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ICD CM AND CPT CODING GUIDELINES FOR ADS by mikeholy

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									AMBULATORY DATA
  SYSTEM (ADS)


 Coding Guidelines



   May 1, 2000
                                                                                                                       May 1, 2000



TABLE OF CONTENTS


SECTION 1. OVERVIEW ................................................................................................. 1-1
  1.1     PURPOSE .................................................................................................................... 1-1
  1.2     DIAGNOSTIC CODING ................................................................................................. 1-1
  1.3     PROCEDURAL CODING ............................................................................................... 1-1
  1.4     THIRD PARTY BILLING ............................................................................................... 1-2
  1.5     ADS HOTLINES.......................................................................................................... 1-2
  1.6     ACRONYMS ................................................................................................................ 1-3
SECTION 2. DIAGNOSTIC CODING ............................................................................ 2-1
  2.1 CODE RANGE ............................................................................................................. 2-1
  2.2 GUIDELINES ............................................................................................................... 2-1
    2.2.1 Prioritized Diagnoses ......................................................................................... 2-1
    2.2.2 Specificity .......................................................................................................... 2-2
    2.2.3 Chronic Conditions ............................................................................................ 2-2
    2.2.4 Ambulatory Procedure Visit (APV) ................................................................... 2-2
    2.2.5 V Codes .............................................................................................................. 2-3
    2.2.6 E Codes .............................................................................................................. 2-4
SECTION 3. PROCEDURAL CODING .......................................................................... 3-1
  3.1 EVALUATION AND MANAGEMENT CODING ................................................................ 3-2
    3.1.1 New and Established Patients ............................................................................ 3-4
    3.1.2 Minimum Documentation Requirements for
          Coding New versus Established Patients ........................................................... 3-4
    3.1.3 Encounter Duration ............................................................................................ 3-5
    3.1.4 E&M Coding for ADS ....................................................................................... 3-5
  3.2 MEDICAL AND SURGICAL SERVICES ........................................................................ 3-11
    3.2.1 Global Care Services........................................................................................ 3-12
    3.2.2 Immunizations.................................................................................................. 3-12
    3.2.3 Ophthalmology................................................................................................. 3-12
    3.2.4 Laboratory and Radiology Services ................................................................. 3-12
    3.2.5 Physical Therapy/Occupational Therapy (PT/OT) Services ............................ 3-13
    3.2.6 Electrocardiogram (EKG) Services.................................................................. 3-13
  3.3 MENTAL HEALTH SERVICES .................................................................................... 3-13
  3.4 MODIFIERS............................................................................................................... 3-13


LIST OF TABLES

TABLE 3-1. SUMMARY OF E&M CODE ASSIGNMENT CRITERIA ............................................. 3-3
TABLE 3.2. E&M CODES FOR OBSERVATION SERVICES ......................................................... 3-7



                                                                   i
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SECTION 1. OVERVIEW

This document provides guidance for Department of Defense (DoD) medical coders.
1.1       Purpose


This document consolidates industry standards with specific guidance for encoding outpatient
diagnoses and procedures to be recorded via the Ambulatory Data System (ADS). It provides
guidance for DoD medical coders. Specific ADS guidance reflects decisions by the Coding
Subgroup of the Unified Biostatistical Utility (UBU). Otherwise, these guidelines are derived
from the following source documents:


         International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-
          CM),
         Current Procedure Terminology (CPT) Manual,
         Health Care Financing Administration Common Procedure Coding System (HCPCS),
         The Coding Clinic, and
         The CPT Assistant.


1.2       Diagnostic Coding


ICD-9-CM diagnosis codes are updated annually and must be downloaded from the Composite
Health Care System (CHCS) to ADS. These updates, which usually affect a portion of the
codes, are effective on 1 October of each year (e.g., the 2000 codes were implemented in the
private sector on 1 October 1999). Implementation by DoD military treatment facilities (MTFs)
is tied to release and distribution of an updated CHCS data tape and the date of actual
implementation may vary from that of private sector timelines.


