Professional Services Coding Guidelines by mikesanye

VIEWS: 204 PAGES: 164

									 1
 2
 3




 4
 5
 6
 7
 8
 9
10        Military Health System Coding Guidance:
11
12   Professional Services and Specialty Coding Guidelines
13
14                             Version 2.0
15
16                Unified Biostatistical Utility
17
18
19                                   2008
20
21             Effective date for this guide version: 1 March 2008
22                  Effective date for audit use: 1 May 2008
                                                           TABLE OF CONTENTS



23   Chapter 1 OVERVIEW ................................................................................................................................... 1-1
24       1.1. Purpose........................................................................................................................ 1-1
25       1.2. Diagnostic Coding ...................................................................................................... 1-2
26       1.3. Procedural Coding ...................................................................................................... 1-2
27       1.4. Evaluation and Management (E&M) Coding ............................................................. 1-3
28       1.5. Coding Table Updates................................................................................................. 1-3
29       1.6. Legal Reference .......................................................................................................... 1-3
30       1.7. Getting Help ................................................................................................................ 1-3
31       1.8. Coding Reviews/Audits of Professional Services....................................................... 1-4
32       1.9. Health Insurance Portability and Accountability Act (HIPAA) ................................. 1-7
33       1.10. Use of the term SADR. .............................................................................................. 1-8

34   Chapter 2 DIAGNOSTIC CODING ............................................................................................................... 2-1
35       2.1. Code Taxonomy (Structure) ....................................................................................... 2-1
36       2.2. Guidelines ................................................................................................................... 2-2

37   Chapter 3 EVALUATION AND MANAGEMENT (E&M) CODING ........................................................ 3-1
38       3.1. E&M Coding: 99201–99499...................................................................................... 3-1
39       3.2. Office Outpatient Services, 99201–99215 .................................................................. 3-5
40       3.3. Hospital Observation Services 99217-99220 and 99234–99236 ................................ 3-5
41       3.4. Hospital Inpatient Services ......................................................................................... 3-7
42       3.5. Emergency Department ………...………………………………………………...…3-8
43       3.6. Telephone Services .................................................................................................... 3-8
44       3.7. Provider (privileged and non privileged)Initiated Telephone Calls ........................... 3-9

45   Chapter 4 CONSULTATION.......................................................................................................................... 4-1
46       4.1. Consultation Guidelines .............................................................................................. 4-1
47       4.2. Consult versus Referral ............................................................................................... 4-1
48       4.3. Documentation for Consultation ................................................................................. 4-1
49       4.4. Consultations that require more than one encounter...................................................4-2
50       4.5. Clearing Patients for Specialty Care . ....................................................................... 4-22
51       4.6. Preoperative Consultation .......................................................................................... 4-2
52       4.7. Preoperative Emergency Department Referrals vs Consultations...............…………4-
53       33
54       4.8. Coding Consults in AHLTA ....................................................................................... 4-4

55   Chapter 5 PROCEDURAL CODING ........................................................................................................... 5-1
56       5.1. Procedures ................................................................................................................... 5-1
57       5.2. Modifiers ..................................................................................................................... 5-1
58       5.3. Bundled Procedures and Global Procedures ............................................................... 5-2
59       5.4. Clinical Pharmacists.................................................................................................... 5-3
60       5.5. Chaplains and Pastoral Counselor .............................................................................. 5-3
61       5.6. Electrocardiogram (ECG or EKG) Services 93000-93042 ......................................... 5-4



                                                                                 i
                                                             TABLE OF CONTENTS


 62       5.7. Laser Tattoo and Hair Removal .................................................................................. 5-4
 63       5.8. On Call ........................................................................................................................ 5-4
 64       5.9. Medical Evaluation Boards (MEB). ........................................................................... 5-4
 65       5.10. Records Review. ....................................................................................................... 5-5
 66       5.11. Injections and Infusions ............................................................................................ 5-5
 67       5.12. Cast/Splint Application………...…………………………………………………...5-6
 68       5.13. Tobacco Use Cessation………...…………………………………………………...5-6
 69       5.14. Physician’s Voluntary Reporting Program Codes…...……………………………..5-6

 70   Chapter 6 SPECIALTY CODING .................................................................................................................. 6-1
 71       6.1. Anesthesia…..………………………………………………...…………………….6-1
 72       6.2. Audiology ................................................................................................................. 6-8
 73       6.3. Chiropractic Services .................................................................................. ………6-13
 74       6.4. Dialysis …………………………………………………………………………...6-15
 75       6.5. End Stage Renal Disease (ESRD).………………………………………………..6-17
 76       6.6. Flight Medicine Services ........................................................................................ 6-21
 77       6.7. Gynecology ............................................................................................................. 6-25
 78       6.8. Mental Health.......................................................................................................... 6-28
 79       6.9. Nutritional Medicine Encounters ............................................................................ 6-31
 80       6.10. Obstetrics Services .................................................................................................. 6-37
 81       6.11. Occupational Therapy ............................................................................................. 6-49
 82       6.12. Ophthalmology/Optometry ..................................................................................... 6-53
 83       6.13. Physical Therapy – Coding for Physical Therapist/Technician .............................. 6-62
 84       6.14. Preventive Medicine Services ............................................................................... 6-666
 85       6.15. Radiation Oncology Services ................................................................................ 6-722
 86       6.16. Radiology, Interventional………....……………………………………………....6-76
 87       6.17. Readiness Assessment .......................................................................................... 6-768
 88       6.18. Reconstructive/Cosmetic Surgery........................................................................... 6-82
 89       6.19. Social Work and Family Advocacy Services.......................................................... 6-84
 90       6.20. Substance Abuse Program Services ...................................................................... 6-888

 91   Chapter 7 CODING AMBULATORY PROCEDURE VISIT (APV) ENCOUNTERS ............................. 7-1
 92       7.1. Definitions................................................................................................................... 7-1
 93       7.2. Coding Pre- and Post Procedure APV Encounters ..................................................... 7-2
 94       7.3. Patient Admitted from APV........................................................................................ 7-3
 95       7.4. Consultation for APV ................................................................................................. 7-3
 96       7.5. Assistant at Surgery .................................................................................................... 7-3
 97       7.6. 99199, Institutional Component of an APV…………………………………………7-3
 98       7.7. Coding Cancelled APVs ............................................................................................. 7-3
 99       7.8. Procedures Not Performed in the APU ....................................................................... 7-4

100   Chapter 8 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
101        SCENARIOS .......................................................................................................................................... 8-1
102       8.1. Use of the ―MAIL‖ Function ...................................................................................... 8-1
103       8.2. For Clinic Use Only, an ADM function...................................................................... 8-1


                                                                                   ii
                                                     TABLE OF CONTENTS


104     8.3. Additional Provider ..................................................................................................... 8-1
105     8.4. Remote Professional Services………………………………………….……...…….8-1
106     8.5. Telehealth .................................................................................................................. 8-53
107     8.6. Resident/GME Services .............................................................................................. 8-8

108   Chapter 9 PROFESSIONAL CODING FOR INPATIENT ENCOUNTERS ............................................. 9-1
109     9.1. Background…………………………………………………………………………..9-1
110     9.2. Definitions………………………………………………………………………...…9-1
111     9.3. Inpatient Professional Services Data Capture……………………………………….9-4
112     9.4. Surgical Services…………………………………………………………………….9-7
113     9.5. Anesthesia Services………………………………………………………………….9-8
114     9.6. Inpatient Consults……………………………………………………………………9-8
115     9.7. Observation Status…………………………………………………………………...9-9
116     9.8. Newborn Early Hearing Detection & Intervention (EHDI)………………………....9-9
117




