999) ............................................................................................................................................................................................Urinary–1 Correct Coding Policies ....................................................................................................................................................................................... Urinary–1 A. Introduction ........................................................................................................................................................................................... Urinary–1 B. Urinary System ..................................................................................................................................................................................... Urinary–1 C. Male Genital System ............................................................................................................................................................................ Urinary–2 D. Female Genital System ........................................................................................................................................................................ Urinary–2 E. Maternity Care and Delivery ................................................................................................................................................................ Urinary–3 F. General Policy Statements .................................................................................................................................................................... Urinary–3 Urinary System Code Tables .............................................................................................................................................................................. Urinary–5 Male Genital System Code Tables.................................................................................................................................................................... Urinary–46 Female Genital System Code Tables ............................................................................................................................................................... Urinary–64 Maternity Care and Delivery Code Tables ..................................................................................................................................................... Urinary–91 Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, Auditory Systems (CPT Codes 60000–69999) .................................... Endocrine–1 Correct Coding Policies ................................................................................................................................................................................... Endocrine–1 A. Introduction ....................................................................................................................................................................................... Endocrine–1 B. Endocrine and Nervous Systems .................................................................................................................................................... Endocrine–1 C. Ophthalmology ................................................................................................................................................................................. Endocrine–2 D. Auditory System ............................................................................................................................................................................... Endocrine–2 E. Operating Microscope ...................................................................................................................................................................... Endocrine–2 F. General Policy Statements ................................................................................................................................................................ Endocrine–3 Endocrine System Code Tables .................................................................................................................................................................... Endocrine–5 Nervous System Code Tables ........................................................................................................................................................................ Endocrine–9 Eye and Ocular Adnexa Code Tables .......................................................................................................................................................... Endocrine–75 Auditory System Code Tables ....................................................................................................................................................................Endocrine–108 Radiology Services (CPT Codes 70000–79999) ...................................................................................................................................................... Radiology–1 Correct Coding Policies ................................................................................................................................................................................... Radiology–1 A. Introduction ....................................................................................................................................................................................... Radiology–1 B. Noninterventional Diagnostic Imaging ........................................................................................................................................... Radiology–1 C. Interventional/Invasive Diagnostic Imaging ................................................................................................................................... Radiology–1 Contents-2

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© 2005 Ingenix, Inc. CPT only © 2005 American Medical Association. All Rights Reserved.

D. Evaluation and Management .......................................................................................................................................................... Radiology–2 E. Nuclear Medicine .............................................................................................................................................................................. Radiology–2 F. Radiation Oncology .......................................................................................................................................................................... Radiology–2 G. General Policy Statements ............................................................................................................................................................... Radiology–2 Radiology Code Tables .................................................................................................................................................................................. Radiology–5 Pathology/Laboratory Services (CPT Codes 80000–89999) .............................................................................................................................Pathology–1 Correct Coding Policies .................................................................................................................................................................................. Pathology–1 A. Introduction ...................................................................................................................................................................................... Pathology–1 B. Organ- or Disease-Oriented Panel .................................................................................................................................................. Pathology–1 C. Evocative/Suppression Testing ....................................................................................................................................................... Pathology–1 D. General Policy Statements ............................................................................................................................................................... Pathology–2 Pathology and Laboratory Services Code Tables ......................................................................................................................................... Pathology–5 Medicine, Evaluation and Management Services (CPT Codes 90000–99999) .......................................................................................... Medicine–1 Correct Coding Policies .................................................................................................................................................................................... Medicine–1 A. Introduction ........................................................................................................................................................................................ Medicine–1 B. Therapeutic or Diagnostic Infusions/Injections and Immunizations .............................................................................................. Medicine–1 C. Psychiatric Services ............................................................................................................................................................................ Medicine–2 D. Biofeedback ........................................................................................................................................................................................ Medicine–2 E. Gastroenterology ................................................................................................................................................................................ Medicine–2 F. Ophthalmology ................................................................................................................................................................................... Medicine–2 G. Otorhinolaryngologic Services .......................................................................................................................................................... Medicine–3 H. Cardiovascular Services ..................................................................................................................................................................... Medicine–3 I. Pulmonary Services ............................................................................................................................................................................. Medicine–4 J. Allergy Testing and Immunotherapy ................................................................................................................................................. Medicine–4 K. Neurology and Neuromuscular Procedures .................................................................................................................................... Medicine–4 L. Central Nervous System Assessments/Tests .................................................................................................................................... Medicine–5 M. Chemotherapy Administration ......................................................................................................................................................... Medicine–5 N. Physical Medicine and Rehabilitation .............................................................................................................................................. Medicine–6 O. Osteopathic Manipulative Treatment ............................................................................................................................................... Medicine–6 P. Chiropractic Manipulative Treatment ................................................................................................................................................ Medicine–6 Q. Miscellaneous Services ..................................................................................................................................................................... Medicine–6 R. Evaluation and Management ............................................................................................................................................................ Medicine–6 S. General Policy Statements ................................................................................................................................................................. Medicine–7 Medicine Services Code Tables ....................................................................................................................................................................... Medicine–9 Evaluation and Management Services Code Tables ................................................................................................................................. Medicine–130 Category III Codes CPT Codes (0001T–0099T) ....................................................................................................................................................Category III–1 Correct Coding Policies ................................................................................................................................................................................ Category III–1 A. Introduction .................................................................................................................................................................................... Category III–1 Category III Code Tables .............................................................................................................................................................................. Category III–3 HCPCS Level II [Supplemental Services] (Codes A0000–V9999) ............................................................................................................................ HCPCS–1 Correct Coding Policies ........................................................................................................................................................................................ HCPCS–1 A. Introduction ............................................................................................................................................................................................ HCPCS–1 B. General Policy Statements ..................................................................................................................................................................... HCPCS–1 HCPCS Level II Supplemental Services Code Tables .......................................................................................................................................... HCPCS–3 Appendix A: Geographic Practice Cost Indices by Medicare Locality .....................................................................................................Appendix A–1 Appendix B: Modifiers .....................................................................................................................................................................................................Appendix B–1

© 2005 Ingenix, Inc. CPT only © 2005 American Medical Association. All Rights Reserved.

January 06

Contents-3

Surgery: Integumentary System

19125

RELATIVE VALUE UNITS Work MP PE–nf 6.05

0.80

PE–f

4.79

3.29

50

Total–f

Global P

RELATIVE VALUE UNITS Work MP PE–nf

11.64

10.14

90

13.51

51

62

66

DOC

NPD

80, 82 NPD

Suprv 09

Status

50

A

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