1.3       Procedural Coding


CPT and HCPCS procedure codes are also updated annually and must be downloaded from
CHCS to ADS. Updated procedure codes also affect a portion of the overall coding schema,
and are effective on 1 January of each year. Like the ICD-9-CM codes, implementation in DoD
MTFs is dependent on release of an updated CHCS data tape and may also be delayed in
comparison with the private sector.




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HCPCS codes are grouped into three levels. Level I, the major portion of the HCPCS coding
system, is CPT and covers most services and procedures. Level II codes supersede CPT codes
for similar encounters, evaluation and management services, or other procedures. Level II
codes are also used to report services, procedures, supplies, materials, and injections when no
CPT code is available (e.g., ambulance transportation services, dental procedures, issue of
durable medical equipment). A supply, material, injection, or service and its code number that
is listed in a specific section of HCPCS does not usually restrict its use to a specific profession
or specialty, although there are a few exceptions. Further, use of Level II codes is not restricted
to Medicare, as its title (“National Level II Medicare Codes”) might suggest. Should a coding
situation occur in which both HCPCS Level I and Level II codes exist, Level II codes are given
priority. HCPCS Level III, Local Codes, which are maintained by local Medicare carriers and
vary from carrier to carrier, will not be used for ADS purposes.


1.4     Third Party Billing


The ADS record is not to be used to bill third party insurers directly. Any questions about the
care provided must be resolved by the documentation in the medical record.


1.5     ADS Hotlines


MTFs can address questions about diagnostic and procedural coding and ADS to the hotlines
listed below.


For ADS software and technical support, contact the Tri-Service Medical System Support
Center (TMSSC) Help Desk:

                Phone
                Commercial:     1-800-600-9332          DSN: 240-4150

For diagnostic and procedural coding support, contact the DoD Ambulatory Hotline:

                Phone
                Commercial:     210-295-8920/1          DSN: 421-8920/1
                                210-221-0579                    471-0579
                Facsimile
                Commercial:     210-221-0263            DSN: 471-0263




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                                                                                  May 1, 2000


1.6     Acronyms


The acronyms used in this document are defined below:


ADS                  Ambulatory Data System
AMA                  American Medical Association
APV                  Ambulatory Procedure Visit
CIW                  Clinical Integrated Workstation
CPAP                 Continuous Positive Airway Pressure
CPT                  Current Procedural Terminology
CHCS                 Composite Health Care System
CNP                  Continuous Negative Pressure
DoD                  Department of Defense
DSN                  Defense Switch Network
E&M                  Evaluation and Management
EKG                  Electrocardiogram
HCFA                 Health Care Financing Administration
HCPCS                Health Care Financing Administration Common Procedure Coding
                     System
ICD-9-CM             International Classification of Diseases, 9th Revision, Clinical
                     Modification
JCAHO                Joint Commission on Accreditation of Healthcare Organizations
MTF                  Military Treatment Facility
PT/OT                Physical Therapy/Occupational Therapy
SSN                  Social Security Number
TMSSC                Tri-Service Medical System Support Center
UBU                  Unified Biostatistical Utility




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                                                                                     May 1, 2000


SECTION 2. DIAGNOSTIC CODING

ALL CODING MUST BE SUPPORTED BY THE DOCUMENTATION IN THE
MEDICAL RECORD.


This section provides outpatient ICD-9-CM coding guidelines that are consistent with both
Health Care Financing Administration (HCFA) and the American Medical Association (AMA)
guidelines. They pertain to both clinic and physician office visits.


2.1    Code Range


ICD-9-CM codes from 001.0 - 999.9 and V01.0 - V82.9 may be used to describe the reason for
seeing a DoD provider. In addition, codes E930 - E949 may be used as supplemental codes to
describe the cause of injury.


2.2    Guidelines


The following guidelines are to be followed for reporting diagnoses in ADS.


2.2.1 Prioritized Diagnoses


All conditions that are documented in the medical record and require or affect patient care,
treatment, or management during the encounter are to be coded. (Note: Currently, the ADS
record limits the number of diagnoses to a maximum of four.)


The primary diagnosis will be the chief reason for the visit, as determined by the provider. For
ADS purposes, up to three additional diagnoses may be prioritized by the provider.


