Coding and Payment Guide for the Physical Therapist

Transcription

Coding and Payment Guide
for the Physical Therapist
An essential coding, billing, and payment
resource for the Physical Therapist
Introduction
Introduction
Coding systems and claim forms are the realities of modern
health care. Of the multiple systems and forms available,
what you use is greatly determined by the setting, the type
of insurance, and your practice style.
This book provides a comprehensive look at the coding and
reimbursement systems used by physical therapists. It is
organized topically and numerically, and can be used as a
comprehensive coding and reimbursement resource and as
a quick-lookup resource for coding.
Coding Systems
The coding systems discussed in this coding and payment
guide seek to answer two questions: What was wrong with
the patient (i.e., the diagnosis or diagnoses) and what was
done to treat the patient (i.e., the procedures or services
rendered).
Health care providers need to be aware of the necessity for
specific diagnosis coding. Using only the first three digits of
the ICD-9-CM diagnosis code when fourth and fifth digits
are available will result in a delay in payment and requests
for additional information from the provider.
HCPCS Level I (CPT) Codes
The Centers for Medicare and Medicaid Services (CMS), in
conjunction with the American Medical Association (AMA),
the American Dental Association (ADA) and several other
professional groups have developed, adopted, and
implemented a three-level coding system describing services
rendered to patients. Level I and the most commonly used
system is the CPT coding system published annually and
copyrighted by the AMA. This system reports outpatient and
provider services.
Coding systems grew out of the need for data collection. By
having a standard notation for the procedures performed
and for the diseases, injuries, and illnesses diagnosed,
statisticians could identify effective treatments as well as
broad practice patterns. Before long, these early coding
systems emerged as the basis to pay claims.
CPT codes predominantly describe medical services and
procedures, and have been adapted to provide a common
billing language that providers and payers can use for
payment purposes. The codes are becoming more widely
used and required for billing by both private and public
insurance carriers, managed care companies, and workers’
compensation programs.
Under the aegis of the federal government, a three-tiered
coding system has emerged for physician offices and
outpatient facilities. Physicians’ Current Procedural
Terminology (CPT) codes report procedures and physician
services comprises Level I. A second level, known as HCPCS
Level II codes, largely report supplies, non-physician
services, and pharmaceuticals. A third level of codes
previously used on a local or regional basis is no longer in
use. Dovetailing with each of the levels is the International
Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM) classification system that reports the diagnosis
of illnesses, diseases, and injuries. (A portion of ICD-9-CM,
Volume 3, also contains codes for inpatient procedures and
is used exclusively by inpatient facilities.) Further
explanations of these coding systems will follow.
The AMA’s CPT Editorial Panel reviews the coding system
annually and adds, revises, and deletes codes and their
descriptions. These changes are published annually and
available for use January 1 of each year. The panel accepts
information and feedback from providers about new codes
and revisions to existing codes that could better reflect the
provided service or procedure. The American Physical
Therapy Association (APTA) is represented on the Health
Care Professional Advisory Committee (HCPAC) for both
the AMA CPT Editorial Panel and the AMA Relative Value
Update Committee (RUC). The CPT HCPAC representative
provides input for the development and revision of CPT
codes, while the RUC HCPAC representative provides input
into the establishment of relative values for the codes.
ICD-9-CM Codes
ICD-9-CM is used to classify illnesses, injuries, and patient
encounters with health care practitioners for services.
The ICD-9-CM classification system is a method of
translating medical terminology into codes. Codes within
the system are either numeric or alphanumeric and are
composed of three, four, or five characters. A decimal point
follows all three-character codes when fourth and fifth
characters are needed. “Coding” involves using a numeric
or alphanumeric code to describe a disease or injury. For
example, frozen shoulder is classified to code 726.0.
Generally, the reason the patient seeks treatment should be
sequenced first when multiple diagnoses are listed. Claims
forms require that the appropriate ICD-9-CM code be
reported rather than a description of the functional deficits.
CPT is a registered trademark of the American Medical Association.
©2003 Ingenix, Inc.
HCPCS Level II Codes
HCPCS Level II codes are commonly referred to as national
codes or by the acronym HCPCS (Health Care Common
Procedure Coding System — pronounced “hik piks”).
HCPCS codes are used for billing Medicare and Medicaid
patients and have also been adopted by some third-party
payers.
HCPCS Level II codes, updated and published annually by
CMS, are intended to supplement the CPT coding system
by including codes for non-physician services, durable
medical equipment (DME), and supplies. These Level II
codes consist of one alphabetic character (A through V)
followed by four numbers. In many instances, HCPCS Level
II codes are developed as a precursor to CPT.
1
Introduction
Non-Medicare acceptance of HCPCS Level II codes is
idiosyncratic. Providers should check with the payer before
billing these codes.
HCPCS Level III (Local) Codes
All HCPCS local codes have been phased out, a process that
began in 2002. As the first step, effective October 16, 2002,
carriers were required to eliminate all local codes and
modifiers that had not been approved by CMS. Carriers had
to identify those codes and modifiers in use, crosswalk
them to national codes, and delete any that were not
approved. If carriers felt that an unapproved code should be
retained for use, they had to submit a request for a
temporary national code for that service/supply, with an
explanation as to why the code should be retained. These
requests were due to the regional offices by April 1, 2002.
The next phase was the elimination of the official HCPCS
Level III local codes and modifiers by December 31, 2003.
Again, carriers were required to review all local codes in
their systems, crosswalk them to appropriate national
codes, and submit requests for replacement temporary
national codes by April 1, 2003. Temporary national codes
that are requested and approved will be implemented
January 1, 2004.
Local codes had been used to denote new procedures or
specific supplies for which there was no national code. For
Medicare, these five-digit alphanumeric codes used the
letters W through Z. Each carrier created local codes as the
need dictated. However, carriers were required to obtain
approval from CMS's central office before implementing
them. The Medicare carrier was responsible for providing
you with these codes.
As a result of the Consolidated Appropriations Act of 2001,
and as part of the National Code Data Sets implemented
under the Health Insurance Portability Accountability Act,
the Secretary of Health and Human Services was instructed
to maintain and continue the use of HCPCS level III codes
through December 31, 2003.
Program Memorandum (PM) AB-01-45 instructed carriers
to take the following steps to implement the law on April
29, 2001:
•
Maintain and accept current level III HCPCS codes and
modifiers until December 31, 2003. However, carriers
were not allowed to create any new HCPCS Level III
codes or modifiers.
•
Carriers were to reinstate any HCPCS Level III codes
and modifiers they may have eliminated after August
16, 2000.
•
Carriers were to publish on their Web sites any HCPCS
Level III codes and modifiers with their descriptors that
were in effect August 16, 2000.
Medicare carriers who wished to establish a temporary
national code were required to submit the request to their
regional office. The regional office then submitted that
recommendation to the central office for approval.
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Claim Forms
Institutional (facility) providers use the UB-92 claim form,
also known as the CMS-1450, to file a Medicare Part A
claim to Medicare Fiscal Intermediaries. Non-institutional
providers and suppliers (private practices or other health
care providers’ offices) utilize the CMS-1500 form to
submit claims to Medicare Carriers for Medicare Part
B-covered services. Medicare Part A coverage includes
inpatient hospital, skilled nursing facilities, hospice, and
home health. Part A providers also include rehabilitation
agencies and comprehensive outpatient rehabilitation
facilities (CORFs). Medicare Part B coverage provides
payment for medical supplies, physician services, and
outpatient services delivered in a private practice setting.
Not all services rendered by a facility are inpatient services.
Providers working in facilities routinely render services on
an outpatient basis. Outpatient services are provided in
settings that include rehabilitation centers, certified
outpatient rehabilitation facilities, skilled nursing facilities,
and hospitals. Outpatient and partial hospitalization
facility claims might be submitted on either a CMS-1500 or
a UB-92 depending on the payer.
For professional component billing, most claims are filed
using ICD-9-CM diagnosis codes, CPT procedure codes, and
CMS-1500 forms.
While discussing claim forms, it is important to note that
due to the administrative simplification provisions of
HIPAA, health care plans, clearinghouses, and providers
who transmit health care information in electronic form
will be subject to the electronic data interchange (EDI)
standards for certain types of information exchanges. All
health care providers using electronic transmittals are
required to use a uniform set of EDI standards for billing
and other health care transactions, and all health plans will
be required to accept these standard electronic claims. The
vast majority of inpatient claims are already submitted in
this format, as are the largest percentage of provider claims.
Although health care providers are not required to transmit
transactions electronically and may continue to use paper
media, the health plans they bill are not prohibited from
independently requiring the EDI standards for paper
transactions as well.
The advantages of electronic claim submission over paper
claim submission are many. Clean electronic claims are
paid in about half the time of clean paper claims, costs are
greatly reduced, and your staff spends less clerical time in
claims processing. Errors can be minimized due to built-in
edits that prevent common errors and omission of required
data-field information. You receive transmission and
validation reports electronically that notify you of
successful file transfers, as well as an “Error/Acceptance”
report within 24 hours that tells you how many claims were
accepted and how many were rejected due to invalid or
missing information.
The Reimbursement Process
•
Services that are not proven to be safe and effective
based on peer review or scientific literature
•
Experimental or investigational services
•
Services that are furnished at a duration, intensity, or
frequency that is not medically appropriate
Coverage Issues
•
Services that are not furnished in accordance with
accepted standards of medical practice
•
Services that are not furnished in a setting appropriate to
the patient’s medical needs and condition
First, you need to know what services are covered. Covered
services are services payable by the insurer in accordance
with the terms of the benefit-plan contract. Such services
must be documented and medically necessary for payment
to be made. Typically, third-party payers define medically
necessary services or supplies as:
•
Services that have been established as safe and effective
•
Services that are consistent with the symptoms or
diagnosis
•
Services that are necessary and consistent with generally
accepted medical standards
•
Services that are furnished at the most appropriate, safe,
and effective level
Documentation must be provided to support the medical
necessity of a service, procedure, and/or other items. This
documentation should show:
•
What service or procedure was rendered
•
To what extent the service or procedure was rendered
•
Why the service, procedure, or other item(s) was
medically warranted
When providing physical therapy services, it is especially
important for providers to thoroughly and individually
document all care given to each patient at each visit,
including the amount of time spent performing each
intervention. When in doubt, providers should consult with
the payer or refer to local medical review policies for guidance.
Verify that all services billed are medically necessary. If the
provider feels that it is medically necessary for the patient
to receive physical therapy treatments that are more or less
than the current standard of practice, clearly document the
rationale used for this decision in the patient’s record.
Physical and occupational therapy services are covered only
for restorative therapy, when there is the expectation of
restoring a patient’s level of function that has been lost due
to injury or illness, and not to maintain a level of function.
Maintenance care is not be reimbursed by CMS. Other
third-party payer policy may vary.
Payer Types
Most providers have to deal with a number of different
payers and plans, each with its own specific policies and
methods of reimbursement. For that reason, it is important
to become familiar with the guidelines for every payer and
plan that your practice has contact with. Some insurance
plans are administered by either federal or state
government, including Medicare, Medicaid, and TRICARE.
Private payers range from fee-for-services plans to health
maintenance organizations.
Medicare
Administered by the federal government, Medicare provides
health insurance benefits to those 65 years of age and older,
and individuals of any age who are entitled to disability
benefits under Social Security or Railroad Retirement
programs. In addition, individuals with end-stage renal
disease that require hemodialysis or kidney transplants are
also eligible for Medicare benefits. Consisting of two parts,
Medicare Part A (for which all persons over 65 are
qualified) covers hospitalization and related care while Part
B (which is optional) covers physician and other related
health services. Fees for Medicare services delivered in the
outpatient setting are based on the Medicare fee schedule.
In addition, the Medicare+Choice plan, created in 1997 as
part of the Balanced Budget Act (BBA), allows managed care
plans, such as health maintenance organizations (HMOs)
and preferred provider organizations (PPOs), to join the
Medicare system. Access to these various options depend on
where the beneficiary lives and the availability of plans in
their community.
Medicaid
Services, procedures, and/or other items that may not be
considered medically necessary are:
Medicaid is administered by the state governments under
federal guidelines to provide health insurance for lowincome or otherwise needy individuals. In addition to the
broad guidelines established by the federal government,
each state has the responsibility to administer its own
program including:
•
Services that are not typically accepted as safe and
effective in the setting where they are provided
•
Establishing eligibility standards
•
•
Services that are not generally accepted as safe and
effective for the condition being treated
Determining the type, amount, duration, and scope of
services
Reimbursement
Receiving appropriate reimbursement for professional services
can sometimes be difficult because of the myriad of rules and
paperwork involved. The following reimbursement guidelines
will help you understand the various requirements for getting
claims paid promptly and correctly.
5
•
Setting payment rates for services
Indemnity Plans
•
Program administration
Under indemnity plans, which are generally fee-for-service,
the payer provides payment directly to the provider of
service when benefits have been assigned by the patient. Many
carriers now include PPO attributes to help reduce costs.
Reimbursement
TRICARE
Formerly called CHAMPUS, TRICARE provides health
insurance to active and retired military personnel and
dependents.
Blue Cross and Blue Shield
Blue Cross (hospital services) and Blue Shield (physician
services) were the first pre-paid health plan in the country.
Although all “Blues” plans are independent, they are united
by membership in the national Blue Cross and Blue Shield
Association (BCBSA). The Blue Cross and Blue Shield
System is responsible for the administration of the four
million-member Federal Employee Program (FEP),
comprising all federal government employees, retirees, and
dependents.
Health Maintenance Organizations (HMOs)
The most common form of managed care is the HMO. This
type of plan has several variations, but basically, the
subscriber pays a monthly fee for services, regardless of the
type or amount of services provided. The primary care
physician (PCP) acts as a gatekeeper to coordinate the
individual’s care and to make decisions regarding specialty
referral and care. In a “group model” HMO, referrals for
care outside of the large independent physician group must
be arranged, care for emergency services must be
preauthorized, and information about care provided in a
life-threatening situation must be communicated to the
plan within a specified period of time. On the other hand,
the managed choice model HMO allows individuals to
access care via the PCP or to go outside of the network to
receive care without permission of the PCP, but at a lower
level of benefits.
Preferred Provider Organizations
Preferred provider organizations (PPOs), are generally
contracted by an employer group or other plans to provide
hospital and physician services at reduced rates. Although
coverage is higher for preferred or participating providers,
individuals have the option to seek services provided by
non-participating providers. A variation of the PPO is the
exclusive provider organization (EPO,) where enrollees
must receive care within the network and must assume
responsibility for all out-of-network costs.
Point-of-Service Plans (POS)
Point-of-service plans permit covered individuals to receive
services from participating or nonparticipating providers,
but with a higher level of benefits when participating
providers are used.