                                                                        iii
118   COPYRIGHT
119
120   The American Medical Association (AMA) copyrights Current Procedural Technology (CPT).
121   All rights reserved. No fee schedules, basic units, relative values or related listings are included
122   in CPT. AMA does not directly or indirectly practice medicine or dispense medical services.
123   AMA assumes no liability for data contained or not contained herein.
124
125   U.S. Government Rights
126   This product includes CPT, which is commercial technical data, computer databases or
127   commercial computer software or computer software documentation, as applicable, developed
128   exclusively at private expense by the AMA, 515 North State Street, Chicago, IL, 60610. U.S.
129   Government rights to use, modify, reproduce, release, perform, display, or disclose these
130   technical data and/or computer databases and/or computer software and/or computer software
131   documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June
132   1995) and to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a)
133   (June 1995), as applicable, for U.S. Department of Defense procurements and the limited rights
134   restrictions of FAR 52.227-14 (June 1987) and to the restricted rights provisions of FAR
135   52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable
136   agency FAR supplements, for non-Department of Defense federal procurements.
137




                                                      iii
                                             OVERVIEW


138   Chapter 1 OVERVIEW
139
140   This document provides guidance for Department of Defense (DoD) coding for professional
141   services. The Military Health System (MHS) is shifting from capturing inpatient and
142   outpatient clinical services to capturing institutional and professional services. MHS
143   systems capture professional encounters in both outpatient and inpatient settings.
144
145   Updating Guidelines—MHS Coding Guidance is reviewed and updated annually, or more
146   frequently as needed, by the Unified Biostatistical Utility (UBU) Working Group. To
147   suggest updates, contact the Service point of contact listed in section 1.7. Updates to coding
148   guidance are on the UBU website, at the url:
149   http://www.tricare.mil/ocfo/bea/ubu/index.cfm
150
151   Guidelines effective immediately upon release for MTF use, effective 1 November for
152   external Audits.
153
154   1.1. Purpose
155   In the simplest sense, coding is the numeric or alphanumeric representation of written
156   descriptions. It allows standardized, efficient data gathering for a variety of purposes. This
157   document supplements industry standards with MHS-specific guidance for coding
158   ambulatory and professional service encounters. These guidelines are derived from the
159   following source documents, but take precedence over them:
160       International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-
161           CM);
162       Current Procedural Terminology (CPT), 4th Edition;
163       Centers for Medicare and Medicaid Services (CMS) Documentation Guidelines for
164           Evaluation and Management (E&M) Services;
165       Healthcare Common Procedure Coding System (HCPCS);
166       The American Hospital Association (AHA) Coding Clinic;
167       The American Medical Association (AMA) CPT Assistant;
168       The Coding Clinic for HCPCS.
169
170   Coding serves a variety of purposes. While it can provide a detailed clinical picture of a
171   patient population, it can also be useful in overseeing population health, anticipating
172   demand, assessing quality outcomes and standards of care, managing business activities, and
173   receiving reimbursements for services.
174
175   When coding for DoD healthcare services, substitute the term privileged providers where
176   the CPT manual description uses the term physicians. Privileges are granted by individual
177   military treatment facilities (MTFs). Common examples of privileged providers are
178   licensed physicians, advanced practice nurses, physician assistants, Independent Duty
179   Corpsman (IDC), oral surgeons, optometrists, residents (other than post-graduate year one
180   [PGY-1]), and physical and occupational therapists.
181

                                               1-1
                                        MHS Coding Guidance
                                            March 2008
                                             OVERVIEW


182   1.2. Diagnostic Coding
183   Diagnostic coding began as a means of gathering statistical information to track mortality
184   and morbidity. Subsequent changes to add clinical information resulted in a coding
185   structure that describes the clinical picture of a patient, as well as non-medical reasons for
186   seeking care and causes of injury. Diagnosis codes are listed in the International
187   Classification of Diseases, 9th revision, Clinical Modifications or, ICD-9-CM.
188
189   1.3. Procedural Coding
190   Healthcare Common Procedure Coding System (HCPCS) codes are grouped in two
191   levels:
192
193      Level I HCPCS are commonly referred to as Current Procedural Terminology (CPT).
194      They form the major portion of the HCPCS coding system, covering most services
195      and procedures. CPT codes supersede Level II codes when the verbiage is identical.
196
197      Level II codes supersede level I codes for similar encounters, when the verbiage of
198      the level II code is more specific. HCPCS includes evaluation and management
199      services, other procedures, supplies, materials, injectables, and dental codes. Having
200      a code number listed in a specific section of HCPCS does not usually restrict its use
201      to a specific profession or specialty.
202
203   HCPCS level I and level II codes, except for codes 99201–99499, are collected in the third
204   data collection screen of the Ambulatory Data Module of the MHS’s computer system.
205
206   Other Specifics Regarding HCPCS Level II Codes
207   Equipment and durable supplies will only be coded if the equipment or supply item is
208   issued to the patient without the expectation that the patient will return the item when no
209   longer needed. For instance, if the patient is issued a C-PAP machine with the
210   expectation the machine will be returned when it is no longer needed, issuance of the
211   machine would not be coded. However, the personalized facemask would be issued with
212   no expectation of return, and so would be coded.
213
214   Pharmaceuticals and Injectables HCPCS Level II codes will only be used when the
215   pharmaceutical or injectable is paid for directly from the clinic’s funds, and is not a
216   routine supply item. If a drug is issued by the pharmacy to the patient, and the patient
217   brings the drug to the clinic for administration, the drug will not be coded, as the
218   pharmacy was the service issuing the drug. Inpatient ward stock will not be coded, as it
219   is part of the institutional component and part of the diagnosis-related group (DRG).
220
221   C Codes These codes are commonly referred to as pass-through codes. They are usually
222   only available for a few years at which time the item is included in a procedure or no
223   longer used. These tend to be for high-cost items. The item must be coded if it is paid
224   for out of clinic funds. As with other drugs, do not code it if the pharmacy issued it to the
225   patient. Frequently, coders will need to query the provider or the clinic supply custodian
226   on the method of acquisition.
                                               1-2
                                        MHS Coding Guidance
                                            March 2008
                                             OVERVIEW


227   1.4. Evaluation and Management (E&M) Coding
228   In the DoD, the term evaluation and management codes refers to the CPT codes inclusive of
229   99201–99499. These codes describe the non-procedural portion of services furnished
230   during a healthcare encounter. They classify services provided by a healthcare provider and
231   indicate the level of service. E&M codes are a subset of CPT codes (Level I HCPCS), yet
232   are referred to as an E&M instead of as a CPT code to distinguish between E&M services
233   and procedural coding. See Section 3 for details about E&M coding.
234
235   1.5. Coding Table Updates
236   ICD-9-CM diagnosis codes are updated annually in the Composite Health Care System
237   (CHCS). These updates, which usually affect a portion of the codes, should be effective on
238   or about 1 October of each year. Implementation by DoD MTFs is tied to release and
239   distribution of CHCS file updates. Actual activation at a specific CHCS host and its client
240   sites requires coordination among coders and CHCS administrators at their facilities.
241   Mechanisms should be in place to ensure record completion by fiscal year end. Corrections
242   may be needed to complete records once the new codes are available.
243
244   CPT and HCPCS codes are updated annually about 1 January. Like the ICD-9-CM codes,
245   implementation in DoD MTFs depends on a release of CHCS file updates and may therefore
246   be later than in the private sector. There may be table updates performed as needed in
247   addition to the annual releases. Even when a table update is required, records will need to
248   be completed within the normal three working days for clinic encounters and fifteen days
249   for same-day surgery or observation. Failure to have all prior year professional services
250   (generates Standard Ambulatory Data Record [SADR]) coding complete before the tables
251   update may result in situations where old codes are no longer available. Health Insurance
252   Portability and Accountability Act (HIPAA) compliant billing requires use of the existing
253   CPT or HCPCS code available at the time of the clinical service.
254
255   1.6. Legal Reference
256   The medical record is the legal record of care. When there is a difference between what is
257   coded in the Ambulatory Data Module (ADM) and what is documented in the medical
258   record, a coder may change a code to more accurately reflect the documentation. When this
259   occurs, the coder must notify the provider. The provider is ultimately responsible for coding
260   and documentation.
261
262   While the data from the CHCS record can be used to create third-party claims, the medical
263   record must support the coding in the claim.
264
265   1.7. Getting Help on Coding Questions
266   For questions on coding issues, please contact the Service Representative, as follows:
267       Army       http://www.pasba3.amedd.army.mil
268       Air Force https://phsohelpdesk.brooks.af.mil or 1-800-298-0230
269       Navy       https://dq.med.navy.mil/dq/coding.htm
270