       Example: A patient is seen for a decubitus ulcer of the sacrum. The patient also has
       emphysema. In this instance, decubitus ulcer of the sacrum (707.0) would be the
       primary diagnosis. No other diagnosis would be recorded, as the patient’s emphysema
       was not considered during the visit.




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        Example: A patient requests a prescription refill. The prescription refill should be
        documented as the primary diagnosis with the appropriate V code (V68.1) and the
        coexisting condition (e.g., hypertension) as the secondary code.


2.2.2 Specificity


Diagnostic codes should be assigned at the highest level of specificity provided by ICD-9-CM.
When a provider is not certain of a diagnosis, the highest level of specificity is captured by
coding signs, symptoms, or abnormal test results.


        Example: A patient is seen for abdominal pain in the upper right quadrant and no
        specific cause has been determined. The appropriate diagnostic code would be 789.01
        (Abdominal Pain, Upper Right Quadrant).


A number of ICD-9-CM codes have been “modified” to meet the needs of the Services.
Numeric characters have been added at the seventh digit level of a coding field for this purpose.
These codes are referred to as DoD extender codes.



2.2.3 Chronic Conditions


When treated on an ongoing basis, chronic disease may be coded as often as treatment and care
are provided to the patient for that condition.


        Example: A patient is treated on a monthly basis with an epidural block and steroid
        injection for chronic low back pain (724.2). This code would be reported each time the
        patient presented for care.


2.2.4 Ambulatory Procedure Visit (APV)


The primary diagnosis for an APV will be the primary reason for which ambulatory surgery was
performed. If the postoperative diagnosis is different from the preoperative diagnosis, the
postoperative diagnosis is to be coded.




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2.2.5 V Codes


The V codes are used to identify circumstances (diagnoses) other than disease or injury that are
the reason for an encounter with a physician or other provider. The V codes are used to
document an encounter and classify a patient who is not currently or acutely ill, but who
requires health care services.


        Example: A person who is not currently ill requests health services for a specific
        purpose, such as a prophylactic vaccination or counseling. In these cases, the ADS
        should be coded with V04.2 for the child seen in the Pediatric Clinic for measles
        vaccination and V65.3 for the diabetic patient who receives dietary counseling.


V codes may be supported by additional ICD-9-CM codes indicating the reason the patient
sought treatment at this encounter.


        Example: A diabetic patient being seen for dietary counseling would be coded as
        follows: V65.3 (Diabetic Counseling) and 250.00 (Diabetes Mellitus).


        Example: A person with a known disease or injury, whether current or resolving,
        encounters the health care system for a specific treatment of that disease or illness, such
        as chemotherapy, physical therapy, or a cast change. The appropriate diagnostic coding
        for a patient seen in the Oncology Clinic for chemotherapy treatment for breast cancer is
        V58.1 (Chemotherapy), and 174.3 (Lower Inner Quadrant Breast Cancer).


In some cases, the V code may only be used as a supplemental code.


        Example: A patient is seen for sinusitis and has a functioning pacemaker. In this
        situation, the diagnostic code 473.9 (Chronic Sinusitis) is coded first, and the V code
        V45.01 (Status Post Cardiac Pacemaker in Situ) is coded second as a supplemental
        code.


For ADS reporting purposes, physical exams should be coded as V70.0. Flight medicine or
occupational health exams should be coded as V70.5. When flyers have already been seen and
treated by a physician and have an appointment to evaluate their condition prior to returning to




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                                                                                       May 1, 2000


active flight status, V68.0 should be used as the diagnostic code and E&M codes 99455 or
99456 should be coded on the associated ADS record.



2.2.6 E Codes


The uses of E codes are supplemental to the application of basic ICD-9-CM codes. E codes
are never to be recorded as primary diagnosis (i.e., first listed in the outpatient setting).


2.2.6.1 General E Code Coding Guidelines


This guidance will be provided at a later date.


2.2.6.2 Place of Occurrence Guidelines


This guidance will be provided at a later date.