Independent Practice Association (IPA)
This type of organization comprises physicians that
maintain separate practices and participate in the IPA as a
means to contract with HMOs or other health plans. The
physicians also generally treat patients who are not
members of the HMO or other plans.
6
Third-Party Administrators (TPAs) and
Administrative Services Organizations (ASOs)
Although neither insurers or health plans, TPAs and ASOs
manage and pay claims for clients such as self-insured
groups. The self-insured group then assumes the risk of
providing the services and may contract directly with
providers or use the services of a PPO.
Physician Hospital Organization (PHO)
Hospitals and physician organizations may create a PHO to
assist in managed care contracting on behalf of the parties.
Degrees of management, common ownership, and
oversight vary depending on the model of the arrangement.
Payment Methodologies
Once covered services are known, the next issue to resolve
is how you will be paid for those services. Over the last
several years, there have been major changes to provider
payment systems. The following will discuss the many
varieties of payment methodologies used by Medicare and
other third-party payers for outpatient and inpatient claims.
Diagnosis-related Groups (DRGs)
DRGs apply to inpatient acute hospital/facility settings
only, grouping multiple diagnoses together. Reimbursement
is based on this grouping rather than on the actual services.
Inpatient stays typically use revenue codes to describe the
treatments or procedures rendered.
Ambulatory Payment Classifications (APCs)
APCs, Medicare’s new outpatient prospective payment
system, is a methodology for payments to hospitals for a
wide range of facility services when performed on an
outpatient or a partial hospitalization basis. It differs from
the Diagnosis-related Grougs (DRGs) used by hospitals in
that DRGs are driven by ICD-9-CM diagnostic groups,
where APCs are grouped by the actual service provided.
CPT and HCPCS codes are organized into payment groups,
with a fixed payment for each group that is geographically
adjusted.
Some services have been exempted from APC payment
methodology and will continue to be paid in accordance
with the respective fee schedules for these specific services.
These services include: end-stage renal disease services;
laboratory; durable medical equipment; screening
mammography; ambulance services; pulmonary
rehabilitation; and clinical trials.
For more information on APCs, see our Ingenix
Publications identified in the front of this publication.
Usual, Customary, and Reasonable
Fee-for-service reimbursement based on reasonable and
customary charges was the method that Medicare, as well as
Documentation — An Overview
Still, until about 35 years ago, no clear standards existed for
recording patient information. Medical documentation was
seen, maintained, and used almost exclusively by
physicians and medical staff. Patient care information was
never submitted to insurance companies or to government
payers; only rarely did medical documentation become the
focus of malpractice suits.
Developments in the mid-1970s, however, irrevocably
affected the role of documentation in medicine. A dramatic
national increase in medical malpractice claims and awards
abruptly altered the strictly clinical nature of documentation.
The patient medical record was swept into the broad realm
of civil law. Since most medical liability suits approach
resolution years after the contested care, the medical record
provides a main source of information about what
happened. The patient record became a legal document, a
basis to reconstruct the quality and quantity of health care
services. In many instances, it also serves as a provider’s
only defense against charges of malpractice.
Marked changes to the Medicare program also served to
broaden the influence for medical documentation during
the 1970s. For example, the Centers of Medicare and
Medicaid Services (CMS), Medicare’s federal administrator,
authorizes the program’s regional carriers to review paid
claims to determine whether the care was medically
necessary, as mandated under the Social Security Act of 1996.
This type of review checks processed and paid claims
against the documentation recorded at the time of service.
The aim is to ensure that Medicare dollars are administered
correctly and, once again, medical documentation must
support the medical necessity of the service, to what extent
the service was rendered, and why it was medically
justified. For example, a physical therapist re-evaluates a
patient after the prescribed treatment plan has been
completed. The physical therapist determines that the
patient would continue to benefit from further encounters
for manual traction and therapeutic exercise. Depending
upon the payer guidelines, this may require prior
authorization from the primary care physician, or the payer.
Medicare does not pay for services that are “medically
unnecessary,” according to Medicare standards. Patients are
not liable to pay for such services if the service is performed
without prior notification from the physician. Medical
necessity requires items and services to be:
•
Consistent with symptoms or diagnosis of disease or
injury
•
Necessary and consistent with generally accepted
professional medical standards (e.g., not experimental
or investigational)
•
Furnished at the most appropriate level that can be
provided safely and effectively to the patient
Computer conversion of the review process in the 1980s
added a new twist: speed and a degree of accuracy. Claims
adjudication, data analysis, and physician profiling revealed
incongruities. A significant number of physicians and
hospitals were found to have billed for services that were
not provided or found to be medically unnecessary.
Projected total estimates in the millions of dollars were
publicized by CMS as findings of fraud and abuse. These
findings led to the creation of the federal fraud and abuse
program coordinated by several federal organizations,
including the Department of Health and Human Services
(HHS) and its agencies, CMS, and the Office of Inspector
General (OIG). In 1997, CMS reported a possible $23
billion in questionable Medicare payments due to
documentation problems in the hospital and outpatient
settings.
Commercial insurance companies were quick to follow suit.
Similar to CMS, private payers monitor claims to uncover
coding mistakes and to verify that the documentation
supports the claims submitted. Although there are no
national guidelines for proper documentation, the
guidelines this chapter provides should ensure better
quality of care and increase the chances of full and fair
reimbursement.
General Guidelines for Documentation
Documentation is the recording of pertinent facts and
observations about a patient’s health history, including past
and present illnesses, tests, treatments, and outcomes. The
medical record chronologically documents the care of the
patient to:
•
Enable a health care professional to plan and evaluate
the patient’s treatment
•
Enhance communication and promote continuity of
care among health care professionals involved in the
patient’s care
•
Facilitate claims review and payment
•
Assist in utilization review and quality of care
evaluations
•
Reduce hassles related to medical review
•
Provide clinical data for research and education
25
Documentation
The role played by medical documentation has always been
a supportive one. As the practice of medicine became more
sophisticated and complex, the need to record specific
clinical data grew in importance. What certainly began as a
simple written mechanism to jog the memory of a treating
physician evolved into a more refined system to service
others assisting in patient care. Tracking patient history
emerged as a fundamental element in planning a course of
treatment. When medical specialties evolved early in the
last century, the patient record offered a means to provide
pertinent data for referrals and consultations.
•
The patient’s progress, including response to treatment,
change in treatment, change in diagnosis, and patient
noncompliance, should be documented.
Payers want to know that their health care dollars are well
spent. Because they have a contractual obligation to
beneficiaries, they look for the documentation to validate
that services are:
•
The written plan for care should include treatments and
medications—specifying frequency and dosage, any
referrals and consultations, patient and family
education, and specific instructions for follow-up.
•
Appropriate for treating the patient’s condition
•
•
Medically necessary for the diagnosis
•
Coded correctly
The documentation should support the intensity of the
patient evaluation and the treatment, including thought
processes and the complexity of medical decision
making.
•
All entries to the medical record should be dated and
authenticated.
•
The codes reported on the health insurance claim form
or billing statement should reflect the documentation
in the medical record.
•
Serve as a legal document to verify the care provided
(e.g., as defense in the case of a professional liability
claim)
Documentation
Coding Tip
Documentation guidelines developed specifically for
the physical therapist by the American Physical
Therapy Association will be discussed in detail
further in this chapter.
To ensure the appropriate reimbursement for
services, the provider should use documentation to
demonstrate compliance with any third-party payer
utilization guidelines.
Principles of Documentation
To provide a basis for maintaining adequate medical record
information, follow the principles of medical record
documentation listed. The principles below have been
developed by representatives of the following
organizations:
•
American Health Information Management Association
(AHIMA)
•
American Hospital Association (AHA)
•
American Managed Care and Review Association
(AMCRA)
•
American Medical Association (AMA)
•
American Medical Peer Review Association (AMPRA)
•
Blue Cross and Blue Shield Association
•
Health Insurance Association of America (HIAA)
Medical Record Documentation
• The medical record should be complete and legible.
•
The documentation of each patient encounter should
include the date, the reason for the encounter,
appropriate history and physical exam (when
applicable), review of lab and x-ray data, as well as
other ancillary services (where appropriate), an
assessment, and plan for care (including discharge plan,
if appropriate).
•
Past and present diagnoses should be accessible to the
treating or consulting health care professional.
•
The reasons for and results of x-rays, lab tests, and other
ancillary services should be documented and included
in the medical record.
•
Relevant health risk factors should be identified.
26
Documentation to Code and Bill
Many insurers rely on written evidence of the evaluation of
the patient, care plan, and goals for improvement to
determine and approve the medical necessity of care. Initial
evaluation findings documenting the diagnosis form the
basis for judging the reasonableness and necessity of care
that was subsequently provided. Consequently, the more
accurately the patient’s evaluation and treatment are
described, the easier it is to code the diagnoses and
procedures properly.
ICD-9-CM Coding
ICD-9-CM codes relate to the medical diagnosis and are
used to classify illnesses, injuries, and reasons for patient
encounters with the health care system. Patients may have a
single primary, or one primary and several secondary
diagnoses. Medical diagnoses are sequenced by order of
severity or importance.
Describing the onset of the problem and objectively
documenting the patient’s impairment are essential to
ensuring accurate coding and description of the diagnosis.
Confirming any diagnosis is based on objective
measurements performed and values obtained during an
assessment. The diagnostic description of the current
problem for which the patient is being treated should be
defined by:
•
Patient’s subjective complaint
•
Problem’s date of onset
•
Objective test values confirming the diagnosis
•
Outcomes expected after treatment
For more information tailored to your specialty, see the
chapter on diagnostic coding.
Coding Tip
At each visit, the therapist should record the medical
condition being treated.
Claims Processing
The most important document for correct reimbursement is
the insurance claim, whether it is submitted electronically
or on a standardized paper claim form. Other information,
such as operative reports, chart notes, and cover letters may
establish medical necessity, but the claim “sets the stage.”
The term “claims processing” describes the course of
submitting a claim to the payer and subsequent
adjudication. Understanding how this process works allows
physicians and staff members to file claims properly and
leads to maximum and timely reimbursement. In addition,
this knowledge will allow the provider’s office to serve as a
resource to patients in understanding the process.
For paper claims, use standard claim forms (CMS-1500 and
the UB-92 described in this chapter) when submitting
charges, and be sure to complete the forms completely and
accurately.
What to Include on Claims
Patient Information
Before filing any claim, obtain clear, accurate information
from the patient, and update the information regularly.
Most offices verify the information at each visit. A uniform
policy for multiple provider offices or clinics makes
everyone accountable for current and correct patient data.
If the office participates with Medicare, an assignment of
benefits and release of billing are necessary.
Determining Coverage
A patient’s insurance coverage should be verified before any
service is rendered with the common sense exception of
emergency treatment. This policy should not apply
exclusively to new patients. Established patients may have
changed employers, married or divorced, or no longer be
covered by the same policy that was in effect during the last
visit. The law requires Medicaid patients to provide current
proof of eligibility with each visit.
Preauthorization
Determining in advance the benefits and allowables
provides the physician’s office with reimbursement figures
before the patient’s visit. Under most circumstances, the
office should be able to discuss the deductible, copayment,
and balance over and above the allowable with the patient
prior to providing costly services. Asking a few pointed
questions of the patient and insurer will provide additional
information regarding deductibles, for example:
•
How much is the deductible and has it been met for the
current year?
Primary vs. Secondary Coverage
•
What are the allowables for the quoted procedures?
Households with dual incomes often have more than one
insurer. Determine which is the primary and which is the
secondary insurance company. For commercial plans, the
subscriber’s or insured’s insurance company is always
primary for the subscriber. In other words, the husband’s
insurance company is primary for him and the wife’s
insurance company is primary for her. However, the
primary insurance company for any dependents is
determined by the insureds’ birthdays, the primary insured
being the individual whose birthday is first during the year.
This is often referred to as the “birthday rule.” For example,
if the husband’s birthday is October 14, 1960 and the wife’s
birthday is March 1, 1962, the wife is primary for their
dependents because her birthday is first during the year
(year of birth is ignored).
•
What percentage of the allowables will be paid?
Assignment of Benefits and Release of
Information
Consider adding an assignment of benefits statement to the
patient information form. It should state that the patient
Clean Claims
Claims submitted with all of the information necessary for
processing are referred to as “clean” and are usually paid in
a timely manner. Paying careful attention to what should
appear on the claim form helps produce these clean claims.
Common errors include the following:
•
Failure to pay attention to communications from
carriers (including Medicare and Medicaid transmittals)
•
An incorrect patient identification number
•
Patients’ names and addresses that differ from the
insurers’ records
•
Physician tax identification numbers, provider numbers,
or Social Security numbers that are incorrect or missing
•
No or insufficient information regarding primary or
secondary coverage
37
Claims
Processing
With commercial insurance companies, submit the claim
directly to the payer or provide the patient with the
necessary information to submit the claim. If there is a
signed agreement with Blue Cross and Blue Shield or with
an HMO or PPO, the office may be required to send the
claim directly to the insurer. Medicare requires that the
office submit all Medicare claims directly to the carrier,
whether participating or not in the Medicare program.
has agreed to have insurance payments sent directly to the
physician and that medical information can be released to
the patient’s insurance company. A signed copy of this
assignment submitted with a claim helps ensure at least
partial payment from most commercial insurers.
Assignments also reduce collection expenses. An alternative,
lifetime assignment of benefits should nearly eliminate the
need to obtain a signature after each date of service;
however, there are payers that require a current signature
with each claim.
•
Missing authorized signatures — patient and/or
physician
•
Dates of service that are incorrect or don’t coincide to
the claims information sent by other providers (such as
hospitals or nursing homes)
•
Dates that lack the correct number of digits
•
A fee column that is blank or not itemized and totaled
•
Incomplete patient information
•
Invalid CPT and ICD-9 codes, or diagnostic codes that
are not linked to the correct services or procedures
•
An illegible claim
Medicare Billing for Independent
Physical Therapists
Claims
Processing
Independent PTs billing Medicare for physical therapy
services need to meet the following criteria:
•
The physical therapist is in an unincorporated solo
practice or unincorporated partnership that meets all
state and local licensure laws; or is an individual
practicing physical therapy as an employee of an
unincorporated practice, professional corporation or
other incorporated therapy practice. It does not include
physical therapists working as provider employees.
•
The physical therapist must be licensed or legally
authorized to be in private practice in accordance to
applicable state laws.
•
•
•
•
Services must be provided in the physical therapist’s
office or in the home of the patient. “In the therapist’s
office” is defined as the location in which the practice is
operated, where the physical therapist is legally
authorized to provide services during the hours in
which he or she engages in practice at that site.