                                               1-3
                                        MHS Coding Guidance
                                            March 2008
                                             OVERVIEW


271   System issues: For ADM functional software and technical support, contact the MHS Help
272   Desk.
273
274   MHS HELP DESK
275
                      CONUS                          1-800-600-9332
                      OCONUS                         866-637-8725
276
277   This information is also available from www.mhs-helpdesk.com
278
279   1.8. Purpose of Coding Reviews and Audits of Professional Services
280   Coded data must be accurate, because they are used for clinical and business decisions
281   and may be used for reimbursement. To attain the goal of quality data, review (or audit)
282   processes need to be in place. Coding audits are currently required as a part of the
283   Department of Defense Instruction (DoDI) 6040.40. Audits can be very informative and
284   provide an objective and sometimes more knowledgeable review for facilities. After
285   audits are completed, appropriate actions should be taken to improve coding quality
286   based on issues identified. Common actions include updating data collection tools,
287   giving feedback to providers and coders, educating providers on documentation and
288   coding, training coders, providing access to current coding books, revising system
289   templates, and developing system change requests to correct problems inherent in the
290   hardware or software of the system. When errors are identified (e.g. wrong E&M,
291   missing procedures, diagnosis not in correct series) they should be corrected..
292
293   1.8.1. Coding Audit Business Rules
294
295   1.8.1.1. Random Record Selection
296   The audit begins with the identification of all professional services encounters that
297   occurred in the target product lines during the period to be audited. This includes all
298   encounters in all clinics of privileged providers, including inpatient and outpatient
299   professional services. Records should include records from clinics’ feeding data to the
300   Clinical Data Repository (CDR), including geographically separated facilities. A
301   systematic approach must be used to select encounters to be audited. If an MTF is
302   selected for an external audit, the same records are reviewed as part of the internal audit.
303
304   1.8.1.2. Availability of Documentation within the Facility
305   Documentation is defined as a signed document for the professional encounter or for the
306   institutional disposition for a period of service. The provider documentation is compared
307   with the electronic data record.
308
309   1.8.1.3. Obtaining the Documentation— the MHS Decentralized Medical Record
310   The MHS has a decentralized medical record system. This means there may be multiple
311   components stored in various areas that are easily and quickly retrievable and can be
312   reassembled as one record. Most documentation can be found in the main outpatient
313   medical record. For some patients, there are components of the medical record in dental,
                                               1-4
                                        MHS Coding Guidance
                                            March 2008
                                           OVERVIEW


314   mental health, obstetrics, ambulatory procedure visits (APV), extended ambulatory
315   record (EAR), and inpatient.
316
317   1.8.1.3.1. Professional Services Documentation
318   For facilities with Armed Forces Health Longitudinal Technology Application (AHLTA),
319   formerly known as CHCS II as well as CHCS, documentation for inpatient professional
320   services will be in the doctor’s notes portion of the paper inpatient record. Rounds
321   appointments will not be documented in AHLTA. Laboratory tests, radiology studies, and
322   prescriptions for inpatients will not be ordered in AHLTA. Documentation may be
323   maintained in either a paper or an electronic record.
324
325   1.8.1.3.2. Documentation in AHLTA
326

327                 DoD Rule
328
329                 Recording of documentation in AHLTA is not a separately codable event.
330                 Encounters that do not meet minimum visit criteria are administrative and
331                 are not a coded visit.

332
333   1.8.1.4. Auditable Issues
334   Auditable issues include availability of documentation, proper documentation, summary
335   sheets being current, legibility, authorized abbreviations, and co-signatures of teaching
336   providers. Proper documentation, at a minimum, includes the name of the treatment
337   facility or location, clinic, date of the encounter, patient identifying data and provider
338   signature, grade or rank, and profession on encounter sheet. Any history of illness or
339   allergies that have no documented impact on patient care need not be coded and are not
340   auditable. Use of 99499 is not auditable on TMA audits because of system discrepancies.
341
342   1.8.1.5. Audit Assessment (Based on Coded Data from MHS Central Database)
343   Medical record audits include ICD-9-CM diagnoses, the first listed E&M, and
344   CPT/HCPCS procedure codes. No entry in the E&M field will be used for APV
345   encounters unless an E&M service is provided that is significantly separate from the
346   service provided. Linkage of diagnosis to CPT/HCPCS, modifiers and second or third
347   listed E&M will not be addressed at this time, since these data elements do not pass
348   through to the SADR and therefore are not available in an MHS central database.
349
350   1.8.1.6. Audit Assessment (Based on Coded Data from MTF Server)
351   These audits may also cover modifiers, quantities and linkage of diagnosis to
352   CPT/HCPCS and additional E&M codes.
353
354   1.8.1.7. TMA Audit Finding Reports
355   The Services will receive a copy of the TMA Audit Findings as soon as they are
356   available.
                                              1-5
                                       MHS Coding Guidance
                                           March 2008
                                                OVERVIEW


357   1.8.2. Auditing Guidelines
358   Records will be audited to the MHS Coding Guidance and then to generally accepted coding
359   standards. Facilities should indicate in their compliance plan which set of CMS
360   guidelines each clinical service will follow (e.g., primary care clinics will use 1995 and
361   specialty clinics will use 1997) and how the encounter was audited (using the CMS 1995
362   or 1997 E&M guidelines). Other references used when determining appropriate code
363   assignment include AHA Coding Clinic and the AMA CPT Assistant.
364


      1995 Documentation   1997 Documentation
         Guidelines.pdf       Guidelines.pdf
365
366
367   1.8.2.1. MHS Data Collection Conventions
368   To be valid, codes must meet the MHS Professional Services and Outpatient Coding
369   Guidelines. The following, when noted during an audit, are not errors, but DoD-specific
370   data collection conventions. Their presence will not cause an error to be indicated on the
371   audit:
372
373   1.8.2.1.1. DoD-Unique Coding Conventions
374   Extenders (V70.5_1, Aviation Exam) or 99199 to indicate the institutional component of
375   an APV, for example, are used to identify certain military requirements.
376
377   1.8.2.1.2. Composite Health Care System (CHCS) limitations
378   The same CPT code cannot be listed twice. For instance, coding medical direction of
379   anesthesia and administration of anesthesia is currently not permitted.
380
381   1.8.3. Data Collection Forms
382   Facilities are encouraged to use the monthly audit form on the UBU website in
383   completing the Monthly Data Quality Commander’s Statement or Service required forms.
384   The UBU website is at http://www.tricare.osd.mil/org/pae/ubu/default.htm.
385
386   1.8.4. Sample Instructions for Manual Audit
387   1. On the Outpatient Coding Audit Worksheet, number (down a column, e.g., 1, 2, 3) and
388   list all the diagnosis codes and CPT codes, including the first listed E&M code, present in
389   the SADR for the encounter under review. If an E&M worksheet is completed, attach it
390   to the audit worksheet.
391
392   2. Secondary codes do not have to be sequenced in any order, except when
393   manifestations are noted or the code is linked to a procedure. Align your secondary
394   codes to the original (SADR) secondary codes so that a mismatch is not recorded because
395   of a difference in sequencing among secondary diagnoses. However, if the original coder
396   selected the correct primary diagnosis code, as determined by the audit, as a secondary
397   diagnosis code, then it is an error in sequencing for the primary diagnosis.
398
                                                  1-6
                                           MHS Coding Guidance
                                               March 2008
                                            OVERVIEW