2.2.6.3 Poisonings and Adverse Effects of Drugs, Medicinal, and Biological Substances
Guidelines


A. Do not code directly from the Table of Drugs and Chemicals (E930 – E949). Always refer
    back to the Tabular List.
B. Use as many codes as necessary to describe completely all drugs, medicinal, or biological
    substances.
C. If the same E code would describe the causative agent for more than one adverse reaction,
    assign the code only once.
D. If two or more drugs, medicinal, or biological substances are reported, code each
    individually unless the combination code is listed in the Table of Drugs and Chemicals. In
    that case, assign the E code for the combination.
E. When a reaction results from the interaction of a drug(s) and alcohol, use poisoning codes.


2.2.6.4 Multiple Cause E Code Coding Guidelines


This guidance will be provided at a later date.




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                                                             May 1, 2000


2.2.6.5 Child and Adult Abuse Guidelines


This guidance will be provided at a later date.


2.2.6.6 Unknown or Suspected Intent Guidelines


This guidance will be provided at a later date.


2.2.6.7 Undetermined Cause


This guidance will be provided at a later date.


2.2.6.8 Late Effects of External Cause Guidelines


This guidance will be provided at a later date.


2.2.6.9 Misadventures and Complications of Care Guidelines


This guidance will be provided at a later date.




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SECTION 3. PROCEDURAL CODING

ALL CODING WILL BE SUPPORTED BY THE DOCUMENTATION IN THE
MEDICAL RECORD.


HCPCS Procedural Coding should be used, to the extent possible, when performing procedural
coding using ADS. When a coding situation occurs in which both HCPCS Level I and Level II
codes exists, Level II codes are given priority.


HCPCS codes are grouped into three levels. Level I, the major portion of the HCPCS coding
system, is CPT and covers most services and procedures. Level II codes are national codes
covering services, procedures, supplies, materials, and injections. Level II codes supersede
CPT codes for similar encounters, evaluation and management services, or other procedures.
Level II codes are also used to report services, procedures, supplies, materials, and injections
when no CPT code is available (e.g., ambulance transportation services, dental procedures, or
issue of durable medical equipment). Listing of a supply, material, injection, or service and its
code number in a specific section of HCPCS does not usually restrict its use to a specific
profession or specialty, although there are a few exceptions. Further, use of Level II codes is
not restricted to Medicare, as its title (“National Level II Medicare Codes”) might suggest.
Should a coding situation occur in which both HCPCS Level I and Level II codes exist, Level II
codes are given priority. HCPCS Level III, Local Codes, which are maintained by local
Medicare carriers and vary from carrier to carrier, will not be used for ADS purposes.


A high level overview of HCPCS National Level II is obtained by reviewing the following list
of 20 sections that comprise the main body of codes:


       Transportation Services                             Chemotherapy
       Chiropractic Services                               Temporary Codes for Durable Medical
                                                             Equipment Regional Carriers
       Medical and Surgical Supplies
                                                            Orthotic Procedures
       Miscellaneous and Experimental
                                                            Prosthetic Procedures
       Enteral and Parenteral Therapy
                                                            Medical Services
       Dental Procedures
                                                            Pathology and Laboratory
       Durable Medical Equipment
                                                            Temporary Codes
       Procedures/Services Temporary
                                                            Diagnostic Radiology Services


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                                                                                    May 1, 2000


         Rehabilitative Services                       Visions Services
         Drugs Administered Other Than Oral            Hearing Services
          Method

3.1       Evaluation and Management Coding


Evaluation and Management (E&M) codes, which are a subset of CPT codes, identify the
overall complexity of a patient encounter. As a reflection of this complexity, any E&M code
selected must be substantiated by provider entries in the patient’s medical record. The key
elements in selecting the appropriate E&M code are history, examination, and medical
decision-making. These components must meet or exceed requirements specified in the CPT
Manual to qualify the choice of E&M code. (The complexity of the encounter and not the
amount of time spent with a patient is the decisive factor in assigning E&M codes.)


Privileged providers may use all E&M codes. E&M code 99211 is the only E&M code that can
be used by the non-privileged provider and it should only be used when the patient does not see
a privileged provider.


If non-privileged providers are going to document their services using ADS, they must be
registered in the CHCS Provider Table. The provider must be registered in CHCS using their
actual social security number (SSN). Generic or pseudo SSNs are not to be used. (Note: The
registration of non-privileged providers such as technicians and nurses by their personal SSNs
does not require or otherwise affect MTF privileging processes.)