A physical therapist in private practice must maintain a
private office even if he or she always provides services
in the patient’s home. When services are provided in
private office space, that space must be owned, leased
or rented by the practice for the exclusive purpose of
operating the practice.
Aides and physical therapists assistants must be
supervised personally by the physical therapist and
employed by the PT, the partnership, or group to which
the PT belongs or in the same private practice that
employs the PT. Personal supervision is defined as
being in the room while the service is being provided to
the patient.
Each physical therapist must enroll with the appropriate
carrier as an individual.
The Health Insurance Portability and
Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act of
1996 (Public Law 104-191) is a complex, multi-faceted law
containing a number of provisions and amendments.
HIPAA was passed in part as a means of improving the
portability and availability of health insurance coverage for
38
individuals and groups. While insurance reform (Title 1) is
an important aspect of the law, it is the anti-fraud and
abuse provisions that have the greatest impact on provider
practices and daily operational activities. Other provisions
promote the use of medical savings accounts, improving
access to long-term care services and coverage, and
simplification of health insurance administration.
Possibly the best approach is to be certain that your
practice keeps abreast of the rapid changes taking place as
the different provisions of HIPAA are implemented. One of
the best sources of information is the CMS web site, which
provides not only background information, but also keeps
you up to date with current rules and CMS requirements.
That address is http://www.cms.hhs.gov/hipaa
Administrative Simplification Provisions
The Administrative Simplification provisions of HIPAA
(Title II) require HHS to establish national standards for
electronic health care transactions and national identifiers
for providers, health plans, and employers. They also
address the security and privacy of protected health
information. Implementing these standards and
encouraging the use of electronic data interchange (EDI) in
health care will improve the efficiency of the nation’s
health care system, reduce the administrative burden on
providers and health care plans, and save more than $30
billion over the next decade.
Under HIPAA, every health care provider will be able to use
EDI standards for billing and other health care transactions,
such as referrals and diagnosis reports. All health plans will
be required to accept these standard electronic claims, and
all health care providers using electronic transmittals will
be required to use the EDI standards.
Guidelines specify that transactions involving the following
types of information exchanges among health care plans,
clearinghouses, and providers are subject to EDI standards:
•
Health care claims and equivalent encounter
information
•
Health care payment and remittance advices
•
Coordination of benefits
•
Health care claim status
•
Enrollment or disenrollment in a health plan
•
Eligibility for a health plan
•
Referral certification and authorization
•
Health insurance plan premiums
The claims standard mandated by HIPAA is the ASC X12N
837, which is designed to accommodate claims billing data
electronically. Implementation guides are available from
the Washington Publishing Company on its Web site at
http://www.wpc-edi.com.HIPAA
Passage of the Administrative Simplification Compliance
Act (ASCA) in December 2001 required providers to submit
electronic claims to Medicare effective October 16, 2003,
with the following exceptions:
CPT Definitions and Guidelines
Physicians’ Current Procedural Terminology, Fourth Edition,
(CPT) is developed, published, and copyrighted by the
American Medical Association annually. CPT codes describe
predominantly medical services and procedures performed
by physicians and nonphysician professionals. The codes
are classified as Level I of the Healthcare Common
Procedure Coding System (HCPCS).
In general, whenever possible, physical therapists should
consider using CPT codes to describe their services. One
reason is that government studies of patient care evaluate
utilization of services by reviewing these codes. Because
payers may question or deny payment for a CPT code,
direct communication is often useful in educating payers
about physical therapy services and practice standards.
Accurate coding also can help an insurer determine
coverage eligibility for services provided.
Appropriate Codes for Physical
Therapists
The CPT book is divided into six major sections by type of
service provided (evaluation and management, anesthesia,
surgery, radiology, pathology and laboratory, and
medicine). These sections are subdivided primarily by body
system.
CPT Symbols
There are several symbols used in the CPT book:
A bullet (●) before the code means that the code is new
to the CPT coding system in the current year.
•
A triangle (▲) before the code means that the code
narrative has been revised in the current year.
•
The symbols w x enclose new or revised text other than
that contained in the code descriptors.
•
Codes with a + symbol are “add-on” codes. Procedures
described by “add-on” codes are always performed in
addition to the primary procedure and should never be
reported alone. This concept is applicable only to
procedures or services performed by the same physician
to describe any additional intraservice work associated
with the primary procedure such as additional digits or
lesions.
•
The symbol * designates a code that is exempt from the
use of modifier 51 when multiple procedures are
performed even though they have not been designated as
“add-on” codes.
•
Prior to 2004, the CPT book also contained a starred
procedure designation (indicated by an asterisk after the
code) that signified a surgical procedure considered by the
American Medical Association (AMA) to be a minor
surgical procedure that did not include pre- or
postoperative services. This designation, which was not
recognized for Medicare purposes, was eliminated in CPT
2004. Check with individual payers to determine their
specific billing guidelines.
The physical therapist in general practice will find the most
relevant codes in the physical medicine subsection of the
medicine section (codes in the 97001–97799 range). Other
services physical therapists provide, particularly those in
specialty areas, are described under their appropriate body
system within the medicine or surgery section.
For example, the neurological procedures most often
performed by physical therapists including
electromyography (EMG), are located in the neurology
subsection of the medicine section, (95831–95999), while
burn care codes (16000–16030) are located in the surgery
section. None of the codes for these procedures are listed in
the physical medicine subsection although they accurately
describe services provided by a physical therapist.
Although codes within the physical medicine series
(97001–97799) may not accurately describe all physical
therapy procedures, they are most easily recognized by
third-party payers as services provided by physical
therapists. In many instances, you may be able to code
accurately using all sections of the manual and obtain
reimbursement if you can provide a reasonable rationale
directly to the payer for the service you are providing and
support it with consistent, accurate documentation.
However, some payers may refuse to pay for services coded
outside the physical medicine sections of CPT, or they may
attempt to limit physical therapists’ use of such codes.
Modifiers
A system of two-digit modifiers has been developed to
allow the provider to indicate that the service or procedure
has been altered by certain circumstances or to provide
additional information about a procedure that was performed,
or a service or supply that was provided. Fee schedules have
been developed based on these modifiers. Some third-party
payers, such as Medicare, require physical therapists to use
modifiers in some circumstances, and others do not
recognize the use of modifiers by physical therapists for
coding or billing. Communication with the payer group
ensures accurate coding. Addition of the modifier does not
alter the basic description for the service, it merely qualifies
the circumstances under which the service was provided.
Circumstances that modify a service include the following:
•
Procedures that have both a technical and professional
component were performed
•
More than one provider or setting was involved in the
service
•
Only part of a service was performed
•
Unusual events occurred
CPT only ©2003 American Medical Association. All Rights Reserved.
CPT is a registered trademark of the American Medical Association
● New Codes
+ Add-On Code
* Modifier 51 Exempt
▲ Changed Codes
69
CPT Definitions
•
For one example, modifier 22 could be used to indicate
that the patient required the participation of more than one
PT during an intervention. For another example, modifier
59 could be used when billing for both 97022, Whirlpool,
and 97601, Wound debridement, to indicate that the two
services were distinct from one another, or performed on
different areas of the body.
session by the same provider, the primary procedure
or service may be reported as listed. The additional
procedure(s) or service(s) may be identified by
appending the modifier 51 to the additional
procedure or service code(s).
52
Reduced Services: Under certain circumstances a
service or procedure is partially reduced or
eliminated at the physician’s discretion. Under these
circumstances the service provided can be identified
by its usual procedure number and the addition of
the modifier 52, signifying that the service is
reduced. This provides a means of reporting reduced
services without disturbing the identification of the
basic service.
59
Distinct Procedural Service: Under certain
circumstances, the physician may need to indicate
that a procedure or service was distinct or
independent from other services performed on the
same day. Modifier 59 is used to identify
procedures/services that are not normally reported
together, but are appropriate under the circumstances.
This may represent a different session or patient
encounter, different procedure or surgery, different site
or organ system, separate incision/excision, separate
lesion or separate injury (or area of injury in extensive
injuries) not ordinarily encountered or performed on
the same day by the same physician. However, when
another already established modifier is appropriate it
should be used rather than modifier 59. Only if no
more descriptive modifier is available, and the use of
modifier 59 best explains the circumstances, should
modifier 59 be used.
76
Repeat Procedure by Same Physician: The physician
may need to indicate that a procedure or service was
repeated subsequent to the original procedure or
service. This circumstance may be reported by adding
the modifier 76 to the repeated procedure/service.
Note that the CPT book uses the term "physician" when
describing how a modifier is to be used. This does not limit
the use of the modifiers to physicians; any practitioner may
use a modifier as long as the service or procedure to be
modified can be performed within that practitioner’s scope
of work.
The list of modifiers used most often by physical therapists:
Unusual Procedural Services: When the services(s)
provided is greater than that usually required for the
listed procedure, it may be identified by adding
modifier 22 to the usual procedure number. A report
may also be appropriate.
25
Significant, Separately Identifiable Evaluation and
Management Service by the Same Physician on the
Same Day of the Procedure or Other Service: The
physician may need to indicate that on the day a
procedure or service identified by a CPT code was
performed, the patient’s condition required a
significant, separately identifiable E/M service above
and beyond the usual preoperative and postoperative
care associated with the procedure that was
performed. 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. This circumstance may be
reported by adding the modifier 25 to the
appropriate level of E/M service. Note: This modifier
is not used to report an E/M service that resulted in a
decision to perform surgery.
CPT Definitions
22
26
Professional Component: Certain procedures are a
combination of a physician component and a technical
component. When the physician component is
reported separately, the service may be identified by
adding the modifier 26 to the usual procedure number.
Coding Tip
Identifies that the professional component is being
reported separately from the technical component for
the diagnostic procedure performed. Payment is
based solely on the professional component relative
value of the procedure.
Coding Tip
Physical therapists in skilled nursing facilities might use
modifier 76 for patients paid under Medicare Part B.
These patients may receive services in both the
morning and the afternoon of the same day, and
modifier 76 would indicate that the services were not
duplicative.
HCPCS Level II modifiers may also be appended to CPT
codes for services. Refer to the HCPCS Level II Definitions
and Guidelines for a listing of the HCPCS Level II modifiers.
Unlisted Procedure Codes
32
Mandated Services: Services related to mandated
consultation and/or related services (eg, PRO, third
party payer, governmental, legislative or regulatory
requirement) may be identified by adding the
modifier 32 to the basic procedure.
51
Multiple Procedures: When multiple procedures,
other than E/M services, are performed at the same
Not all medical services or procedures are assigned CPT
codes. The book does not contain codes for infrequently
used, new, or experimental procedures. Each code section
contains codes set aside specifically for reporting unlisted
procedures. Before choosing an unlisted procedure code,
carefully review the CPT code list to ensure that a more
specific code is not available. Also, check for HCPCS Level
70
MED: Medicare Reference
CPT Index
Cognitive Function Tests, 96115
Cognitive Skills Development, 97532
Cold Pack Treatment, 97010
Communication Device
Non-speech-generating, 92605–92606
Speech-generating, 92607–92609
Community/Work Reintegration
Training, 97537
Conference
Medical
with Interdisciplinary Team, 99361–99373
Telephone
Brief, 99371
Complex, 99373
Intermediate, 99372
Continuous Positive Airway Pressure (CPAP), 94660
Contrast Bath Therapy, 97034
CPAP (Continuous Positive Airway Pressure), 94660
CPR (Cardiopulmonary Resuscitation), 92950
Debridement
Burns, 16020–16030
Wound
Non-Selective, 97602
Selective, 97601
Denis-Browne Splint, 29590
Developmental Testing
Evaluation
Limited, 96110
Diathermy, 97024
Dressings
Burns, 16020–16030
ECG, 93015–93018
EKG, 93015–93018
Elbow
Strapping, 29260
Electrical Stimulation
Physical Therapy
Attended, Manual, 97032
Unattended, 97014
Electromyography
Anus
Biofeedback, 90911
Needle
Extremities, 95861–95864
Face and Neck Muscles, 95867
Limited Study, 95869
Other than Paraspinal, 95870
Single Fiber Electrode, 95872
Thoracic Paraspinal Muscles, 95869
Rectum
Biofeedback, 90911
Surface
Dynamic, 96002–96003
EMG (Electromyography, Needle), 95861–95872
EPIS, 95925–95930
Evaluation and Management
Athletic Training
Evaluation, 97005
Re-evaluation, 97006
Case Management Services, 99361–99373
Occupational Therapy Evaluation, 97003
Physical Therapy Evaluation, 97001
CPT Index
Activities of Daily Living (ADL)
Training, 97535–97537
Acupuncture
One or More Needles
with Electrical Stimulation, 97781
without Electrical Stimulation, 97780
ADL
Activities of Daily Living, 97535
Aerosol Inhalation
Inhalation Treatment, 94640
Pentamidine, 94642
Ankle
Strapping, 29540
Anorectal Procedure
Biofeedback, 90911
Anus
Biofeedback, 90911
Aphasia Testing, 96105
Application
Neurostimulation, 64550
Aquatic Therapy
with Exercises, 97113
Arm, Lower
Splint, 29125–29126
Arm, Upper
Splint, 29105
AROM, 95851, 97110
Back/Flank
Strapping, 29220
Bayley Scales of Infant Development
Developmental Testing, 96110
Biofeedback
Anorectal, 90911
Blood Pressure, 90901
Blood-flow, 90901
Brainwaves, 90901
EEG (Electroencephalogram), 90901
Electro-Oculogram, 90901
Electromyogram, 90901
EMG (with Anorectal), 90911
Eyelids, 90901
Nerve Conduction, 90901
Other (unlisted) Biofeedback, 90901
Perineal Muscles, 90911
Urethral Sphincter, 90911
Blood Gases
by Pulse Oximetry, 94760
Bohler Splinting, 29515
Bronchospasm Evaluation, 94060
Pulmonology, Diagnostic, Spirometry, 94010, 94060
Burns
Debridement, 16020–16030
Dressing, 16020–16030
Cardiac Rehabilitation, 93797
Cardiology
Diagnostic
Stress Tests
Cardiovascular, 93015–93018
Therapeutic
Cardiopulmonary Resuscitation, 92950
Cardiopulmonary Resuscitation, 92950
Case Management Services
Team Conferences, 99361–99362
Telephone Calls, 99371–99373
Chest Wall
Manipulation, 94667
95
CPT Index
Evaluation
Occupational Therapy
Physical Therapy
Evoked Potential
Somatosensory Testing, 95925–95927
Visual, CNS, 95930
Exercise Stress Tests, 93015–93018
Exercise Test
Ischemic Limb, 95875
Exercise Therapy, 97110–97113
Expired Gas Analysis, 94680–94690
Extremity Testing
Physical Therapy, 97750
Finger
Splint, 29130–29131
Strapping, 29280
Flow Volume Loop/Pulmonary, 94375
Foot
Splint, 29590
Strapping, 29540
Gait Training, 97116
H-Reflex Study, 95934
Hand
Strapping, 29280
Heart
Cardiac Rehabilitation, 93797
Resuscitation, 92950
Hip
Strapping, 29520
Hot Pack Treatment, 97010
Hubbard Tank Therapy, 97036
Hydrotherapy (Hubbard Tank), 97036
Infrared Light Treatment, 97026
Inhalation
Pentamidine, 94642
Iontophoresis, 97033
Joint
Mobilization, 97140
Kinetic Therapy, 97530
Knee
Strapping, 29530
Leg
Lower
Splint, 29515
Strapping, 29580
Unna Boot, 29580
Upper
Splint, 29505
Strapping, 29580
Unna Boot, 29580
Manipulation
Chest Wall, 94667
Dislocation and/or Fracture
Chest Wall, 94667
Manometry
Rectum
Anus, 90911
Manual Therapy, 97140
Massage
Therapy, 97124
Microwave Therapy, 97020
Motion Analysis
by Video and 3-D Kinematics, 96000
Computer-based, 96000
Muscle Testing
Manual, 95831–95834
Muscle
Biofeedback Training, 90911
Myofascial Release, 97140
Nerve Conduction
Motor Nerve, 95900
Sensory Nerve, 95904
Neurology
Diagnostic
Electromyography
Ischemic Limb Exercise Test, 95875
Needle, 95861–95872
Surface
Dynamic, 96002–96003
Higher Cerebral Function
Aphasia Test, 96105
Cognitive Function Tests, 96115
Developmental Tests, 96110
Motion Analysis
by Video and 3-D Kinematics, 96000
Computer-based, 96000
Muscle Testing
Manual, 95831–95834
Nerve Conduction
Motor Nerve, 95900
Sensory Nerve, 95904
Neuromuscular Junction Tests, 95937
Neurophysiological Testing
Intraoperative, 95920
Neuropsychological Testing, 96117
Plantar Pressure Measurements
Dynamic, 96001
Range of Motion Test, 95851
Reflex
H-Reflex, 95934
Reflex Test
Blink Reflex, 95933
Somatosensory Testing, 95925–95927
Visual Evoked Potential, CNS, 95930
Neuromuscular Junction Tests, 95937
Neuromuscular Reeducation, 97112
Intraoperative, Per Hour, 95920
Neurophysiologic Testing
Intraoperative, Per Hour, 95920
Neuropsychological Testing, 96117
Neurostimulation
Application, 64550
Occupational Therapy
Evaluation, 97003
Orthotics
Check-Out, 97703
Training and Fitting, 97504
Oximetry (Noninvasive)
Blood O2 Saturation
Ear or Pulse, 94760–94761
Oxygen Saturation
Ear Oximetry, 94760–94761
Pulse Oximetry, 94760–94761
Paraffin Bath Therapy, 97018
Peak Flow Rate, 94150
Pentamidine
Performance Test,
Physical Medicine/Therapy/Occupational Therapy
Activities of Daily Living, 97535
Aquatic Therapy
96
ICD-9-CM Definitions and Guidelines
The International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) is a classification system
in which diseases and injuries are arranged in groups of
related cases for statistical purposes. Based on the World
Health Organization’s (WHO) International Classification
of Diseases, the ICD system has been revised periodically to
meet the needs of statistical data usage. In the United
States, the system has been expanded and modified (-CM)
to meet unique clinical purposes. Clinical uses include
indexing medical records, facilitating medical care reviews,
and completing reimbursement claims.