399   3. If the original codes are wrong or should be omitted, record a comment describing
400   the reason the code is incorrect. The comment field is next to the field where the
401   auditor’s codes are entered. Additional space is provided at the bottom of the form to
402   continue a comment or to add general comments. When a comment is continued, append
403   the line number to the information that is continued.
404
405   4. If there are missed codes that should be added, put them in the blank numbered
406   spaces, up to the maximum number allocated in the worksheet. If an original code is not
407   correct, but a different code should have been added, and there are no remaining blank
408   spaces, record the code next to the incorrect original code.
409
410   5. After completing the review, check off whether the record has a pass or fail score.
411   A pass means all of the codes are correct, supported by the documentation, and primary
412   diagnosis selection is correct. A fail means there was at least one coding error, or the
413   assignment of the primary diagnosis was incorrect.
414
415   6.      If documentation is unavailable, such as a missing anesthesia report, so a portion
416   of the encounter cannot be coded, be sure to annotate which part of the documentation is
417   missing.
418
419   7. If a pathology/radiology report is unavailable to the coder at the time coding occurs
420   then the results of the report may not be held against the facility at the time of auditing.
421   Please refer to the date the report was transcribed and the date the encounter was coded in
422   CCE to determine the appropriate dates to use for auditing purposes.
423
424   1.8.5. Monthly Coding Audit Summary Report
425   On the Monthly Coding Audit Summary Report, identify the number of records requested
426   and the number of records received from the facility.
427
428         Identify the number of records received containing encounter documentation for
429          the encounter.
430         Document the number of records with illegible documentation.
431         Document the number of records with use of non-approved abbreviations or
432          acronyms. Abbreviations and acronyms are considered approved for this audit if
433          the term is completely spelled out initially, with the abbreviation listed
434          afterwards, if the term is on the approved list of MTF abbreviations or if the term
435          is on the DoD list of approved abbreviations.
436
437   1.9. Health Insurance Portability and Accountability Act (HIPAA)
438   HIPAA has standardized code sets for electronic transactions, including billing. ICD-9-CM,
439   CPT, and HCPCS codes are all standardized code sets used in electronic billing. Unless a
440   code is to be used to generate an electronic claim using a standardized code set, HIPAA
441   does not affect coding. The MHS has non-standardized codes associated with ICD-9-CM in


                                               1-7
                                        MHS Coding Guidance
                                            March 2008
                                            OVERVIEW


442   the form of DoD extender codes. MHS-defined codes, such as the extender codes, are not
443   used in billing. Therefore, HIPAA does not apply to the extenders.
444
445   1.10. Use of the Term SADR
446   The Standard Ambulatory Data Record or SADR is a subset of outpatient data collected
447   in the ambulatory data module (ADM) in the CHCS. Data collected for professional
448   services in the MHS is referred to as coding a SADR. Data collected for inpatient
449   institutional services in the MHS is referred to as coding a standard inpatient data record
450   (SIDR).
451
452   The SADR provides two electronic file transmissions. One is exported daily from ADM
453   and sent to a central MHS database. A second file is transmitted to the Third-Party
454   Outpatient Collection System (TPOCS). The TPOCS file is similar to the SADR, but
455   includes multiple E&M, all CPT/HCPCS, modifiers, and quantities. The following items
456   are not currently included in the SADR, but are collected in the ADM:
457
458         Modifier fields and unit fields,
459         Second and third E&M codes,
460         Link between diagnoses and procedures,
461         Diagnoses after the first four diagnoses,
462         Procedures after the first four procedures.




                                              1-8
                                       MHS Coding Guidance
                                           March 2008
                                      DIAGNOSTIC CODING


463   Chapter 2 DIAGNOSTIC CODING
464
465   ALL CODING MUST BE SUPPORTED BY THE DOCUMENTATION IN THE
466   MEDICAL RECORD.
467
468   This section provides ICD-9-CM coding guidelines for data collection in the DoD. The
469   following guidelines pertain to professional services coding, which includes outpatient
470   clinic, observation, APVs (same-day surgeries), and inpatient professional services.
471
472   2.1. Code Taxonomy (Structure)
473   ICD-9-CM codes are 3- to 5-digit numeric and alphanumeric codes. These codes are used
474   to describe diseases, conditions, symptoms, and other reasons for seeking healthcare
475   services. Some codes are modified for special use in the DoD. The first three digits usually
476   represent a single disease entity, or a group of similar or closely related conditions. The
477   fourth digit subcategory provides more specificity on the etiology, site, or manifestation. In
478   some cases, fourth-digit subcategories have been expanded to the fifth-digit level to provide
479   even greater specificity.
480
481   2.1.1. Factors Influencing Health Status and Contact with Health Services
482   ICD-9-CM codes beginning with the letter V are used when the patient seeks healthcare for
483   reasons other than illness or injury. Examples include a well-baby exam or a physical. See
484   section 2.2.8 in this chapter for more guidance.
485
486   2.1.2. External Causes of Injury
487   ICD-9-CM codes beginning with the letter E describe external causes of injury, poisoning
488   and adverse reactions. They are used to describe where, why, and how an injury occurred.
489   See section 2.2.9 in this chapter for more guidance.
490
491   2.1.3. Not Otherwise Specified (NOS)
492   Only use NOS codes when the documentation is insufficient to use a more specific code.
493   This is synonymous with unspecified.
494
495      Example: A provider note indicates the patient has otitis media. Code 382.9,
496      unspecified otitis media, is the appropriate code if the diagnostic statement or record
497      lacks additional information, such as purulent or serous.
498
499   2.1.4. Not Elsewhere Classifiable (NEC)
500   Use NEC codes when there is no specific code in the classification system for the condition,
501   even though the diagnosis may be very specific.
502
503      Example: 008.67 Enteritis due to Enterovirus NEC (Coxsackie virus, echovirus;
504      excludes poliovirus). In this example, this code would be reported even if a specific
505      enterovirus, such as echovirus, had been identified, because ICD-9-CM does not
506      provide a specific code for echovirus.
507
                                                  2-1
                                           MHS Coding Guidance
                                               March 2008
                                        DIAGNOSTIC CODING


508   2.2. Guidelines
509   The following guidelines are to be followed when reporting diagnoses in ADM. The ICD-
510   9-CM diagnostic codes are used for professional services furnished in both the inpatient and
511   ambulatory setting. ICD-9-CM procedure codes are only used for inpatient institutional
512   MHS coding and not professional services MHS coding.
513
514   2.2.1. Prioritized Diagnoses
515   The primary diagnosis is the reason for the encounter, as determined by the documentation.
516   When a diagnosis has a codeable manifestation, co-morbid condition, or etiology, the linked
517   codes should be sequenced together whenever possible (e.g., diabetic skin ulcer of the ankle,
518   coded with 250.8x and 707.13). For some cases, ICD-9-CM conventions indicate that the
519   underlying cause should be coded first, before a manifestation. In these instances,
520   manifestations cannot be coded as a primary diagnosis.
521
522   The chief complaint does not have to match the primary diagnosis.
523
524   2.2.2. Pre-Existing Conditions
525   Conditions or diseases that exist at the time of the encounter, but do not affect the current
526   encounter are not coded. Documented conditions or diseases that affect the current
527   encounter, are considered in decision making, and are treated or assessed, are coded.
528
529   2.2.3. Specificity in Coding Classification
530   Specificity in coding is assigning all the available digits for a code. Diagnostic codes should
531   be assigned at the highest level of specificity. If a code has five digits, all five digits must be
532   used.
533        Assign three-digit codes only if there are no four-digit codes within that code
534           category.
535        Assign four-digit codes only if there is no fifth-digit sub-classification for that
536           category.
537        Assign the fifth-digit sub-classification code for those categories where it exists.
538        Assign a DoD extender code if one exists (refer to the DoD Diagnosis Extender
539           section in 2.2.6).
540
541       Example: A patient is seen for abdominal pain in the upper right quadrant; no
542       specific cause has been determined. The appropriate diagnostic code would be the
543       five-digit code 789.01—other symptoms involving abdomen and pelvis, right upper
544       quadrant—as opposed to the four-digit code 789.0 (other symptoms involving
545       abdomen and pelvis, unspecified site).
546
547   2.2.4. Selection of the Most Explicit Code
548   Coding should be as explicit as the documentation permits. For instance, when the provider
549   documents acute serous OM, code 381.01 acute serous otitis media, not 382.9 unspecified
550   OM.
551
552
                                                    2-2
                                             MHS Coding Guidance
                                                 March 2008
                                      DIAGNOSTIC CODING