Chaplains are not considered to be health care providers and are not to report patient encounters
using ADS.


Table 3-1 provides a summary display of E&M code assignment criteria. Additional details are
specified in the CPT Manual.




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Table 3-1. Summary of E&M Code Assignment Criteria
                              Minimal               Problem             Expanded Problem               Detailed             Comprehensive            Comprehensive/
                                                    Focused                 Focused                                                                      High

 New patient                                         99201                     99202                     99203                   99204                     99205

 Established patient            99211                99212                     99213                     99214                   99215                     99215

 Consultation                                        99241                     99242                     99243                   99244                     99245

 History                  Nurse’s assessment    Chief complaint;       Chief complaint; brief      Extended history        Extended history of      Extended history of
                                                 brief history of     history of present illness   of present illness;       present illness;     present illness; complete
                                                 present illness                                       pertinent          complete past/family     past/family and social
                                                                                                    past/family and         and social history             history
                                                                                                     social history

 Examination               Does not require    One area of the body   Problem pertinent area        More extrinsic       Complete single-system   Complete single-system
                             presence of                                and system review              exam              or multi-system review   or multi-system review
                              physician

 Severity of presenting        Minimal         Self-limited; minor       Low to moderate               Moderate             Moderate to high         Moderate to high
 problems

 Diagnoses or                 Under the           Minimal (one)               Limited                  Multiple                Multiple                  Extensive
 Management Options        supervision of a
                              physician

 Amount/ complexity                             Minimal or none               Limited                  Moderate                Extensive                 Extensive
 of data to be reviewed

 Risk of complications                              Minimal                     Low                    Moderate                  High                      High

 Face-to-face time with         5 min           10 min (new)           20 min (new)                 30 min (new)          45 min (new)              60 min (new)
 patient and/or family*                         10 min (est)           15 min (est)                 25 min (est)          25 min (est)              40 min (est)
                                                15 min (consult)       30 min (consult)             40 min (consult)      60 min (consult)          80 min (consult)

*It is important to remember that, although time is a factor for assignment of the E&M code, time should not be used as the sole
determining factor.

Legend: Min= minutes; Est= established; Consult= consultation



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                                                                                         May 1, 2000


3.1.1 New and Established Patients


This section repeats guidance from the Federal Register and the CPT Manual to distinguish
between new and established patients.


In general, patients are considered to be new patients the first time they appear at a facility for
health care services. They are also new patients when they are referred to a physician of a
different specialty in the same facility. After the initial visit or consultation, patients are
considered to be established patients. Patients that have not been seen by a provider of any
specific clinic in a facility or group practice for three years are also considered to be new
patients.


Patients are considered to be established patients if they have been seen within three years by a
provider of the same specialty in a facility or group practice and are returning for another visit.
An example would be a patient seen by a family practice provider who returns to the facility
after a period of less than three years for another visit and is seen by a different family practice
provider.


For ADS purposes, patients transferred to another base and MTF will be new patients the first
time they seek medical services at the new MTF. After the initial visit, patients are considered
to be established patients. Patients referred to another provider of a different specialty at the
same MTF are also new patients.


3.1.2 Minimum Documentation Requirements for Coding New versus Established
        Patients


For new patients, all of the three key components (i.e., history, examination, and medical
decision-making) must meet or exceed the stated requirements to qualify the selection of a
particular level of E&M service. For established patients, two of the three key components (i.e.,
history, examination, and medical decision-making) must meet or exceed the stated
requirements to qualify the selection of a particular level of E&M service.




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                                                                                     May 1, 2000


3.1.3 Encounter Duration


Time is not a dominant factor for assigning the appropriate E&M code. The time frames
identified in E&M code descriptions are intended to represent a general range of times that will
vary depending on actual clinical circumstances. The severity of illness as documented by
history, examination, and medical decision-making should determine the choice of E&M code.


       Example: An initial visit to Dermatology by a 15-year-old female for severe cystic acne
       will be less complicated than an initial visit to Rehabilitation by a 15-year-old female
       for evaluation of progressive scoliosis.