The responsibility for maintenance of the classification
system is shared between the National Center for Health
Statistics (NCHS) and the Centers for Medicare and
Medicaid Services (CMS). These two organizations co-chair
the ICD-9-CM Coordination and Maintenance Committee,
which meets twice a year in a public forum to discuss
revisions to the classification system. Final decisions
concerning any revisions to the system are made by the
director of NCHS and the administrator of CMS. Once
determined, the final decisions are published in the Federal
Register and become effective October 1 of each year.
The ICD-9-CM coding system is a method of translating
medical terminology for diseases and procedures into
codes. Codes within the system are either numeric or
alphanumeric and are made up of three, four, or five
characters. A decimal point follows all three-character codes
when fourth and fifth characters are required. “Coding”
involves using a numeric or alphanumeric code to describe
a disease or injury. For example, frozen shoulder is
translated into code 726.
This chapter provides information on the structure of
ICD-9-CM. We have also identified coding tips and
guidelines for the ICD-9-CM chapters that are pertinent to
the physical therapy provider.
Coding Tip
Be sure that your ICD-9-CM coding system contains
the most up-to-date information available. Changes
take place October 1 of every year, and your code
book must be current to ensure accurate coding.
The ICD-9-CM system contains two classifications, one for
diseases and the other for procedures. It consists of three
volumes:
•
Volume 1, Diseases: Tabular List
•
Volume 2, Diseases: Alphabetic Index
•
Volume 3, Procedures: Tabular List and Alphabetic
Index
Volume 3, Procedures, is used primarily for inpatient
coding. The physician office, outpatient clinics, or
ambulatory surgery centers coding staff should use the CPT
system for coding procedures. Therefore, only Volume 1
(Tabular List) and Volume 2 (Alphabetic Index) of
ICD-9-CM are used in the physician office for assigning
diagnosis codes. For this manual, only physical therapy
related index entries are listed.
The Structure of the Alphabetic Index
The Alphabetic Index of ICD-9-CM, commonly referred to
as the Index, is used in the first step in assigning a code.
The Index is divided into three sections: the “Alphabetic
Index to Disease and Injury,” the “Table of Drugs and
Chemicals,” and the “Alphabetic Index to External Causes
of Injury and Poisoning.” For this book, physical therapy
related index entries are listed.
Alphabetic Index to Diseases and Injuries
Included in this section is an alphabetic list of diseases,
injuries, symptoms, and other reasons for contact with the
physician. This section also contains two tables that classify
hypertension and neoplasms.
Table of Drugs and Chemicals
The drugs and chemicals that are the external causes of
poisoning and other adverse effects are organized in table
format. Specific drugs and chemical substances that the
patient may have taken, or been given, are listed
alphabetically. Each of these substances is assigned a code
to identify the drug as a poisoning agent, resulting from
incorrect substances given, incorrect dosages taken,
overdose, or intoxication. The five columns titled, External
Cause, list E codes for external causes depending upon if
the circumstances involving the use of the drug were
accidental, for therapeutic use, a suicide attempt, an assault,
or undetermined.
Alphabetic Index to External Causes of Injury
and Poisoning (E Codes)
This section is an alphabetic list of environmental events,
circumstances, and other conditions that can cause injury
and adverse effects.
99
ICD-9-CM
Definitions
Although hospitals and other health care facilities have
used ICD-9-CM codes for many years, health care provider
offices are also required to use ICD-9-CM codes for all
Medicare billings. Thus, it is essential that coding staff,
regardless of setting, become more knowledgeable,
proficient, and accurate in their use of the ICD-9-CM
diagnosis coding system. By improving coding skills,
appropriate reimbursement, and efficient claims processing,
coders limit audit liability and decrease the number of
denied claims and requests for additional information.
The Structure of ICD-9-CM
The Structure of the Tabular List
The Tabular List contains codes and their narrative
descriptions. There are three sections: the Classification of
Disease and Injuries, Supplementary Classifications, and
the Appendices.
Section 1: Classification of Diseases and
Injuries
The first section of the Tabular List contains 17 chapters.
Ten chapters are devoted to major body systems. The other
seven chapters describe specific types of conditions that
affect the entire body. This classification contains only
numeric codes, from 001.0 to 999.9.
ICD-9-CM
Definitions
Chapter
Chapter Title
Category
Code Range
decimal point followed by another digit. The fourth digit
provides specificity or more information regarding such
things as etiology, site, and manifestation. Four-digit codes
are referred to as “subcategory codes” and take precedence
over three-digit category codes.
Subclassification—Five-digit codes. Greater specificity has
been added to the ICD-9-CM system with the expansion of
four-digit subcategories to the fifth-digit subclassification
level. Five-digit codes are the most precise subdivisions in
the ICD-9-CM system.
Section 2: Supplementary Classifications (V
Codes and E Codes)
Classification of Factors Influencing Health Status and
Contact with Health Services (V Codes). The codes in this
classification, otherwise known as V codes, are
alphanumeric and begin with the letter “V.” These codes are
used to describe circumstances, other than a disease or
injury, that are the reason for an encounter with the health
care delivery system or that have an influence on the
patient’s current condition.
1.
Infectious and Parasitic Diseases
001–139
2.
Neoplasms
140–239
3.
Endocrine, Nutritional and Metabolic
Diseases, and Immunity Disorders
240–279
4.
Diseases of the Blood and Blood
forming Organs
280–289
Example
5.
Mental Disorders
290–319
V70.0
6.
Diseases of the Nervous System
and Sense Organs
320–389
7.
Diseases of the Circulatory System
390–459
8.
Diseases of the Respiratory System
460–519
9.
Diseases of the Digestive System
520–579
10.
Diseases of the Genitourinary System 580–629
11.
Complications of Pregnancy,
Childbirth and the Puerperium
630–677
12.
Diseases of the Skin and
Subcutaneous Tissue
680–709
13.
Diseases of the Musculoskeletal
System and Connective Tissue
710–739
14.
Congenital Anomalies
740–759
15.
Certain Conditions Originating in
the Perinatal Period
760–779
16.
Symptoms, Signs and
Conditions
780–799
Injury and Poisoning
800–999
17.
Each of the 17 chapters in the Classification of Diseases
and Injuries is divided into the following:
Subchapters. Subchapters are a group of closely related
conditions. Separate titles describe the contents of each
subchapter.
Category—Three-digit codes. Three-digit codes and their
titles are called “category codes.” Some three-digit codes are
very specific and are not subdivided. These three-digit codes
can stand alone to describe the condition being coded.
Subcategory—Four-digit codes. Most three-digit categories
have been further subdivided with the addition of a
100
Routine general medical examination at a
health care facility
V codes are sequenced depending on the circumstance or
problem being coded. Some V codes are sequenced first to
describe the reason for the encounter, while others are
sequenced second because they identify a circumstance that
affects the patient’s health status but is not in itself a
current illness. Assignment of V codes will be discussed in
depth in a separate section.
Classification of External Causes of Injury and Poisoning
(E Codes). These codes are also alphanumeric and begin
with the letter “E.” They are used to describe circumstances
and conditions that cause injury, poisoning, or other
adverse side effects. They may be used in addition to codes
in the main classification (001–999) to identify the external
cause of an injury or condition. They may never be used
alone and may never be listed as the first diagnosis.
Example
821.01 Right femur shaft fracture
E814.7 Pedestrian struck by motorcycle
Section 3: Appendices
Appendix A: Morphology of Neoplasms. This appendix is
an adaptation of the International Classification of Diseases
for Oncology (ICD-O), a coded nomenclature of the
morphology of neoplasms. These codes are alphanumeric
and begin with the letter “M.” An example is code
M8000/0, Neoplasm, benign.
Appendix B: Glossary of Mental Disorders. This glossary
consists of psychiatric terms that are used in ICD-9-CM
chapter 5, titled “Mental Disorders.” This glossary can be
used to ensure that their terminology is consistent with the
ICD-9-CM coding system.
ICD-9-CM Index
This ICD-9-CM chapter contains a comprehensive
alphabetic listing of ICD-9-CM diagnosis codes for
diagnosed conditions that could be treated by providers
using this coding and payment guide. This book is based
on official Centers for Medicare and Medicaid Services
(CMS) material and uses the most up-to-date diagnosis
coding information available.
This chapter is meant only as a quick reference for physical
therapy services. It does not replace Ingenix ICD-9-CM code
books.
Providers and hospitals are required by law to submit
diagnosis codes for Medicare reimbursement. A passage in
the Medicare Catastrophic Coverage Act of 1988 requires
health care provider offices to include appropriate diagnosis
codes when billing for services provided to Medicare
beneficiaries on or after April 1, 1989. The repeal of the Act
has not changed this requirement. CMS designated ICD-9-CM
as the coding system physicians must use.
This chapter concentrates on the most common diagnoses
that are utilized by physical therapy services. Easy to use, it
contains an alphabetic list of diagnoses, and has symbols
(see the symbol key) to identify common coding principles.
Understanding these principles will increase the efficiency
and promptness of claim submission for Medicare and
other third-party payers.
Codes effective October 1, 2003 to September 30, 2004
The ICD-9-CM coding conventions, or rules, used in this
book are outlined below. All ICD-9-CM coding rules can be
found in the front of any ICD-9-CM code book.
The symbol K is used to indicate when a fifth-digit
subclassification is required to complete a code. This
symbol refers the coder to corresponding boxed
information that defines the appropriate fifth digits.
Modifiers
The physician’s diagnostic statement usually contains
several medical terms. To translate the terms into diagnosis
codes, choose only the condition as the main term. The
other terms may be considered modifiers.
There are two types of modifiers, nonessential and essential:
Stricture (see also Stenosis)
urethra (anterior) (meatal) (organic) (posterior) (spasmodic) 598.9 2
Cross-References
Cross-references make locating a code easier. Two types of
cross-references are used in this book: see and see also.
The “see” cross-reference directs the coder to look for
another term elsewhere in the book. For example:
Tumor
dermois — see Neoplasm, by site, benign
The “see also” cross-reference provides the coder with an
alternative main term if the appropriate description is not
found under the initial main term, such as:
Stricture (see also Stenosis)
urethra (anterior) (meatal) (organic) (posterior) (spasmodic) 598.9 2
Abbreviations
NEC — “Not elsewhere classifiable.” Not every condition
has its own ICD-9-CM code. The NEC abbreviation is used
with those categories of codes for which a more specific
code is not available. The NEC code describes all other
specified forms of a condition. For example:
Essential modifiers are indented under the main term.
When there is only one essential modifier, it is listed next
to the main term after a comma. Essential modifiers affect
code assignment; therefore, they should be used in the
NOS — “Not otherwise specified.” Coders should use an
NOS code only when they lack the information necessary
for assigning a more specific code.
Coding Neoplasms
The index contains a neoplasm table in which the codes for
each particular type of neoplasm are listed for the body
part, system, or tissue type affected. The columns divide the
codes into neoplasm type: malignant, benign, uncertain
behavior, and unspecified with three distinct columns
appearing under the malignant heading for primary,
secondary, and carcinoma in situ.