553   2.2.4.1. Renewal/Replacement Prescription Refills
554   Code V68.1 is the primary diagnosis when documentation only supports a prescription
555   refill. In most cases, this is an administrative function.
556
557   When a patient presents to a privileged provider and an assessment is made then the
558   condition for which the assessment is being performed is your primary diagnosis and not
559   the V code for prescription refill. The prescription refill V68.1 will not be used in this
560   scenario.
561
562   2.2.5. Unconfirmed Diagnosis
563   When a provider is not certain of a diagnosis, capture the known manifestations, signs,
564   symptoms, or abnormal test results.
565
566      Example: The diagnosis documented ―rule out malignant neoplasm of the pancreas‖
567      cannot be coded, as the diagnosis is unconfirmed. The documentation indicates a mass
568      on the pancreas. The terms mass and neoplasm are not synonymous. Therefore, the
569      most appropriate code would be 577.9, unspecified disease of pancreas.
570
571   Although ADM permits designation of uncertain (unconfirmed) diagnoses with a U instead
572   of a number, unconfirmed diagnoses are not traditionally coded. If a U designator is used
573   for a diagnosis in ADM, those data are only available at the local server. The U-designated
574   diagnosis cannot be the only diagnosis captured; there must be a primary diagnosis other
575   than the U diagnosis. Currently, Air Force is the only Service that permits use of a U
576   designator in ADM.
577
578      Example: A patient comes in with chest pain, and the provider wants to rule out
579      myocardial infarction. The provider documents the specific symptom of chest pain as
580      the primary diagnosis and documents the myocardial infarction code as an
581      unconfirmed diagnosis. The provider could document the myocardial infarction code
582      as an unconfirmed U diagnosis if that Service permits the designation.
583
584   NOTE: For inpatient professional services, see Chapter 9.
585
586   2.2.6. DoD Diagnosis Extender Codes
587   A number of ICD-9-CM codes have been modified to meet the needs of the Services. These
588   codes are referred to as DoD extender codes. The one-character extender is paired with a
589   specific ICD-9-CM code to acquire a unique meaning. The DoD established extender codes
590   to address a number of specific reporting requirements, including physicals, asthma,
591   hepatitis, abortion, bacterial disease, and Gulf War-related diagnoses. If an extender has
592   been established in accordance with specificity guidelines, the root code is no longer valid
593   for use without an extender code. See Appendix D for a complete list of DoD Extender
594   codes. Many coders annotate the DoD extender codes in their ICD-9-CM books so they do
595   not overlook them when looking up codes to develop superbills.
596
597
                                                 2-3
                                          MHS Coding Guidance
                                              March 2008
                                      DIAGNOSTIC CODING


598   2.2.6.1. Asthma
599   Currently there is no extender code to identify unspecified asthma.        To capture this
600   information, code to 493.xx_1 Asthma, mild.
601
602   2.2.6.2. Acquired Absence of Body Part(s) or Organ(s)
603   For population health purposes, use V45.71 and V45.77 with the appropriate extender code
604   to capture acquired absence of body part(s) or organ(s). The extender portion of these codes
605   is not auditable; as the codes are used for population health to exclude patients from
606   preventive exams, such as mammograms.
607
608   2.2.6.3. Reaction to Vascular Devices
609   Codes for infection and inflammatory reactions to vascular devices and grafts, 996.62, are
610   located in Appendix D.
611
612   2.2.6.4. Traumatic Brain Injury (TBI)
613   A list of TBI codes are located in Appendix D.
614
615   2.2.6.4.1.
616   TBI will be coded based upon documentation contained within the medical record for
617   symptoms presenting after the acute phase of the injury. V15.5_* will be reported as a
618   secondary diagnosis code followed by any late effect or manifestation codes.
619

620                  DoD Rule
621
622                  Code V15.5_* (and V70.5_* when TBI is related to deployment), must
623                  be sequenced in the secondary diagnosis field (position 2-4) on the
624                  SADR, to be followed by late effect and manifestation codes.

625
626
627   NOTE: ICD-9-CM rules state that possible, likely or suspected TBI would not be
628   coded on an outpatient basis. When a patient is treated as an outpatient and the
629   provider documents the encounter as possible, likely, or suspected TBI, the
630   informational needs of the MHS require for the encounter to be coded as if the
631   patient actually had a documented history of TBI.
632
633   When a TBI patient presents for treatment the provider must document the subjective and
634   objective findings within the medical record.
635
636   When an individual has a confirmed or suspected TBI, select one of codes listed below to
637   be placed in a secondary diagnosis field (SADR position 2 – 4). If a patient has a
638   confirmed injury to the brain such as a penetrating head wound, concussion, and/or is
639   suffering from post concussion syndrome then codes from the V15.5_* will not be used.
640   The following codes were made available for use as of 1 October 2007:
                                                 2-4
                                          MHS Coding Guidance
                                              March 2008
                                  DIAGNOSTIC CODING


      V15.5_1 PERSONAL HISTORY OF TBI, GLOBAL WAR ON TERRORISM (GWOT)
              RELATED, UNKNOWN LEVEL OF SEVERITY
      V15.5_2 PERSONAL HISTORY OF TBI, GWOT RELATED, MILD (GLASGOW
              COMA SCALE 13-15),LOC<1HR,POST TRAUMA AMNESIA<24HR
      V15.5_3 PERSONAL HISTORY OF TBI ,GWOT RELATED, MODERATE
              (GLASGOW COMA SCALE 9-12),LOC 1-24 HRS, POST TRAUMA
              AMNESIA 1-6 DAYS
      V15.5_4 PERSONAL HISTORY OF TBI, GWOT RELATED, SEVERE (GLASGOW
              COMA SCALE 3-8),LOC >24HRS,POST TRAUMA AMNESIA >6 DAYS
      V15.5_5 PERSONAL HISTORY OF TBI, GWOT RELATED, PENETRATING
              INTRACRANIAL WOUND
      V15.5_6 PERSONAL HISTORY OF TBI, NOT GWOT RELATED, UNKNOWN
              LEVEL OF SEVERITY
      V15.57 PERSONAL HISTORY OF TBI, NOT RELATED TO GLOBAL WAR ON
              TERRORISM, MILD (GLASGOW COMA SCALE 13-15),LOC<1HR,POST
              TRAUMA AMNESIA<24HR
      V15.5_8 PERSONAL HISTORY OF TBI, NOT RELATED TO GLOBAL WAR ON
              TERRORISM (GWOT), MODERATE (GLASGOW COMA SCALE 9-12),LOC
              1-24 HRS, POST TRAUMA AMNESIA 1-6 DAYS
      V15.5_9 PERSONAL HISTORY OF TBI, NOT RELATED TO GWOT, SEVERE
              (GLASGOW COMA SCALE 3-8),LOC >24HRS,POST TRAUMA AMNESIA
              >6 DAYS
      V15.5_ PERSONAL HISTORY OF TBI, NOT RELATED TO GWOT, PENETRATING
      A       INTRACRANIAL WOUND
      V15.5_ PERSONAL HISTORY OF TBI, UNKNOWN IF GWOT RELATED,
      B       UNKNOWN SEVERITY LEVEL
      V15.5_ PERSONAL HISTORY OF TBI, UNKNOWN IF RELATED TO GWOT, MILD
      C       (GLASGOW COMA SCALE 13-15),LOC<1HR,POST TRAUMA
              AMNESIA<24HR
      V15.5_ PERSONAL HISTORY OF TBI, UNKNOWN IF RELATED TO GWOT,
      D       MODERATE (GLASGOW COMA SCALE 9-12),LOC 1-24 HRS, POST
              TRAUMA AMNESIA 1-6 DAYS
      V15.5_ PERSONAL HISTORY OF TBI, UNKNOWN IF RELATED TO GWOT,
      E       SEVERE (GLASGOW COMA SCALE 3-8),LOC >24HRS,POST TRAUMA
              AMNESIA >6 DAYS
      V15.5_F PERSONAL HISTORY OF TBI, UNKNOWN IF RELATED TO GWOT,
              PENETRATING INTRACRANIAL WOUND
641
642    Example: A service member presents to the local MTF stating she is suffering from
643    headaches. She has a history of headaches dating back to an explosion occurring in
644    Iraq. Provider determines an injury occurred along with alteration of consciousness.
645    The provider determines the headaches are TBI related:
646
647
648    Primary diagnosis:               784.0 (Headache)
                                              2-5
                                       MHS Coding Guidance
                                           March 2008
                                      DIAGNOSTIC CODING