Care scenarios for counseling and coordination are the only exception to the statement that
“time is not a dominant factor” in selecting the E&M code. In these cases, time is the principal
factor in selecting an E&M code. This occurs when the counseling or coordination of care
represents more than 50 percent of the time a provider spends face-to-face with the patient, the
family, or both. The amount of time spent performing these services must be specifically
documented in the patient’s medical record in addition to the key elements of history,
examination, and medical decision-making.


3.1.4 E&M Coding for ADS


3.1.4.1 Required E&M Code


A minimum of one E&M code is required for all encounters.


3.1.4.2 Telephone Consults


Privileged providers may choose from the three E&M codes for telephone consults (i.e., 99371,
99372, and 99373). In addition to using the appropriate E&M code, the telephone consult
indicator on the ADS record should be marked. Non-privileged providers will document
telephone services using E&M code 99211, but will not mark the telephone consult indicator on
the ADS record.




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                                                                                    May 1, 2000


3.1.4.3 Prolonged Services


E&M code 99354 will be used when patients require an unusual amount of face-to-face
privileged provider time. Under these circumstances, the prolonged service code will be used
instead of other E&M codes due to the current ADS requirement for one, and only one, E&M
code for each visit. This practice should be observed until the limitations on coding multiple
E&M codes in ADS are lifted.


Prolonged service E&M code 99354 is not used in the Emergency Room.


3.1.4.4 Observation Services


Placement in observation status requires an order from a provider with admitting privileges.


E&M codes will be used to document the length and acuity of observation care services in
ADS. Observation E&M codes relate to the number of calendar days (dates) the patient spends
in observation status and the acuity of the stay. Only one E&M code per observation patient
will be recorded, according to the number of days (up to three) that the patient was under
observation care, until ADS allows entry of multiple E&M codes.


      If a patient is placed in, and released from observation care on the same date of service,
       report the appropriate code from the code series 99234 - 99236.
      If a patient is placed in observation care on Day 1 and released on Day 2, report the
       appropriate code from the code series 99218 - 99220.
      If a patient is placed in observation care on Day 1, remains in observation care through
       Day 2, and is released on Day 3, report only code 99217.




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Table 3.2 summarizes the appropriate use of E&M codes for observation care services.


Table 3.2. E&M Codes for Observation Services
    LENGTH OF OBSERVATION                      DAY OF     OBSERVATION E&M
   (CALENDAR DAYS OR DATES)                   SERVICE     CODES FOR ACUITY
                                                         LOW     MEDIUM   HIGH
Observation care services provided within      Day 1     99234    99235   99236
one calendar day (same day).
Observation care services provided over a      Day 2     99218    99219   99220
period of two calendar days (two dates)
with release on Day 2.
Observation care services provided over a      Day 3     99217    99217   99217
period of three calendar days (three dates)
with release on Day 3, not exceeding 48
total hours.


The following services are not covered as outpatient observation services:


A. Observation services which exceed 24 hours unless an exception is deemed necessary
    following a medical necessity review.
B. Services which are not reasonable or necessary for the diagnosis or treatment of the
    patient but are provided for the convenience of the patient, his or her family, or a
    physician (e.g., following an uncomplicated treatment or procedure; physician busy when
    patient is physically ready for discharge; patient awaiting placement in a long-term care
    facility).
C. Inpatient services.
D. Services associated with ambulatory procedure visits.
E. Routine preparation services furnished prior to the testing and recovery afterwards. For
    patients who undergo diagnostic testing in a hospital outpatient department.
F. Observation concurrent with treatments such as chemotherapy.
G. Services for postoperative monitoring.
H. Any substitution for an outpatient observation service for a medically appropriate
    inpatient admission.
I. Services that were ordered as inpatient services by the admitting physician but reported as
   outpatient observation services by the hospital.
J. Standing orders for observation following outpatient services.
K. Discharges to outpatient observation status after an inpatient hospital admission.




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If a patient is admitted from observation status, the ADS record for the observation care should
be closed out with a disposition type of “admitted.”


When a patient is referred from observation to an APV, the ADS record for the observation care
is closed out with disposition type of “immediate referral.”