Malignant neoplasms are uncontrolled new tissue growths
or tumors that can progressively invade tissue in other parts
of the body by spreading or metastasizing the disease
producing cells from the initial site of malignancy. Primary
defines the body site or tissue where the malignancy first
began to grow and spread from there to other areas.
Secondary malignancies are those sites that have been
invaded by the cancer cells coming from another part of the
body and are now exhibiting cancerous growth. Carcinoma
in situ is confined to the epithelium of the vessels, glands,
organs, or tissues in the body area where it originated and
has not crossed the basement membrane to spread to the
neighboring tissues.
E Signs & symptoms
K Codes that require a fifth-digit
131
ICD-9-CM Index
Nonessential modifiers are shown in parentheses after the
term that they modify. Nonessential modifiers may be
either present or absent in the diagnostic or procedure
statement without affecting the code selection. These
modifiers do not affect the code selection.
2 Unspecified
In the following example, “anterior,” “meatal,” “organic,”
“posterior,” and “spasmodic” are nonessential modifiers,
and “urethra” is an essential modifier.
Disorder (see also Disease)
bone NEC 733.90 2
ICD-9-CM Coding Conventions
coding process only if they are specified in the physician’s
diagnosis.
Benign neoplasms are those found not to be cancerous in
nature. The dividing cells adhere to each other in the tumor
and remain a circumscribed lesion. Neoplasms of uncertain
behavior are those whose subsequent behaviour cannot
currently be predicted from the present appearance of the
tumor and will require further study. Unspecified indicates
simply a lack of documentation to support the selection of
any more specific code.
Manifestation Codes
As in the following example, when two codes are required
to indicate etiology and manifestation, the manifestation
code appears in italics and brackets. The manifestation code
is never a principal/primary diagnosis. Etiology is always
sequenced first.
and, therefore, appear together in these guidelines without
distinguishing one from the other.
Though the conventions and general guidelines apply to all
settings, coding guidelines for outpatient and physician
reporting of diagnoses will vary in a number of instances
from those for inpatient diagnoses, recognizing that: 1) the
Uniform Hospital Discharge Data Set (UHDDS) definition
of principal diagnosis applies only to inpatients in acute,
short-term, general hospitals, and 2) coding guidelines for
inconclusive diagnoses (probable, suspected, rule out, etc.)
were developed for inpatient reporting and do not apply to
outpatients.
A.
In the outpatient setting, the term “first-listed
diagnosis” is used in lieu of principal diagnosis.
Arthritis, arthritic (acute) (chronic)
due to or associated
with enteritis NEC 009.1 [711.3]
In determining the first-listed diagnosis, the coding
conventions of ICD-9-CM, as well as the general and
disease-specific guidelines, take precedence over the
outpatient guidelines. Diagnoses often are not
established at the time of the initial encounter/visit. It
may take two or more visits before the diagnosis is
confirmed.
Official ICD-9-CM Guidelines for
Coding and Reporting
The Public Health Service and CMS of the U.S. Department
of Health and Human Services (DHHS) present the
following guidelines for coding and reporting using
ICD-9-CM. These guidelines should be used as a companion
document to the official versions of the ICD-9-CM.
These guidelines for coding and reporting have been
developed and approved by the cooperating parties for
ICD-9-CM: American Hospital Association, American
Health Information Management Association, and the
National Center for Health Statistics. These guidelines
appear in the second quarter 2002 Coding Clinic for
ICD-9-CM, published by the American Hospital
Association, where they are updated regularly.
The most critical rule involves beginning the search for
the correct code assignment through the Alphabetic
Index. Never begin searching initially in the Tabular
List as this will lead to coding errors.
B.
The appropriate code or codes from 001.0 through
V83.89 must be used to identify diagnoses, symptoms,
conditions, problems, complaints, or other reason(s)
for the encounter/visit.
C.
For accurate reporting of ICD-9-CM diagnosis codes,
the documentation should describe the patient's
condition, using terminology which includes specific
diagnoses as well as symptoms, problems, or reasons
for the encounter. There are ICD-9-CM codes to
describe all of these.
These guidelines have been developed to assist the user in
coding and reporting in situations where the ICD-9-CM
book does not provide direction. Coding and sequencing
instruction in the three ICD-9-CM volumes take precedence
over any guidelines.
ICD-9-CM Index
These guidelines are not exhaustive. The cooperating parties
are continuing to conduct review of these guidelines and to
develop new guidelines as needed. Users of ICD-9-CM
should be aware that only guidelines approved by the
cooperating parties are official. Revisions of these
guidelines and new guidelines will be published by the
DHHS when they are approved by the cooperating parties.
D. The selection of codes 001.0 through 999.9 will
frequently be used to describe the reason for the
encounter. These codes are from the section of
ICD-9-CM for the classification of diseases and injuries
(e.g., infectious and parasitic diseases; neoplasms;
symptoms, signs, and ill-defined conditions, etc.).
E.
Codes that describe symptoms and signs, as opposed
to diagnoses, are acceptable for reporting purposes
when a diagnosis has not been established (confirmed)
by the physician. Chapter 16 of ICD-9-CM, Symptoms,
Signs, and Ill-defined Conditions (codes 780.0–799.9)
contains many, but not all, codes for symptoms.
F.
ICD-9-CM provides codes to deal with encounters for
circumstances other than a disease or injury. The
Supplementary Classification of Factors Influencing
Health Status and Contact with Health Services
(V01.0–V83.89) is provided to deal with occasions
Diagnostic Coding and Reporting Guidelines
for Outpatient Services (Hospital-Based and
Physician Office)
These coding guidelines for outpatient diagnoses have been
approved for use by hospitals and physicians in coding and
reporting hospital-based outpatient services and physician
office visits.
The terms “encounter” and “visit” are often used
interchangeably in describing outpatient service contacts
132
2 Unspecified
E Signs & symptoms
Selection of first-listed condition
K Codes that require a fifth-digit
HCPCS Level II Definitions and Guidelines
a temporary national code for that service/supply, with an
explanation as to why the code should be kept. These
requests were due to their regional office by April 1, 2002.
One of the keys to gaining accurate reimbursement lies in
understanding the multiple coding systems that are used to
identify services and supplies. To be well versed in
reimbursement practices, coders should be familiar not
only with the CPT coding system (HCPCS Level I) but also
with HCPCS Level II codes which are becoming
increasingly important to reimbursement as they are
extended to a wider array of medical services.
The next phase was the elimination of the official HCPCS
Level III local codes and modifiers by December 31, 2003.
Again, carriers were required to review all local codes in
their systems, crosswalk them to appropriate national codes
and submit requests for replacement temporary national
codes by April 1, 2003. Temporary national codes that are
requested and approved will be implemented January 1,
2004.
HCPCS Level II codes commonly are referred to as national
codes or by the acronym HCPCS (pronounced “hik-piks”),
which stands for the Healthcare Common Procedure
Coding System. HCPCS codes are used for billing Medicare
and Medicaid patients and have been adopted by some
third-party payers.
Local codes had been used to denote new procedures or
specific supplies for which there was no national code. For
Medicare, these five-digit alphanumeric codes use the letters
W through Z. Each carrier may create local codes as the
need dictates. However, carriers were required to obtain
approval from CMS's central office before implementing
them. The Medicare carrier was responsible for providing
you with these codes.
These codes, updated and published annually by the
Centers for Medicare and Medicaid Services (CMS), are
intended to supplement the CPT coding system by
including codes for nonphysician services, administration
of injectable drugs, durable medical equipment and office
supplies.
Due to the Consolidated Appropriations Act of 2001, and
as part of the National Code Data Sets implemented under
the Health Insurance Portability Accountability Act, the
Secretary of Health and Human Services was instructed to
maintain and continue the use of HCPCS level III codes
through December 31, 2003.
When using HCPCS Level II codes, keep the following in
mind:
•
•
•
•
•
CMS does not use consistent terminology for unlisted
services or procedures. The code descriptions may
include any one of the following terms: unlisted, not
otherwise classified (NOC), unspecified, unclassified,
other and miscellaneous.
Program Memorandum (PM) AB-01-45 instructed Carriers
to take the following steps to implement the law on April
29th, 2001:
If billing for specific supplies and materials, avoid CPT
code 99070 (general supplies) and be as specific as
possible unless the local carrier directs otherwise.
•
Maintain and accept current level III HCPCS codes and
or modifiers until December 31, 2003. However,
Carriers were not allowed to create any new HCPCS
Level III codes and or modifiers.
•
Refer to Medicare coverage references to determine
whether the care provided is a covered service.
Carriers were to reinstate any HCPCS level III codes
and/or modifiers they may have eliminated after August
16, 2000.
•
When both a CPT and HCPCS Level II code share nearly
identical narratives, apply the CPT code. If the narratives
are not identical, select the code with the narrative that
better describes the service. Generally, for Medicare
claims, the HCPCS Level II code is more specific and
takes precedence over the CPT code.
Carriers were to publish on their websites any HCPCS
level III and modifiers with their descriptors that were
in effect August 16, 2000.
Medicare carriers who wished to establish a temporary
national code had to submit the request to their regional
office. The regional office then submitted that
recommendation to the central office for approval.
Coding and billing should be based on the service
provided. Documentation should describe the patient’s
problems and the service provided to enable the payer
to determine reasonableness and necessity of care.
HCPCS Level III—Local Codes
● New Codes
Structure and Use of HCPCS Level II
Codes
The main terms are in boldface type in the index. Main term
entries include tests, services, supplies, orthotics, prostheses,
medical equipment, drugs, therapies and some medical and
surgical procedures. Where possible, entries are listed under
a “common” main term. In some instances, the “common”
term is a noun; in others, the main term is a descriptor.
▲ Changed Codes
217
HCPCS
Definitions
All HCPCS level III local codes have been recently phased
out, a process that began in 2002. As the first step, effective
October 16, 2002, carriers were required to eliminate all
local codes and modifiers that had not been approved by
CMS. Carriers had to identify those codes and modifiers in
use, crosswalk them to national codes and delete any that
were not approved. If carriers felt that an unapproved code
should be retained for use, they had to submit a request for
Searching the Index
Section Guidelines
The steps to follow for searching the index are:
Examine the instructions found at the beginning of each of
the 17 sections. Instructions include the guidelines, notes,
unlisted procedures, special reports and the modifiers that
pertain to each section.
1. Analyze the statement or description provided that
designates the item to be coded.
2. Identify the main term.
3. Locate the main term in the index.
4. Check for relevant subterms under the main term. Verify
the meaning of any unfamiliar abbreviations.
5. Note the codes found after the selected main term or
subterm.
6. Locate the code in the alphanumeric list to ensure the
specificity of the code. If a code range is provided,
locate the code range and review all code narratives in
that code range for specificity.
In some cases, an entry may be listed under more than one
main term.
Never code directly from the index. Always verify the code
choice in the alphanumeric list and the index.
HCPCS Level II codes: Sections A–V
Level II codes consist of one alphabetic character (letters A
through V) and four numbers. Similar to CPT codes, they
also can have modifiers, which can be alphanumeric or two
letters. National modifiers can be used with all levels of
HCPCS codes.
HCPCS
Definitions
The HCPCS coding system is arranged in 17 sections:
A codes
A0021–A9999
B codes
C codes
B4034–B9999
C1000–C9999
D codes
E codes
G codes
D0120–D9999
E0100–E9999
G0001–G9999
H codes
H0001–H9999
J codes
J0120–J9999
K codes
K0001–K9999
L codes
L0100–L9999
M codes
P codes
Q codes
M0064–M9999
P2028–P9999
Q0035–Q9999
R codes
T codes
S codes
R0070–R9999
T1000–T9999
S0009–S9999
V codes
V2020–V9999
218
Transportation Services, Including
Ambulance, Chiropractic Services,
Medical and Surgical Supplies
and Miscellaneous and
Investigational
Enteral and Parenteral Therapy
Temporary Codes for use with
Outpatient PPS
Dental Procedures
Durable Medical Equipment
Temporary Procedures/
Professional Services
Alcohol and Drug Abuse
Treatment Services
Drugs Administered Including
Oral and Chemotherapy Drugs
Durable Medical Equipment
Prosthetics, Orthotics, Supplies
and Dressings (DMEPOS)
Orthotic and Prosthetic
Procedures, Devices
Medical Services
Pathology and Laboratory Services
Miscellaneous Services
(Temporary Codes)
Radiology Services
Medical Services
Commercial Payers (Temporary
Codes)
Vision, Hearing and SpeechLanguage Pathology Services
● New Codes
▲ Changed Codes
Use the alphabetic index to initially locate a code by
looking for the type of service or procedure performed. The
same rule applies: never code directly from the index.
Always check the specific code in the appropriate section.
The Conventions: Symbols and
Modifiers
Symbols used in the HCPCS Level II system may be
presented in various ways, depending on the vendor. In this
publication the pattern established by the AMA in the CPT
code books is followed. For example, bullets and triangles
signify new and revised codes, respectively.
When a code is new to the HCPCS Level II system, a bullet
(●) appears to the left of the code. This symbol is
consistent with the CPT system’s symbol for new codes. The
bullet represents a code never before seen in the HCPCS
coding system.
Example
●
A6442
Conforming bandage, non-elastic,
knitted/woven, non-sterile, width less
than three inches, per yard
A triangle (▲) is used (as in the CPT system) to indicate
that a change in the narrative of a code has been made
from the previous year’s edition. The change made may be
slight or significant, but it usually changes the application
of the code.
Example
▲
E0141
Walker, rigid, wheeled, adjustable or fixed
height
Modifiers
In certain circumstances, modifiers must be used to report
the alteration of a procedure or service or to furnish
additional information about the service, supply or
procedure that was provided. In HCPCS Level I (CPT),
modifiers are two-digit suffixes that usually directly follow
the five-digit procedure or service code.
In HCPCS Level II, modifiers are composed of two alpha or
alphanumeric characters that range from “AA” to “VP.”
E0260-NU
Hospital bed, semi-electric (head and
foot adjustment), with any type side
rails, with mattress
NU = identifies the hospital bed as new equipment
Although both alpha and numeric modifiers are common
throughout the country, some regional carriers do not
recognize their use due to software limitations. It may be
necessary to provide a cover letter, an invoice or other
specific documentation with the claim for clarification.