649      Secondary diagnosis:         V15.5_1 (Personal History of TBI, Global War on
650         Terrorism (GWOT) Related, Unknown Level of severity):
651                           V70.5_6 (Post deployment encounter)
652
653      Example: A service member presents to the MTF. He is depressed and has had
654      ringing in his ears for the past several months. The provider obtains the patient’s
655      history and notes the patient was involved in a motor vehicle accident while deployed
656      in Afghanistan. He struck his head on the steering wheel and lost consciousness for
657      ten minutes. The provider diagnoses the patient with depression and tinnitus; these
658      diagnoses are related to a TBI during his deployment to Afghanistan. The encounter
659      would be coded as follows:
660
661      Primary diagnosis:     311 (Depression)
662      Secondary diagnoses:   388.30 (Tinnitus)
663                             V15.5_2 Personal History of TBI, GWOT Related, Mild
664          (Glasgow Coma Scale 13-15), LOC<1HR, Post Trauma Amnesia<24HR
665                             V70.5_6 (Post deployment encounter)
666
667      Example: A family member presents to the MTF complaining of chronic neck pain
668      and vertigo following a motor vehicle accident two months prior to this encounter. He
669      experienced loss of consciousness for 25 minutes. The encounter would be coded as
670      follows:
671
672      Primary diagnosis:      723.1 (Neck Pain)
673      Secondary diagnoses:    780.4 (Vertigo)
674                              V15.5_7 Personal History of TBI, not related to Global
675          War on Terrorism, Mild (Glasgow Coma Scale 13-15), LOC<1HR, Post Trauma
676          Amnesia<24HR
677
678   2.2.7. Chronic Conditions
679

680                  DoD Rule
681
682                  When assessed by the clinician, assign ―tobacco use‖ or ―history of
683                  tobacco use‖ codes (305.1 or V15.82) in order to manage our
684                  population health.
685

686
687   When a chronic disease is treated on an ongoing basis, it may be coded as often as treatment
688   and care are provided to the patient for that condition.
689


                                                 2-6
                                          MHS Coding Guidance
                                              March 2008
                                      DIAGNOSTIC CODING


690      Example: A patient is treated monthly with an epidural block and steroid injection
691      for chronic low back pain (724.2). The code for low back pain would be reported
692      each time the patient presented for care for this problem.
693
694   A chronic condition not addressed during the encounter that does not affect the care
695   provided during the visit should not be coded with the encounter. Remind providers that
696   medical decision making can be supported for higher levels of service if providers properly
697   document.
698
699      Example: The same patient listed above also has hyperlipidemia. The patient is
700      coming in for chronic low back pain, so unless hyperlipidemia is a factor in the care
701      received for low back pain, it does not get coded.
702
703   2.2.8. V Codes—Factors Influencing Health
704   DoD extender codes have been paired with selected V codes to further specify military
705   unique services. The addition of DoD extender codes to the root code enables
706   differentiation of the types of health assessments. The V codes are used to identify
707   circumstances (diagnoses) other than disease, symptom, or injury that are the reason for an
708   encounter, or that explain why a service or procedure was furnished. V codes are used to
709   classify a patient in the following circumstances:
710
711   When a person is not currently or acutely ill, but requires healthcare services for some
712   purpose, such as preventive education and counseling or prophylactic vaccinations.
713
714      Examples: V04.2 would be used for the child receiving a measles vaccination in a
715      pediatric clinic; V65.3 would be used for the diabetic patient who receives dietary
716      counseling.
717
718      V04.89 would be used for Human Papilloma virus (HPV) vaccination of girls and
719      women 9-26 years old. Use procedure codes 90649 (HPV vaccine) and 90471
720      (administration).
721
722   When a circumstance or problem influences the patient’s current illness or injury, but is not
723   in itself a current illness or injury.
724
725      Example: A patient visits a provider’s office with a complaint of chest pain with an
726      undetermined cause; patient status is post open-heart surgery for mitral valve
727      replacement. Code 786.50 would be used to identify the chest pain, unspecified, and
728      code V43.3 would be used to identify the heart valve replaced by other means.
729
730   When a person with a known disease or injury uses the healthcare system for specific
731   treatment of that disease or injury:
732
733      Example: Encounter for occupational therapy for patient with cognitive deficits
734      secondary to an old cerebral vascular accident (CVA) would be coded V57.21, 438.0.
                                                  2-7
                                           MHS Coding Guidance
                                               March 2008
                                    DIAGNOSTIC CODING


735   2.2.8.1. DoD-Unique V-Code Guidance for Flyer Status
736   The annual flight physical or aviation exam is coded using V70.5_1. Flyers returning to
737   active flight status who have an appointment to evaluate their condition should be coded
738   using V68.09 (medical certificate).
739
740   2.2.8.2. DoD-Unique V-Code Guidance for Assessments, Exams, Education, and
741             Counseling
742   DoD extender codes have been paired with selected V codes to further specify military
743   unique services. The addition of DoD extender codes to the root code enables
744   differentiation of the types of health assessments. See section 6.17. for E&M coding
745   guidance.
746
747          V70.5_0       Armed Forces medical exam: This is the initial general
748                        accession exam. For pre-enlistment, this initial qualifying
749                        exam is a ―yes” test that a person meets the requirements to
750                        join the military. Excludes exams covered under V70.5_8
751                        Special Program Accession Exam.
752
753          V70.5_1       Aviation Exam: Initial qualifying and any recurring aviation
754                        exam.
755
756          V70.5_2       Periodic Health Assessments (PHA) or Prevention Assessment:
757                        Includes service member PHA documented on DD2766. Also
758                        use for a complete military physical exam which is not an
759                        accession, occupational, separation, termination or retirement
760                        exam.
761
762          V70.5_3       Occupational exam: Both initial qualifying and recurring
763                        exams because the individual works in a specific occupation or
764                        in support of occupational medicine programs (workers’
765                        compensation). Examples include: diving, firefighter, Personal
766                        Reliability Program (PRP), protection of the president, crane
767                        operator and submariner. For return to duty following a non-
768                        aviation occupation-related condition, use V70.5_7.
769
770          V70.5_4       Pre-Deployment Related Encounter: Encounter related to a
771                        projected deployment. Could include family members
772                        experiencing a condition related to the projected deployment
773                        of the sponsor or other family member. Excludes V70.5_D
774                        which codes the encounter documented on the DD2795.
775
776          V70.5_5       Intra-Deployment encounter: Any deployment-related
777                        encounter performed while individual (active duty [AD],
778                        contractor, etc.) is deployed. Could include family members