3.1.4.5 Ambulatory Procedure Visits (APVs)


E&M code 99499 will be used to code APVs along with the APV indicator on the ADS record.
Pre- and post-operative appointments will be documented in ADS as separate encounters if
performed on any day other than the day that the procedure is performed. These appointments
are not APVs and should not be coded using the APV indicator or E&M code 99499. This is a
departure from civilian practices that might include these encounters in the APV under the
concept of global care.


An APV patient will continue in APV status until the patient is either released or admitted as
an inpatient, regardless of the location of the patient’s bed.


When an APV patient requires a consultation, the consulting provider will report the
consultation services using a separate ADS record for their specialty.


If a patient is admitted from an APV, the ADS record should be closed out with a disposition
type of “admitted.”


If a patient presents for an APV, but the APV is not performed for one of the following reasons,


   The patient has a medical condition which prohibits the performance of the APV,
   The provider is unavailable to perform the APV, or
   Supplies or necessary resources are not available to support the APV,


the ADS record should be coded with the initial diagnosis, the appropriate V64* code to
indicate that the APV was cancelled, and the diagnosis code that indicates the reason for
cancellation (* indicates any appropriate code in the V64 code series).




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                                                                                     May 1, 2000


3.1.4.6 Consultation and Referral


The AMA and HCFA use the following criteria to define a consultation:


      The consultation is requested by another physician or source such as a third party payer.
      The consultant renders an opinion or advice.
      The consultant initiates diagnostic or therapeutic services.
      The requesting physician has documented the request and the need for the consultation
       in the patient record.
      The consultant’s opinion, advice, and any services rendered are documented in the
       patient record and communicated to the requesting physician or source, generally in the
       form of a written report in accordance with Joint Commission on Accreditation of
       Healthcare Organizations (JCAHO) standards.


Subsequent clinic encounters initiated by the consultant are coded as established patient clinic
encounters, not as consultations.


Office or other outpatient consultation E&M codes may also be used to report a preoperative
clearance by the patient’s primary care physician when requested to do so. Primary care
physicians requested to clear the patient for surgery may report the service as an office
consultation. Documenting the problem(s) to be evaluated by the consultation establishes the
medical necessity for the consultation.


Office consultation codes may also be used to report consultations provided in the Emergency
Department. When the consultant is called to the Emergency Department to render a
consultation at the request of the emergency department physicians, appropriate office
consultation codes are assigned.


ADS can be used to document telemedicine services. These encounters will result in the
generation of two ADS records: one for the face-to-face encounter and one for the telemedicine
consultant. (Note: Mini-registration at the site providing the telemedicine consultation will be
required to schedule the consultation in CHCS and ADS.)




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3.1.4.7 Preventive Medicine Services


E&M codes are provided to report the preventive medicine evaluation and management of
infants, children, adolescents, and adults, such as a scheduled annual physical examination for
flight medicine or a well-baby check-up. The extent and focus of these services will depend on
the age of the patient.


When an annual check-up or physical examination reveals a significant problem and the
problem requires additional work to perform the key components associated with E&M code
selection, an E&M code from the series 99201 - 99215 should be assigned instead of a
preventive medicine code (series 99381 - 99397). An insignificant or trivial problem that is
encountered in the process of performing the preventive E&M service, and that does not require
additional work and the performance of the key components of a problem-oriented E&M
service, should not be reported.


3.1.4.8 Counseling and Risk Factor Reduction Intervention


E&M codes are also used to report counseling and risk factor reduction services to a healthy
patient. These services are provided to a patient during separate encounters for the purpose of
promoting health and preventing illness or injury. The counseling provided during these
encounters will vary with age and should address such issues as family problems, diet and
exercise, substance abuse, injury prevention, sexual practices, and dental health. Counseling
and risk factor reduction intervention E&M codes are not to be used to document services
provided to patients with symptoms or established illness.


Physician educational services for groups of patients with symptoms or established illness are
reported using procedure code 99078. (Note: 99078 is not an E&M code). For ADS purposes
the appropriate E&M code (99212 or 99213) is also required. Nursing education services for
groups are reported using E&M code 99211. This is a departure from civilian practices that do
not require an E&M code for all encounters.