HCPCS Index
HCPCS Level II Index
Abdomen/abdominal
dressing holder/binder, A4462
Abdominal binder
elastic, A4462
Abduction
pillow, E1399
Absorption dressing, A6251-A6256
Accessories
ambulation devices, E0153-E0159
beds, E0277-E0280
Adhesive
pads, A6203-A6205, A6212-A6214, A6237-A6239
remover, A4455
tape, A4452
Algiderm, alginate dressing, A6196-A6199
Alginate dressing, A6196-A6199
Algosteril, alginate dressing, A6196-A6199
Ambulation device, E0100-E0159
Ambulation stimulator
spinal cord injured, K0600
Anterior-posterior orthosis, L0530
lateral orthosis, L0520
Apnea monitor,
electrodes, A4556
Arm
sling
deluxe, A4565
mesh cradle, A4565
universal
arm, A4565
elevator, A4565
Auto-Glide folding walker, E0143
Back supports, L0500-L0540, L0600-L0620, L0810, L0861
Baseball finger splint, A4570
Bath chair, E0240
Battery,
TENS, A4630
Bed
cradle, any type, E0280
Bell-Horn
sacrocinch, L0510
Belt
extremity, E0945
pelvic, E0944
Binder
extremity, nonelastic, A4465
lumbar-sacral-orthosis (LSO), A4462
Biofeedback device, E0746
Body jacket
lumbar-sacral orthosis (spinal), L0500-L0540, L0610
Body Wrap
foam positioners, E0191
therapeutic overlay, E0199
Boot
pelvic, E0944
Brake attachment, wheeled walker, E0159
Burn garment, A6501
Cane, E0100
accessory, A4636-A4637
Easy-Care quad, E0105
quad canes, E0105
Quadri-Poise, E0105
wooden canes, E0100
Carex
aluminum crutches, E0114
cane, E0100
folding walker, E0135
Cervical
collar, L0120, L0150
halo, L0810
orthosis, L0120, L0140-L0174
traction equipment, not requiring frame, E0855
Chair
shower or bath, E0240
Chin
cup, cervical, L0150
Cida
exostatic cervical collar, L0140
form fit collar, L0120
Cleaning solvent, Nu-Hope
16 oz bottle, A4455
4 oz bottle, A4455
Collagen
wound dressing, A6021-A6024
Collar, cervical
contour (low, standard), L0120
nonadjust (foam), L0120
Philly One-piece Extrication collar, L0150
tracheotomy, L0172
Philadelphia tracheotomy cervical collar, L0172
Composite dressing, A6203-A6205
Compression bandage
high, A6452
light, A6448
medium, A6451
Compression
burn garment, A6501-A6506, A6509-A6512
stockings, L8100-L8190, L8200-L8230
Conductive
garment (for TENS), E0731
paste or gel, A4558
Conforming bandage, A6442-A6447
Contact layer, A6206-A6208
Corset, spinal orthosis, L0970-L0976
Cover, wound
alginate dressing, A6196-A6198
collagen dressing,
foam dressing, A6209-A6214
hydrocolloid dressing, A6234-A6239
hydrogel dressing, A6242-A6248
specialty absorptive dressing, A6251-A6256
Cradle, bed, E0280
Crutch
substitute, E0118
Crutches, E0110-E0116
accessories, A4635-A4637
aluminum, E0114
articulating, spring assisted, E0117
forearm, E0111
Ortho-Ease, E0111
underarm, other than wood, pair, E0114
Quikfit Custom Pack, E0114
Red Dot, E0114
underarm, wood, single, E0113
Ready-for-use, E0113
wooden, E0112
Curasorb, alginate dressing, A6196-A6199
Cushion
decubitus care, E0190
233
HCPCS Index
Decubitus care equipment, E0185, E0190-E0191, E0197-E0199
pressure pads, overlays, E0197-E0199
Body Wrap, E0199
Geo-Matt, E0199
Iris, E0199
PressureKair, E0197
Richfoam Convoluted and Flat, E0199
protectors
Heel or elbow, E0191
Body Wrap Foam Positioners, E0191
Pre-Vent, E0191
Decubitus care
cushion or pillow, E0190
Dialysis
heating pad, E0210
Don-Joy
cervical support collar, L0150
rib belt, L0210
 Night Splint, A4570
Dorsiwedge
Drainage
board, postural, E0606
Dressing (see also Bandage), A6021-A6259, A6266-A6402
alginate, A6196-A6199
collagen,
composite, A6200-A6205
contact layer, A6206-A6208
film, A6257-A6259
foam, A6209-A6215
gauze, A6216-A6230, A6402
holder/binder, A4462
hydrocolloid, A6234-A6241
hydrogel, A6242-A6248
specialty absorptive, A6251-A6256
tape, A4452
transparent film, A6257-A6259
Dropper, A4649
Dunlap
heating pad, E0210
hot water bottle, E0220
Durable medical equipment (DME), E0100-E0159, E0185,
E0190-E0191, E0197-E0200, E0205-E0220, E0225, E0231E0240, E0247-E0248, E0277-E0280, E0371-E0373, E0606,
E0720-E0731, E0744-E0748, E0855-E0860, E0944-E0945,
E1399, E1800-E1802, E1806, E1811, E1816-E1820
Durr-Fillauer
cervical collar, L0140
Easy Care
folding walker, E0143
quad cane, E0105
Elastic
support, L8100-L8190, L8200-L8230
Elbow
orthosis (EO), E1800
protector, E0191
Electric stimulator supplies, A4595
Electrodes, per pair, A4556
EMG, E0746
Exercise
equipment, A9300
Exo-Static overdoor traction unit, E0860
Extremity belt/harness, E0945
EZ Fit LSO, L0500
Filler, wound
alginate, A6199
foam, A6215
hydrocolloid, A6240-A6241
hydrogel, A6248
Film
dressing, A6257-A6259
234
Finger
baseball splint, A4570
fold-over splint, A4570
four-pronged splint, A4570
Foam
dressing, A6209-A6215
Fold-over finger splint, A4570
Folding walker, E0135
Foot, cast boot
Specialist Toe Insert for Specialist Closed-Back Cast Boot
and Specialist Health/Post Operative Shoe, A9270
Foot, insoles/heel cups
Specialist Heel Cups, L3485
Forearm crutches, E0110
Fortex, alginate dressing, A6196-A6199
Four-pronged finger splint, A4570
Gauzem A6216-A6230, A6266
impregnated, A6222-A6230, A6266
nonimpregnated, A6216, A6402
pads, A6216-A6230, A6402
Johnson & Johnson, A6402
Kendall, A6402
Moore, A6402
Gel
conductive, A4558
sheet, dermal or epidermal, A6025
Geo-Matt
therapeutic overlay, E0199
Goldthwaite apron-front, sacroiliac orthosis, L0620
Halo procedures, L0810
Handgrip (cane, crutch, walker), A4636
Harness, E0945
Heat
application, E0200, E0205-E0220, E0225, E0231-E0239
lamp, E0200, E0205
pad, E0210-E0215, E0218
units, E0239
Hydroacollator, mobile, E0239
Thermalator T-12-M, E0239
Heating pad, Dunlap, E0210
for peritoneal dialysis, E0210
Heel
pad, L3480-L3485
protector, E0191
shoe, L3480-L3485
Hollister
remover, adhesive, A4455
Hot water bottle, E0220
Hydrocollator, E0225
Hydrocolloid dressing, A6234-A6241
Hydrogel dressing, A6242-A6248
Impregnated gauze dressing, A6222-A6230
Injection (see also drug name),
procedure
sacroiliac joint, G0255
Iris therapeutic overlays, E0199
Jacket
body (LSO) (spinal), L0500-L0540
Kaltostat, alginate dressing, A6196-A6199
Knight apron-front, spinal orthosis, L0520
Laser
application, S8948
Leg
extensions for walker, E0158
strap, A5113-A5114
Lerman Minerva spinal orthosis, L0174
LSO, L0500-L0540
Medicare Official Regulatory Information*
Publication #
Title
The Centers for Medicare and Medicaid Services (CMS)
initiated its long awaited transition from a paper-based
manual system to a Web-based system on October 1, 2003,
which updates and restructures all manual instructions. The
new system, called the online CMS Manual system,
combines all of the various program instructions into an
electronic manual, which can be found at
http://www.cms.hhs.gov/manuals.
Pub. 100-7
Medicare State Operations (The new
manual is under development.
Please continue to use the paperbased manual.)
Medicare Program Integrity
Medicare Contractor Beneficiary
and Provider Communications
Medicare Quality Improvement
Organization
Reserved
State Medicaid (The new manual is
under development. Please
continue to use the paper-based
manual.)
Medicaid State Children's Health
Insurance Program
(Under development)
Medicare End Stage Renal Disease
Network
Medicare State Buy-In
Medicare Managed Care
Medicare Business Partners Systems
Security
Medicare Business Partners
Security Oversight
Demonstrations
One-Time Notification
Effective September 30, 2003, the former method of
publishing program memoranda (PMs) to communicate
program instructions was replaced by the following four
templates:
•
One-time notification
•
Manual revisions
•
Business requirement
•
Confidential requirements
The Web-based system has been organized by functional
area (e.g., eligibility, entitlement, claims processing, benefit
policy, program integrity) in an effort to eliminate
redundancy within the manuals, simplify the updating
process, and make CMS program instructions available in a
more timely manner. The initial release will include Pub.
100, Pub. 100-02, Pub. 100-03, Pub. 100-04, Pub. 100-05,
Pub. 100-09, Pub. 100-15, and Pub. 100-20.
The Web-based system contains the functional areas
included in the table below:
Publication #
Title
Pub. 100
Pub. 100-1
Introduction
Medicare General Information,
Eligibility, and Entitlement
Medicare Benefit Policy (basic
coverage rules)
Medicare National Coverage
Determinations (national
coverage decisions)
Medicare Claims Processing
(includes appeals, contractor
interface with CWF, and MSN)
Medicare Secondary Payer
Medicare Financial Management
(includes Intermediary Desk
Review and Audit)
Pub. 100-3
Pub. 100-4
Pub. 100-5
Pub. 100-6
Pub. 100-10
Pub. 100-11
Pub. 100-12
Pub. 100-13
The Office of Strategic Operations and Regulatory Affairs
(OSORA), Division of Issuances, will continue to
communicate advanced program instructions to the regions
and contractor community every Friday as it currently does.
These instructions will also contain a transmittal sheet to
identify changes pertaining to a specific manual,
requirement, or notification.
Pub. 100-2
Pub. 100-8
Pub. 100-9
Pub. 100-14
Pub. 100-15
Pub. 100-16
Pub. 100-17
Pub. 100-18
Pub. 100-19
Pub. 100-20
Table of Contents
The table below shows the paper-based manuals used to
construct the Web-based system. Although this is just an
overview, CMS is in the process of developing detailed
crosswalks to guide you from a specific section of the old
manuals to the appropriate area of the new manual, as well
as to show how the information in each section was
derived.
Paper-Based Manuals
Internet-Only Manuals
Pub. 06–Medicare Coverage
Issues
Pub. 100-01–Medicare General
Information, Eligibility, and
Entitlement
Pub. 09–Medicare Outpatient
Physical Therapy
Pub. 10–Medicare Hospital
Pub. 11–Medicare Home
Health Agency
Pub. 12–Medicare Skilled
Nursing Facility
Pub. 13–Medicare Intermediary
Manual, Parts 1, 2, 3, and 4
Pub. 14–Medicare Carriers
Manual, Parts 1, 2, 3, and 4
Pub. 100-02–Medicare Benefit Policy
Pub. 100-03–Medicare National
Coverage Determinations
Pub. 100-04–Medicare Claims
Processing
Pub. 100-05–Medicare Secondary
Payer
*Medicare Carriers Manual (MCM) and Coverage Issues Manual (CIM) sections are printed verbatim from these manuals and are current at the
time of printing of this publication. These references may be changed by CMS at any time thoughout the year.
237
MCM/CIM
References
Revisions to the CMS Manual System
Paper-Based Manuals
MCM/CIM
References
Pub. 21–Medicare Hospice
Pub. 100-06–Medicare Financial
Management
Pub. 27–Medicare Rural
Pub. 100-08–Medicare Program
Health Clinic and Federally
Integrity
Qualified Health Center
Pub. 29–Medicare Renal
Pub. 100-09–Medicare Contractor
Dialysis Facility
Beneficiary and Provider Communications
Paper-Based Manuals
Pub. 19–Medicare Peer
Review Organization
Pub. 07–Medicare State
Operations
Pub. 45–State Medicaid
Pub. 100-10–Medicare Quality
Improvement Organization
Pub. 100-07–Medicare State
Operations
Pub. 100-12–State Medicaid
Pub. 100-13–Medicaid State
Children’s Health Insurance
Program
Pub. 81–Medicare End Stage Pub. 100-14–Medicare End Stage
Renal Disease Renal Disease
Network Organizations
Network Organizations
Pub. 24–Medicare State Buy-In Pub. 100-15–Medicare State Buy-In
Pub. 75–Health Maintenance Pub. 100-16–Medicare Managed
Organization/Competitive
Care
Medical Plan
Pub. 76–Health Maintenance
Organization/Competitive
Medical Plan (PM)
Pub. 77–Manual for Federally
Qualified Health Maintenance
Organizations
Pub. 13–Medicare
Pub. 100-17–Business Partners
Intermediaries Manual, Part 2 Systems Security
Manual, Part 2
Pub. 13–Medicare
Pub. 100-18–Business Partners
Intermediaries Manual, Part 2
Security Oversight
Manual, Part 2
Demonstrations (PMs)
Pub 100-19–Demonstrations
Program instructions that
Pub 100-20–One-Time Notification
impact multiple manuals
or have no manual impact.
Program Memoranda
Pub. 60A–Intermediaries
Pub. 60B–Carriers
Pub. 60AB–Intermediaries/Carriers
NOTE: Information derived from Pub. 06 to Pub. 60AB was used to
develop Pub. 100-01 to Pub. 100-09 for the Internet-only manual.
National Coverage Determinations
Manual
The National Coverage Determinations Manual (NCD),
which is the electronic replacement for the Coverage Issues
Manual (CIM), is organized according to categories such as
diagnostic services, supplies, and medical procedures. The
table of contents lists each category and subject within that
238
category. A revision transmittal sheet will identify any new
material and recap the changes as well as provide an
effective date for the change and any background
information. At any time, one can refer to a transmittal
indicated on the page of the manual to view this
information.
By the time it is complete, the book will contain two
chapters. Chapter 1 includes a description of national
coverage determinations that have been made by CMS.
When available, chapter 2 will contain a list of HCPCS
codes related to each coverage determination. To make the
manual easier to use, it is organized in accordance with
CPT category sequences. Where there is no national
coverage determination that affects a particular CPT
category, the category is listed as reserved in the table of
contents.
Medicare Benefit Policy Manual
The Medicare Benefit Policy Manual replaces current
Medicare general coverage instructions that are not national
coverage determinations. As a general rule, in the past these
instructions have been found in chapter II of the Medicare
Carriers Manual, the Medicare Intermediary Manual, other
provider manuals, and program memoranda. New
instructions will be published in this manual. As new
transmittals are included they will be identified.