                                                2-8
                                         MHS Coding Guidance
                                             March 2008
                        DIAGNOSTIC CODING


779             experiencing a condition related to the deployment of the
780             sponsor or other family member.
781
782   V70.5_6   Post-deployment related encounter: Specifically performed
783             because an individual was deployed. Could include family
784             members experiencing a condition related to a prior
785             deployment of the sponsor or other family member. Excludes
786             V70.5_E and V70.5_F which code the encounters
787             documented on the DD2796 and DD2900.
788
789   V70.5_7   Duty Status Determination encounter: Used for service
790             members when the primary reason for being seen is to
791             determine the ability to perform their duties. Includes
792             determination or change in status of temporary or permanent
793             duty limitations, deployment limiting conditions, temporary
794             and permanent duty retirement list (TDRL/PDRL), medical
795             evaluation board (MEB) assessments, and return to duty
796             following pregnancy or surgery and treatment. See section
797             5.9.2.for MEB coding. Excludes return to flight/dive status
798             (e.g., upchit) which is V68.09.
799
800   V70.5_8   Special Program Accession Encounter: A special medical
801             examination on individuals being considered for special
802             programs prior to Service entry. Exams are usually for
803             officer candidates (Reserve Officer Training Corps [ROTC]
804             programs, college graduates, professional schools, etc.)
805             Other examples are DoD Medical Review Board exams,
806             Health Professional School Program (HPSP) exams, and
807             supplemental exams in support of Medical Examination
808             Processing Stations.
809
810   V70.5_9   Separation/Termination/Retirement Exam: Examination
811             performed at the end of employment and for retirement or
812             separation.
813
814   V70.5_A   Health Exam of defined subpopulations: Performed on a
815             person in a specified group (refugees, prisoners, preschool
816             children, etc.) other than exams identified above. Includes
817             examinations related to the Exceptional Family Member
818             Program (EFMP) and Overseas Screening. This is not the
819             appropriate code for sport/school physicals, for such
820             guidance see 6.14.1.2.1.
821
822   V70.5_B   Abbreviated Separation/Termination/Retirement Exam: This
823             code would be used when a partial examination is done
                                   2-9
                            MHS Coding Guidance
                                March 2008
                                         DIAGNOSTIC CODING


824                             within a defined period after a complete examination as an
825                             update. Guidance for abbreviated separation, termination or
826                             retirement exam will be provided by each service.
827
828              V70.5_C        Physical Readiness Test (PRT) Evaluation: Evaluation of service
829                             member by a provider who is privileged to determine participation
830                             in Physical Fitness Assessment program (PFA) or physical
831                             conditioning.
832
833              V70.5_D        Pre-Deployment Assessment: Documented on DD2795.
834
835              V70.5_E        Initial Post-Deployment Assessment: Documented on DD2796.
836
837              V70.5_F        Post Deployment Health Reassessment (PDHRA): Documented on
838                             DD2900.
839
840              V70.5_G        Other Exam Defined Population: To be used for Global War on
841                             Terrorism (GWOT)/Wounded Warriors (WW).
842
843   2.2.8.3. Deployment Related Assessments
844   To proactively and reactively provide healthcare related to deployments, the DoD must be
845   able to identify healthcare needs caused by deployments. Codes V70.5 4/5/6 may be used in
846   the second, third, or fourth position to indicate some aspect or the encounter is deployment
847   related for inpatient and outpatient reporting. Codes V70.5_4/5/6/D/E/F are to be used as a
848   primary diagnosis for an exam, assessment, or screening encounter when the purpose of the
849   encounter is specifically deployment related.
850
851   Codes V70.5_4/5/6/D/E/F will be used in the subsequent diagnosis positions when the
852   primary purpose of the encounter was not specifically deployment related, but ―deployment
853   related‖ concerns were found that should be coded as additional diagnoses.
854
855          Example: An AD member who recently returned from deployment presents to the clinic
856          for an evaluation of a rash. The provider evaluates the patient and diagnoses the patient
857          with cutaneous leishmaniasis related to his recent deployment to Iraq. The primary
858          diagnosis in this scenario is 085.9 (unspecified cutaneous leishmaniasis) and the
859          secondary code would be V70.5_6. If during this encounter the provider discovers that
860          the patient has not completed his DD2976 and has the patient complete it, then V70.5_E
861          should be added as an additional diagnosis.
862
863   2.2.8.4. Reporting Scenarios for V70.5 Extender Codes. *
864
865   PRT (V70.5_C)


      *
          www.pdhealth.mil
                                                     2-10
                                              MHS Coding Guidance
                                                  March 2008
                                      DIAGNOSTIC CODING


866   Prior to doing Physical Readiness Testing all service members must complete a PRT
867   screening questionnaire. If all answers are ―no‖ the member is not referred for further
868   follow up and completes the PRT. There is no medical encounter or coding. If any
869   answers are ―yes‖ the member comes in for a medical evaluation.
870
871          1. Service Member has a known medical problem, example post ACL repair.
872   Provider does not do an exam of the Service Member. Service Member is issued a
873   waiver from PRT. Use ICD-9 code V 70.5_C as the primary diagnosis and the medical
874   problem(s) as secondary.
875
876           2. Service Member is referred for additional assessment based upon answers on
877   the PRT questionnaire. Provider reviews assessment and determines Service Member is
878   cleared for PRT. Use E&M 99420 and ICD-9 code V70.5_C. For example, the member is
879   referred based solely on their age, but are otherwise healthy with no complaints, the
880   provider finds them fit to complete the PRT.
881
882          3. Service Member is referred for medical evaluation based upon answers on the
883   PRT questionnaire. Provider reviews the assessment and finds the patient requires further
884   evaluation and management. The encounter should be coded based on documentation and
885   code V70.5_C as primary and other diagnoses as secondary.
886
887   Pre-deployment (DD Form 2795) (V70.5_D)
888   Collection of this information is for military readiness to ensure assessment is done
889   prior to deployment.
890
891           1. The DD Form 2795 is determined to be a negative assessment and is reviewed
892   only by a non-privileged provider, and the form is filed. Code the ICD-9 code V70.5_D
893   under the technician’s name.
894
895         2. The privileged provider reviews the form and makes a final medical disposition.
896   Code E&M 99420 and the ICD-9 code V70.5_D.
897
898           3. The provider identifies, addresses and documents a medical problem. The
899   encounter should be coded based on documentation and code V70.5_D as primary and
900   other diagnoses as additional.
901
902   Post Deployment Assessments (V70.5_E/F)
903   Exams will always be conducted by a face to face encounter with a privileged
904   provider.
905
906          Initial Post Deployment (DD Form 2796) (V70.5_E)
907
908           1. If the purpose of the encounter is to complete the DD Form 2796 by the
909   privileged provider and no medical conditions are found, code V70.5_E first and use
910   99420 for the E&M.
                                                 2-11
                                          MHS Coding Guidance
                                              March 2008
                                      DIAGNOSTIC CODING