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3.1.4.9 Critical Care


E&M code 99291 will be used to report all critical care exceeding 30 minutes, regardless of the
amount of additional time spent on patient care. This is a departure from civilian practices that
permit use of more than one E&M code to report these services.


3.1.4.10 Emergency Services


All procedure codes may be used in conjunction with Emergency Department care as long as
they are not classified as critical care services. The procedures listed below may not be coded
in conjunction with critical care E&M code 99291.


         36000     Introduction of needle or intracatheter into a vein
         36600     Arterial puncture
         36410     Venipuncture requiring physician skill
         36415     Routine venipuncture
         71010     Frontal view chest x-ray
         71020     Frontal and lateral view chest x-ray
         91105     Gastric intubation
         92953     Temporary transcutaneous pacing
         93561     Arterial or venous catheterization; with cardiac output measurement
         93562     Arterial or venous catheterization; subsequent cardiac output
                    measurement
         94656     Ventilation assistance and management; first day
         94657     Ventilation management; subsequent days
         94660     Continuous positive airway pressure (CPAP) ventilation
         94662     Continuous negative pressure (CNP) ventilation
         99090     Analysis of information stored in computers.


3.2       Medical and Surgical Services


This section provides guidelines for the specific types of services indicated.




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3.2.1 Global Care Services


Since DoD does not perform global billing for prenatal care, fracture care, and global surgery,
each encounter associated with these services should be documented using individual ADS
records. If these services are performed by non-privileged providers, E&M code 99211 should
be used to document the ADS record; otherwise, the appropriate E&M code should be used.


3.2.2 Immunizations


When an immunization is the only service provided, E&M code 99211 may be assigned in
addition to the injection CPT code.


       Example: When the nurse or technician in an immunization clinic provides an
       immunization to the patient.


For ADS purposes, a patient seen in a specialty clinic setting and then sent to an immunization
clinic for injections requires two encounter forms. One will document the clinic visit and the
other will document the immunization. If the injections were given during the initial specialty
clinic visit, one encounter form will be used to document both the visit E&M code and the
injection CPT code.


3.2.3 Ophthalmology


Although there are separate E&M codes (92002, 92004, 92012, and 92014) for new and
established ophthalmology patients, they are not currently recognized in ADS as valid E&M
codes. Until ADS allows these codes to be recognized, the codes to be used are 99204 or 99205
for new patients and 99214 or 99215 for established patients.


3.2.4 Laboratory and Radiology Services


Laboratory and radiology procedures that are obtained from centralized services are not to be
reported using ADS. Only those radiology and laboratory procedures that are actually
performed in the immediate confines of a specialty clinic are to be reported in ADS. This
restriction ensures reporting of only those procedures that are actually completed and avoids
double-counting centralized procedures that are reported through CHCS.


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3.2.5 Physical Therapy/Occupational Therapy (PT/OT) Services


This guidance will be provided at a later date.


3.2.6 Electrocardiogram (EKG) Services


If the procedure and the interpretation of the EKG are performed in the same clinic, one ADS
record should be used to document both services. If the procedure and interpretation are
performed by different clinics, the procedure should be documented as an ancillary service, and
the interpretation may be documented using ADS. If the physician elects to document the
interpretation in ADS, the patient must be appointed to the physician’s clinic service, and the
ADS record should be coded with E&M code 99212 and one of the following CPT codes:
93010, 93014, 93018, 93042, 93227, 93233, 93237, or 93272.


3.3     Mental Health Services


ADS will be used to document all mental health diagnoses, E&M codes, and CPT codes for
treatment provided to patients who have not been admitted to mental health inpatient status.
This documentation requirement extends to all outpatients; partially hospitalized patients (e.g.,
day patients); and inpatients who have outpatient appointments in mental health clinics,
physician offices, or other clinics where patients are seen for ambulatory visits (e.g., services
affiliated with residential treatment facilities).


ADS records will be prepared for each day of partial hospitalization.


3.4     Modifiers


At this time, modifiers will not be used for either ADS or Clinical Integrated Workstation
(CIW) purposes.




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