On the CMS Web site, a crosswalk from the new manual to
the source manual is provided with each chapter and may
be accessed from the chapter table of contents. In addition,
the crosswalk for each section is shown immediately under
the section heading.
The list below is the table of contents for the Medicare
Benefit Policy Manual:
Chapter
Title
One
Inpatient Hospital Services
Two
Inpatient Psychiatric Hospital Services
Three
Duration of Covered Inpatient Services
Four
Inpatient Psychiatric Benefit Days
Reduction and Lifetime Limitation
Five
Lifetime Reserve Days
Six
Hospital Services Covered Under Part B
Seven
Home Health Services
Eight
Coverage of Extended Care (SNF)
Services Under Hospital Insurance
Nine
Coverage of Hospice Services Under
Hospital Insurance
Ten
Ambulance Services
Eleven
End Stage Renal Disease (ESRD)
Twelve
Comprehensive Outpatient
Rehabilitation Facility (CORF) Coverage
Correct Coding Initiative
v
Indicates a mutually exclusive edit
0018T
90802v-90857v, 90862, 90865v-90871v,
90880v
0001F
No CCI edits apply to this code.
0001T
0002Tv, 34800v-34804v, 36000, 36410,
90780
0019T
0020T, 76880, 76977-76999
0020T
76880, 76977-76999
0002F
0021T
36000, 36410, 90780
0003F
0023T
0003T
0024T
0004F
0005F
0005T
35201-35206, 35226, 35261-35266, 35286,
36000, 36410, 36620-36625, 37202, 37205v,
69990, 76000, 76003, 76360, 76393, 76942,
90780
33210-33211, 33234-33235, 35201-35206,
35226, 35261-35266, 35286, 36000, 36010,
36013-36014, 36120-36140, 36410, 3660036640, 37202, 71034, 76000, 90780, 93540,
93545-93556
0026T
80500-80502
0027T
00600-00620, 00630, 00670, 36000, 36410,
37202, 62281-62284, 62310-62319, 6441564417, 64450-64470, 64475, 64479, 64483,
64722, 69990, 72265, 72275, 76000, 7600376005, 90780
0006T
0007F
0028T
0007T
35201-35206, 35226, 35261-35266, 35286,
36000, 36410, 37202, 76360v, 90780
0029T
90901v-90911v, 97530, 97533
0008F
0030T
0008T
00740, 00810, 36000, 36410, 43200, 4320243235, 43255, 69990, 89130, 90780-90784,
91105, 94760-94761
0031T
0032T
0031T
0033T
01926, 36000, 36410, 37202, 62318-62319,
64415, 64417, 64450-64470, 64475, 69990,
90780
0034T
01926, 36000, 36410, 37202, 62318-62319,
64415, 64417, 64450-64470, 64475, 69990,
90780
0035T
01926, 36000, 36410, 37202, 62318-62319,
64415, 64417, 64450-64470, 64475, 69990,
90780
0036T
0037T
36000, 36410, 37202, 62318-62319, 64415,
64417, 64450-64470, 64475, 69990, 90780
0038T
01916
29870-29871, 29874-29875, 2987729879, 29884, 29886-29887, 36000, 36410,
37202, 62318-62319, 64415-64417, 6445064470, 64475, 90780
0039T
01916
0040T
01916
0041T
29870-29871, 29874-29875, 29877, 2988029884, 36000, 36410, 37202, 62318-62319,
64415-64417, 64450-64470, 64475, 90780
0042T
01922, 36000, 36410, 90780
0043T
0044T
0045T
0046T
0009F
0009T
36000, 36410, 57100, 57180, 57400-57410,
57452, 57500, 57530, 57800, 58100-58120,
58353v, 58558, 58563v, 64435, 69990,
76362, 76394, 76490, 76942, 76986, 90780
0010F
0010T
0011F
0012T
29870-29871, 29874-29875, 29877-29879,
29884, 29886-29887, 36000, 36410, 37202,
62318-62319, 64415-64417, 64450-64470,
64475, 90780
0013T
0012Tv,
0014T
0016T
36000, 36410, 90780
0017T
36000, 36410, 90780
277
CCI
0006F
CCI
Coding and Payment Guide For The Physical Therapist
0047T
0048T
0049T
0050T
0051T
0052T
0053T
0054T
0055T
0056T
0057T
0058T
0059T
0060T
0061T
16020
01995, 11100, 11719, 16000v-16015v,
16025v-16030v, 36000, 36410, 37202,
62318-62319, 64415-64417, 64450-64470,
64475, 69990, 90780, 97022, 97601v
16025
01995, 11100, 16015v, 16030v, 36000, 36410,
37202, 62318-62319, 64415-64417, 6445064470, 64475, 69990, 90780, 97022
29505
29445v, 29515, 29540, 36000, 36410, 37202,
62318-62319, 64415-64417, 64450-64470,
64475, 69990, 90780
29515
11055-11056, 29445v, 29540-29580, 36000,
36410, 37202, 62318-62319, 64415-64417,
64450-64470, 64475, 69990, 90780
29520
29445v, 36000, 36410, 37202, 62318-62319,
64415-64417, 64450-64470, 64475, 69990,
90780
29530
12002, 29445v, 36000, 36410, 37202, 6231862319, 64415-64417, 64450-64470, 64475,
69990, 90780
29540
11900, 12004, 29445v, 29550, 36000, 36410,
37202, 62318-62319, 64415-64417, 6445064470, 64475, 69990, 90780
29550
11719, 11900, 36000, 36410, 37202, 6231862319, 64415-64417, 64450-64470, 64475,
69990, 90780, G0127
29580
12002-12004, 15852, 29540-29550, 29700,
36000, 36410, 37202, 62318-62319, 6441564417, 64450-64470, 64475, 69990, 87070,
87076-87077, 90780
29590
29540, 36000, 36410, 37202, 62318-62319,
64415-64417, 64450-64470, 64475, 69990,
90780
64550
36000, 36410, 61850v-61880v, 62318-62319,
64415-64417, 64450-64470, 64475, 69990,
90780
v
16030
01995, 11100, 16015 , 36000, 36410, 37202,
62318-62319, 64415-64417, 64450-64470,
64475, 69990, 90780, 97022
90901
29125
12001-12002, 12032, 12042-12044, 13121,
13132, 29130, 29260, 36000, 36410, 37202,
62318-62319, 64415-64417, 64450-64470,
64475, 69990, 90780, G0168
51784-51785, 51795, 64550, 90804-90857,
90865, 90880, 91122
90911
51784-51785, 51795, 64550, 90804-90857,
90865, 90880, 90901, 91122, 95860-95872,
97032, 97110-97112, 97530, 97535, 97750
29126
36000, 36410, 37202, 62318-62319, 6441564417, 64450-64470, 64475, 69990, 90780
92605
29130
36000, 36410, 37202, 62318-62319, 6441564417, 64450-64470, 64475, 69990, 90780
92606
92607
29131
36000, 36410, 37202, 62318-62319, 6441564417, 64450-64470, 64475, 69990, 90780
92608
92609
29200
36000, 36410, 37202, 62318-62319, 6441564417, 64450-64470, 64475, 69990, 90780
92610
92511
29220
36000, 36410, 37202, 62318-62319, 6441564417, 64450-64470, 64475, 69990, 90780
92611
76120-76125, 92511, 92610v
92950
36000, 36410, 90780, 92961v
29240
36000, 36410, 37202, 62318-62319, 6441564417, 64450-64470, 64475, 69990, 90780
93015
36000, 36410, 90780-90784, 93000-93010,
93016-93018, 93040-93042, 94760-94761
29260
36000, 36410, 37202, 62318-62319, 6441564417, 64450-64470, 64475, 69990, 90780
93016
36000, 36410, 90780-90784, 93000-93010,
93040-93042, 94760-94761
29280
36000, 36410, 37202, 62318-62319, 6441564417, 64450-64470, 64475, 69990, 90780
93017
36000, 36410, 90780-90784, 93000-93010,
93040-93042
93018
36000, 36410, 90781-90784, 93000-93010,
93040-93042, 93278, 94760-94761, 96410
278
Glossary
codes are never reported as stand-alone services. They are
reported secondarily in addition to the primary procedure.
Aberrant. A deviation or wandering from the normal or
usual course, condition, or pattern.
Adduction. To pull toward a reference line such as from the
midline of the body or the midline of the foot.
Ablation. Removal or destruction of tissue either by cutting,
electrical energy, chemical substances, or excessive heat
application.
Adhesion. An abnormal fibrous connection between two
structures, either soft tissue or bony structures, that may
occur as the result of surgery, infection, or trauma.
Abrasion. Removal of layers of the skin.
Advance Beneficiary Notice (ABN). If a provider has reason
to believe a particular service or procedure, including
laboratory tests, will be denied by Medicare because of lack
of medical necessity, the provider may ask the patient to
waive protection from liability by asking the patient to sign
an advanced beneficiary notice. The ABN must specify each
service and each date of service, and the specific reason why
it is believed the service will be denied.
Abscess. A circumscribed collection of pus resulting from
bacteria; frequently associated with swelling and other signs
of inflammation.
Absorbable sutures. Strands prepared from collagen or a
synthetic polymer and capable of being absorbed by tissue
over time. Examples include surgical gut; collagen sutures;
or synthetics like polydioxanone (PDS), polyglactin 910
(Vicryl), poliglecaprone 25 (Monocryl), polyglyconate
(Maxon), and polyglycolic acid (Dexon).
Abuse. As defined by Medicare, an incident that is
inconsistent with accepted sound medical, business, or
fiscal practices and directly or indirectly results in
unnecessary costs to the Medicare program, improper
reimbursement, or reimbursement for services that do not
meet professionally recognized standards of care or which
are medically unnecessary. Examples of abuse include
excessive charges, improper billing practices, billing
Medicare as the primary insurance instead of other thirdparty payers that are primary, and increasing charges for
Medicare beneficiaries, but not to other patients.
Acetabuloplasty. Plastic repair/reconstruction of the
acetabulum. The acetabulum is the rounded cavity on the
external surface of the innominate bone that receives the
head of the femur.
Achilles tendon. The tendon attached to the posterior of the
calcaneus that plantar flexes the foot.
Acromioplasty. Repair of the part of the shoulder blade that
connects to the deltoid muscles and clavicle.
Activities of daily living.* The self-care,communication,
and mobility skills (eg, bathing, bed mobility, dressing,
eating, grooming, toileting, and transfers)required for
independence in everyday living.
Acquired. A condition, which is not genetic, that is
produced by outside influences.
Acute. Sudden, severe.
Acute lymphadenitis. Sudden, severe inflammation,
infection, and swelling in lymphatic tissue.
Add-on codes. A procedure performed in addition to the
primary procedure and designated with a + in CPT. Add-on
Algoneurodystrophy. A neuropathy of the peripheral
nervous system of the body.
Alignment. The establishment of a straight line or
harmonious relationship between structures.
Alloplastic. Inert material (foreign body), such as plastic or
metal, implanted into tissues for the purpose of
construction, augmentation, or reconstruction.
Amputation. The removal of all or part of a limb or digit
through the shaft or body of a bone either by surgery or
accidental injury.
Anticoagulant. A substance that reduces or eradicates the
blood’s ability to clot.
Alternative delivery system (ADS). A phrase indicating any
health care delivery system other than traditional fee-forservice.
Aneurysmal bone cyst. Solitary bone lesion that bulges
into the periosteum; marked by calcified rim.
Angiodysplasia. Vascular abnormalities, with or without
bleeding.
Angioplasty. Reconstruction or repair of a diseased or
damaged blood vessel.
Ankylosis. Abnormal immobility and consolidation of a
bone or joint.
Anterior. The front area or toward the front area of the
body; an anatomical reference point used to show the
position and relationship of one body structure to another
body structure.
Anterolateral. Situated in the front part and off to one side.
Anteromedial. Situated in the front part and off to the
medial side.
Anteroposterior. Front to back.
* Starred definitions printed with permission from the Guide to Physical Therapist Practice, 2nd ed. Phys Ther. 2001; 81: 9-744.
265
Glossary
Abduction. To pull away from a reference line such as from
the midline of the body or the midline of the foot.
Appeal. A specific request (reconsideration) to reverse a
denial or adverse coverage or payment decision and
potential restriction of benefit reimbursement. An appeal is
a special kind of formal complaint to let the carrier know
that you disagree with any decision about health care
services. This complaint is made directly to the health plan
by following a specific process set up by the health plan.
The insured or the health care provider can initiate appeals
when the insured and the plan disagree with a plan’s
decision to deny or limit care.
Appliance. Device providing function to a body part.
Glossary
Appropriateness of care. Term often used to denote proper
setting of medical care that best meets the patient’s
diagnosis.
Arthrocentesis. Aspiration of fluid from a joint with a
needle.
Arthrodesis (fusion). Surgical fixation of a joint.
Arthrogram. An x-ray of a joint after the injection of
contrast material.
Arthrography. Contrast study of a joint performed in
radiology to diagnose joint disorders.
Arthroplasty. Restoration of a joint.
Arthrotomy. Surgical incision into a joint.
Aseptic necrosis. A condition sometimes following a
traumatic dislocation of the hip or shoulder in which the
head of the femur or humerus shows increasing signs of
sclerosis and cystic changes.
Aspirate. To withdraw fluid or air from a body cavity by
suction.
Assessment.* The measurement or quantification of a
variable or the placement of a value on something.
Assessment should not be confused with examination or
evaluation.
Assigned claim. A claim from a physician or supplier who
has agreed to accept the Medicare allowable amount as
payment in full for the services rendered. Payment for an
assigned claim is made directly to the provider or supplier
of the item or service. Under the terms of assignment, the
physician or supplier may not collect from the beneficiary
or another insurer the difference between the Medicare
allowable and the physician’s actual charge for the item or
service (excluding the beneficiary’s 20 percent coinsurance
and deductible).
Assignment. An arrangement in which the provider
submits the claim on behalf of the patient and is
reimbursed directly by the patient’s plan. By doing so, the
provider agrees to accept what the plan pays after
deductibles and copayments are met.
Assistive devices.* A variety of implements or equipment
used to aid patients/clients in performing actions, activities,
movements, or tasks. Assistive devices include canes,
crutches, long-handled reacher, power devices, static and
dynamic splints, walkers, and wheelchairs.
266
Atony. Absence of normal muscle tone and strength.
Atrophy. Reduction in size or activity in an anatomic
structure, due to disease or other factors.
Autograft. Tissue grafted from one anatomical site of a
person to another anatomical site of the same person.
Other terms for autograft include autogenic graft,
autologous graft, and autotransplant.
Avulsion. Forcible removal of a part, such as the partial or
total removal of a toenail.
Axon. An extension from a neuron that carries impulses to
receiving terminal branches.
Balance billing. An arrangement where a health care
provider may bill a covered person for charges above the
amount reimbursed by the health plan (i.e., the difference
between billed charges and the amount paid). This may or
may not be appropriate, depending upon the contractual
arrangements between the health care provider and carrier
and/or any government regulations (i.e., Medicare).
Medicare risk plan members cannot be balance billed by
contracted providers; Medicare fee-for-service participants
cannot be balance billed by participating providers.
Bell’s palsy. A lesion of the facial nerve that results in
unilateral facial paralysis that onsets suddenly.
Beneficiary. A person entitled to receive Medicare or other
payer benefits and who maintains a health insurance policy
claim number.
Bicipital tenosynovitis. An inflammatory condition
affecting the bicipital tendon.
Brachial plexus lesions. Acquired defect in tissues along
the network of nerves in the shoulder, causing
corresponding motor and sensory dysfunction.
Bundled. 1) The gathering of several types of health
insurance policies under a single payer, 2) The inclusive
grouping of codes related to a procedure when submitting a
claim.
Bursa. A cavity or sac containing fluid.
Bursectomy. The surgical excision of a bursa.
Bursitis. Inflammation of a bursa.
Calcifying tendinitis. Inflammation and hardening of the
tissue (due to calcium salt deposits), occurring in the
tendons and tendon-muscle attachments.
Cancellous bone. Spongy bone containing many large
spaces filled with bone marrow or embryonal connective
tissue. Cancellous bone makes up most of the bone tissue
of short, flat, and irregular shaped bones as well as most of
the epiphysis (end portion) of the long bones. It makes the
bones lighter.
Capsulectomy. Excision of a structure that has something
enclosed. The capsule can be either hard or soft.
Capsulorrhaphy. Suturing of a joint capsule.
Capsulotomy. Incision of a joint capsule.
Index
Bell's palsy, 79, 144, 246, 266
Belt, extremity, 233
Beneficiary late filing, 45
Benign neoplasm, 184-193
Biofeedback, device, 228, 233
Biofeedback, training, 74, 96, 98
Blue Cross and Blue Shield, 6, 26, 37
Bronchitis, acute, 113
Bronchitis, chronic, 157-158, 163,
194-195, 212
Burns, local treatment, 72
Calculating costs, 8
Cane, 221, 226, 233-236, 249, 252,
262
Capitation, 8, 47, 62
Cardiac rehabilitation, 66, 75-76, 9596, 244-247
Cardiopulmonary resuscitation, 75, 95
Cardiovascular services, 75
Cardiovascular stress test, 76
Casts, 72, 256
Cast Supplies, 221
Category II codes, 91
Category III codes, 91
CCI, 11-12, 277-281
Cellulitis, 115, 134, 148, 168, 176,
198, 267
Cerebrovascular disease, 107, 109, 111112, 153, 172, 178-179
Cervical, collar, 230, 233-235
Cervical, traction, 85, 228, 252, 262
CHF, 111, 114
Chronic obstructive pulmonary
disease, 113-114, 146, 252, 262
CIM, 3, 72-74, 76-78, 84-86, 90, 220221, 225-229, 231, 237-264
Circadian respiratory pattern
recording, 78
Claims, adjudicator, 41
Claims, correction, 42
Claims, processing, 2-3, 11, 19, 35, 3767, 99, 237, 269
CMS, 1-2, 5, 7, 10-12, 15, 17, 19, 25,
32-33, 35, 38-39, 41-43, 45-46, 4950, 57, 63, 71, 88, 99, 131-132, 217,
220, 229, 231, 237-239, 267, 269272
CMS-1500, 2-3, 37, 39, 50, 54, 56-57,
62, 71, 271
Coding systems, 1, 3, 217
Collection policies, 42-43
Complications, 32, 86, 100-101, 104107, 120, 123, 126, 130, 133, 149,
210, 212, 214, 246, 258
Concussion, 124, 145, 149-150, 163,
169, 176, 209
Congenital anomalies, 100, 121-122
Congestive heart failure, 111, 114, 162
Constant attendance, 71, 86, 88, 252
Convulsions, 122, 140
COPD, 113-114, 146, 157
Correct Coding Initiative, 11-12, 90,
268, 277, 279, 281
Coverage issues, 3, 5, 71, 74-75, 85,
232, 237-238, 244, 257, 272
Coverage Issues Manual, 3, 74-75,
237-238, 244, 257, 272
CPAP, 77, 95, 97, 250, 260
CPR, 7, 95, 97
CPT, definitions and guidelines, 3, 69,
71, 73, 75, 77, 79, 81, 83, 85, 87,
89, 91, 93
CPT, index, 3, 95-98
CPT, modifiers, 218
Custom-fitted orthotic, 230
CVA, 111, 136
Debridement, burns, 95
Decubitus ulcers, 245, 249, 259
Definitions and guidelines, 3-4, 69-71,
73, 75, 77, 79, 81, 83, 85, 87, 89,
91, 93, 99, 101, 103, 105, 107, 109,
111, 113, 115, 117, 119, 121, 123,
125, 127, 129, 217, 219, 221, 223,
225, 227, 229, 231
Denis-Browne splint strapping, 73
Derangement joint, 148, 159, 180,
203
Dermatitis, 73, 112, 115, 155, 168,
203, 207, 210, 214
Developmental Screening Test II, 83
Diabetes, 86, 104-108, 141, 155, 168,
182, 194, 196, 201, 213, 255, 263
Diathermy, 85, 95, 97, 245, 250, 260
Dislocation, 72, 96, 119, 123, 139,
148, 154-155, 158-159, 162, 166,
168, 179-181, 208, 266-267, 270,
272-274
Disuse atrophy, 79, 119, 161, 246, 248
DME, 1, 10, 46-47, 62, 220-221, 225,
230-231, 234, 247, 249, 256-257,
259
Dressings, 62, 72-73, 89-90, 95, 129,
218, 221, 247, 255-257, 268
Durable medical equipment, 1, 6, 910, 17, 46, 53, 62, 217-218, 220,
225, 228, 234, 248-249, 251, 256259, 261, 268
E code, 107, 112, 115, 120, 125-126,
130
Ear oximetry, 96
ECG, 76, 95, 156, 175, 245-247, 264
EEG, 10, 79, 95
EKG, 10, 54, 95, 111, 248, 254
Electrical stimulation, 74, 79, 81, 8586, 90, 95, 97, 229, 245-248
Electrodes, 73, 79, 81-83, 85, 149,
221, 228, 233-234, 245-248
Electromyography, 69, 74, 78-83, 9596, 228, 245
Electrotherapy, 79, 246
Embolisms, 111-112
Encephalitis, 102, 108, 156, 176, 179182, 198
283
Index
Abdominal dressing, 220, 233
ABGs, 114
ABN, 12-13, 15, 17, 219, 221, 265,
270
Abnormal findings, 108, 122
Action plan, 35
Acupuncture, 13, 90, 95, 244, 247
Acute poliomyelitis, 102
Acute respiratory infections, 113
Add-on code, 69, 71, 73, 75, 77, 79,
81, 83, 85, 87, 89, 91, 93
Adjudication, 25, 37, 41, 46, 49, 58
Adhesive solvent*****
ADL, 86, 89, 95, 97, 269
Advance beneficiary notice, 12-13, 15,
17-18, 219, 221, 265, 270
Alginate dressing, 233-234, 236
Alzheimer's, 109, 138, 143, 154, 156,
204, 208
APC, 6
Appeals, 12, 19-20, 23, 42-46, 237,
266
Application, 33, 48, 72-74, 84-86, 8990, 95-96, 218, 221, 227, 232, 234,
248, 250, 260, 265
APTA, 1, 10, 12, 27, 88
Aquatic therapy, 3, 87, 95-97
ARDS, 115
Arthritis, 85, 102, 107, 116-120, 132,
134, 141-143, 158, 164, 175-176,
181, 183, 196, 201, 203, 205, 208211, 213
Arthropathy, 116-118, 142, 148, 155,
211
ARU, 49
Assignment of benefits, 37
Asthma, 113-115, 143, 149, 162, 168,
182, 202-205, 208-209, 214, 244245
EOB, 21, 46, 52
Epilepsy, 109, 163, 168, 183, 214
Evaluation and Management, 69-70,
76, 90-91, 95, 253-254, 264, 270
Evaluation, occupational, 96
Evaluation, physical therapy, 84
Evaluation, spirometry, 76
Exercise therapy, 96, 136, 245-247
External counterpulsation, 246, 264
Flat foot, 121, 206, 263
Foam Dressing, 222, 233-234, 236
Foot care, 12, 15, 54, 263
Foreign body, 114, 123-124, 126, 166,
168, 177, 194, 203, 208, 265, 267
Fracture, multiple, 179
Fracture, skull, 123
Fraud and abuse, 25, 33-35, 46
FTT, 122
F-wave, 81
Index
Gait, training, 9, 71, 87, 96-97, 137,
270
Gout, 108, 117, 168, 194
Gradient compression stocking, 231
Group therapy, 61, 88, 252
Guidelines for physical therapy
documentation, 27
HCPCS, Level III Codes, 2, 39, 217
Health Maintenance Organizations, 56, 238
Heat, lamp, 227, 250, 260
Heat, pad, 227, 236
Heel pad, 231, 234
Hemiplegia, 109, 141, 144, 169-170,
178, 204, 211
Hemorrhage, subarachnoid, 138, 141,
165, 169-170
Hemorrhage, subdural, 169-170
Herpes zoster, 102, 115
HIV, 92, 101-102, 110, 127, 129, 157,
165, 176
Home management training, 87, 89
Hot water bottle, 227, 234
Huntington's chorea, 109, 154, 170
Hydrocephalus, 121, 135, 137, 153,
170, 180
Hydrocollator unit, 227
Hydrocolloid dressing, 223, 233-234,
236
Hydrogel dressing, 223-224, 233-234,
236
Hypertension, 99, 101, 110, 141, 143,
145, 147-149, 151-154, 156-157,
161-164, 170, 172-175, 183, 202,
204-205, 207-209, 212
Hypotension, 112, 175, 198, 211
284
ICD-9-CM, definitions and guidelines,
3, 99, 101, 103, 105, 107, 109, 111,
113, 115, 117, 119, 121, 123, 125,
127, 129
ICD-9-CM, Index, 3, 116, 124, 131215
Ice cap or collar, 227
IDDM, 104-105, 138-139, 141-143,
148, 155, 168, 181-182, 193-194,
196, 201-202, 209, 213
Immunity disorders, 100, 104, 108
Incident to, 86, 229, 244-245, 248,
253-258, 262
Independent practice, 6, 253, 262, 264
Independent Practice Association, 6
Index, 3-4, 95-99, 104, 110, 113, 115116, 122, 124, 126, 130-215, 217218, 233-236
Infectious & parasitic diseases, 100102, 108, 115, 132
Insurance, 1-2, 5-7, 12, 19-23, 25-26,
32, 37-38, 40, 42, 49-53, 63, 65, 78,
103, 217, 232, 237-238, 257-258,
265-266, 268, 270-271, 273-274
IPPB, 77, 250-251, 260
Kyphosis, 151, 153, 178, 201, 213, 270
Leukemia, 103
Limiting charge, 18-20, 44, 48, 270
Lordosis, 153, 180, 213
LSO, 230, 233-236
Lupus, 115-116, 157, 163, 180, 183,
199, 201, 211
Malignant neoplasm, 102, 129, 170,
182-184, 195, 201, 267
Malnutrition, 104, 107-108
Manifestation codes, 117, 132-133
Manipulation, 54, 78, 87, 95-97, 244,
264, 267, 271
Manual therapy techniques, 87, 271
MCM, 3, 52, 54-55, 77-91, 220-228,
231, 237-264, 271
Medicaid, 1, 5, 9-10, 25, 32-34, 37,
45, 49, 52, 57, 62-64, 88, 99, 131,
217, 220, 237-238, 267-272
Medical necessity, 3, 5, 12, 15, 17, 2526, 37, 42, 44-45, 47, 49, 55, 84,
87, 221, 245, 248, 253-255, 257,
264-265, 268, 271
Medicare, benefit notices, 46
Medicare, Carriers Manual, 3, 71, 237238, 244, 247, 249, 252, 264, 271272
Medicare, Official Regulatory
Information, 3, 237, 239, 241, 243,
245, 247, 249, 251, 253, 255, 257,
259, 261, 263
Medicare, remittance advice, 22
Medicare, summary notice, 46
Medigap, 18-19, 49, 51-53, 56-57, 271
Meningitis, 101-102, 108-109, 176,
179, 181
Metabolic diseases, 100, 104
Migraine, 109, 137, 144, 148, 157,
169-170, 180-182, 193, 195, 208210
Motion analysis, 82-83, 96
Multiple sclerosis, 109, 156, 244
Muscle testing, 79-80, 96
Muscular dystrophy, 147, 156, 161,
168, 183, 202
Musculoskeletal System, 72, 92, 100,
116, 137, 157, 160, 175, 196, 202
Myasthenia gravis, 109, 272
Neoplasm, 100, 102-104, 119, 129,
131, 136, 162, 170, 182-195, 197,
201, 209, 213, 267
Neoplasm, benign, 100, 184
Neoplasm, malignant, 184
Neoplasm, table, 103, 131
Neoplasm, uncertain behavior, 184
Nerve conduction, 78-81, 95-96, 111,
229
Nervous system, 73, 79, 81-83, 100,
102, 106, 108-109, 134-137, 139140, 144, 149-152, 154, 156-157,
160, 162, 165, 175-182, 184, 187,
190, 192, 202, 208, 265, 272
Neurobehavioral status exam, 83
Neurology, 69, 78, 96
Neuromuscular electrical stimulation,
246, 248
Neuromuscular, junction testing, 82
Neuromuscular, reeducation, 75, 87,
96-97
NIDDM, 104-105, 138-139, 141-143,
148, 155, 168, 181-182, 193-194,
196, 201-202, 209, 213
Non-Covered Services, 15, 17, 47
Non-participating providers, 6, 12, 18,
20, 43
Non-speech-generating device, 74
OIG, 25, 33-35
Open wounds, 123-124, 270, 273
Orthotic, 29-31, 61, 84, 88, 90, 137,
212, 218-219, 229-231, 235, 246,
267
Orthotic, devices, 230-231, 235, 267
Orthotic, shoes, 231
Orthotic, training, 137, 246
Osteoarthrosis, 118, 141-143, 154,
157, 175, 195-196, 272
Osteogenic stimulation, 245
Osteomyelitis, 107, 116, 155, 168,
183, 195-196, 272

Coding and Payment Guide for the Physical Therapist

Transcription

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