911          2. If the purpose of the encounter is to complete the DD Form 2796 and
912   assessment and medical evaluation identifies medical conditions requiring treatment,
913   code V70.5_E first and then code appropriate ICD9 codes. Use 99420 for the E&M code
914   and additional E&M based on the documentation with modifier 25.
915
916          3. If during an encounter for other reasons, it is determined that a required DD
917   Form 2796 has not been completed, code the appropriate ICD9 code for the principal
918   reason for the visit and use code V70.5_E in the first four diagnosis codes. Use
919   appropriate office visit E&M code based on the documentation.
920
921          Post Deployment Health Reassessment (PDHRA) (DD Form 2900) (V70.5_F)
922
923           Encounters involving completion of the DD Form 2900, should be coded in the
924   same manner as specified for DD Form 2796 Initial Post-Deployment Assessment,
925   substituting V70.5_F in place of V70.5_E.
926
927   Scenarios for coding primary complaints that are deployment related.
928
      Type of           Example                               Primary          2nd, 3rd or 4th
      Patient                                                Diagnosis         Dx Code
      Symptoms,         New onset bed wetting of 5-yr-    788.36 (nocturnal    V70.5_4
      Pre-              old boy whose mother is about     enuresis)
      Deployment-       to leave on 12 month
      Related           deployment.
      Asymptomatic      AD soldier recently returned      V65.5 (person        V70.5_ 6
      Concerned,        from deployment. Pregnant         with feared
      Post-             wife has concerns about           complaint)
      Deployment-       depleted uranium exposure.
      Related
      Symptoms,         13-yr-old girl with significant   783.21               V70.5_ 5
      Intra-            weight loss. Mother suspects      (abnormal weight
      Deployment-       concern is related to father’s    loss)
      Related           current deployment to Iraq.

      Symptoms,         23-yr-old Marine developed      692.6 (contact         V70.5_ 5
      Intra-            poison ivy rash while deployed. dermatitis caused
      Deployment-                                       by plants)
      Related
      Medically         49-yr-old retired beneficiary     799.8 (other ill-    V70.5_ 6
      Unexplained       has been evaluated over 3         defined
      Physical          months (5 visits) for             conditions and
      Symptoms,         intermittent joint pain,          unknown causes
      Deployment-       intermittent vertigo and severe   of morbidity)
      Related           fatigue. Patient says he

                                                  2-12
                                           MHS Coding Guidance
                                               March 2008
                                      DIAGNOSTIC CODING


                        believes he was exposed to
                        something in Kuwait on
                        mission two years ago. Work-
                        up to date is complete, but
                        negative.
929
930   This guidance is subject to change. More detailed information on program management is at
931   http://www.pdhealth.mil/.
932
933   2.2.8.5. V68.09 Issue of Medical Certificates
934   Medical certificates are frequently completed as part of an examination or physical. Use
935   code V68.09 when there is no medical indication for the encounter, the patient’s reason for
936   the encounter was solely to obtain a medical certificate; there is not another more
937   appropriate code to reflect the primary reason for the encounter, and no symptoms,
938   conditions, or diseases were evaluated or treated. See Section 6.6 Flight Medicine Services
939   for an example involving flight medicine ground testing. The code V68.09 would not be
940   used, for instance, when a student needs a sports physical, as there is a more appropriate
941   code to reflect the reason for the visit, V70.3—other medical exam for administrative
942   purpose.
943
944   2.2.8.6. Case Management Services
945   The Case Management coding and reporting framework can be found in Appendix E.
946
947   2.2.9. External Cause of Injury—E Codes
948   E codes should be used only for the first encounter at the MTF for treatment of an
949   injury. If the patient was treated at a local civilian emergency department and
950   received follow up or after care at the MTF, the first encounter at the MTF should
951   have an E code. Providers should be taught always to document when initial care
952   is received elsewhere. For follow-up care without documentation of the initial
953   visit, assume the patient was initially treated at the MTF and do not use an E code.
954
955   An E code should be used with any diagnosis that indicates an injury, poisoning,
956   or adverse effect with an external cause. In general, when the diagnosis code is in
957   the range of 800–999, and V71.3–V71.6, at least one E code should be entered on
958   the ADM record the first time the patient is seen for the condition. An example of
959   when an E code would not be used for the codes listed above would be in
960   conjunction with 917.2, blister without mention of infection, caused by walking in
961   new shoes without wearing socks.
962
963   As many E codes should be assigned as necessary to fully explain each cause. All
964   ICD-9-CM codes describing the reason for treatment must precede the E codes. If
965   only one E code can be reported in ADM, assign the E code most related to the
966   primary diagnosis or injury. Use the full range of E codes to completely describe
967   the cause, the intent, and the place of occurrence, if applicable, for all injuries,
968   poisoning, and adverse effects of drugs.
                                                 2-13
                                          MHS Coding Guidance
                                              March 2008
                                       DIAGNOSTIC CODING


 969   Owing to limited number of reporting fields (currently four diagnoses) in the
 970   SADR extract, the E codes may not be reported upward. The E codes should be
 971   assigned after the more critical injuries are listed. Only use E codes for external
 972   causes of injury. There is no additional code for most repetitive stress injuries
 973   and other injuries, such as knee pain owing to obesity or back pain caused by
 974   pregnancy.
 975
 976   2.2.10. Child and Adult Abuse Guidelines
 977   Child and adult abuse codes may only be documented in ADM when substantiated.
 978
 979   When the cause of an injury or neglect is intentional child or adult abuse, the first listed E
 980   code should be assigned from categories E960–E968 (Homicide and Injury Purposely
 981   Inflicted by Other Persons), except category E967. An E code from category E967
 982   (Child and Adult Battering and Other Maltreatment), should be added as an additional
 983   code to identify the perpetrator, if known.
 984
 985   In cases of neglect, when the intent is determined to be accidental, E code E904.0
 986   (Abandonment or Neglect of Infant and Helpless Person) should be the first listed E code
 987   (not the primary diagnosis).
 988
 989   2.2.11. M Codes: Morphology of Neoplasm’s
 990   The morphology of neoplasm is not collected in the ADM.
 991
 992   2.2.12. Abortions
 993   The number of legal—elective or therapeutic—and illegal abortions performed in DoD
 994   MTFs must be reported to Congress annually. Use of the 635, 636, and 637 codes should
 995   be carefully scrutinized. Coding personnel will not use 635–638 without authorization
 996   from their supervisor. Some of the basic rules that apply include the following:
 997
 998         Fifth-digit-1, incomplete, indicates that all of the products of conception have
 999          not been expelled from the uterus prior to the episode of care.
1000         Fifth-digit-2, complete, indicates that all of the products of conception have
1001          been expelled from the uterus.
1002         Code 635 requires additional code to identify the reason for the abortion. Codes
1003          from categories 640–648 and 651–657 (with fifth digits 3) may be used as
1004          additional codes with an abortion code to indicate the complication leading to
1005          the abortion.
1006         Codes from the 660–669 series are not to be used for complication leading to the
1007          abortion.
1008         Retained products of conception following an abortion: Subsequent encounters
1009          with the diagnosis of retained products of conception following a spontaneous or
1010          legally induced abortion are assigned the appropriate code from category 634,
1011          spontaneous abortion, or 635, legally induced abortion, with a fifth digit of 1


                                                   2-14
                                            MHS Coding Guidance
                                                March 2008
                                         DIAGNOSTIC CODING


1012           (incomplete). This advice is appropriate even when the patient was discharged
1013           previously with a diagnosis of complete abortion.
1014          A patient who has an abortion performed outside the MTF and presents for
1015           treatment without complications is assigned code V58x. To treat a complication
1016           following an abortion, code the complication using 639x codes. Category code
1017           639 is to be used for all complications following complete abortions. Code 639
1018           cannot be assigned in the presence of codes 634–638.
1019          Illegally induced abortion (636): Not performed within prescribed statutes,
1020           performed by an unqualified individual, or performed at an unauthorized
1021           location. Do not use in DoD.
1022          Unspecified abortion (637): No details about the abortion are available. Do not
1023           use in DoD.
1024          Failed abortion (638): The elective procedure failed to evacuate or expel the
1025           products of conception (fetus) and the patient is still pregnant.
1026          If a code from 636 or 637 must be used, supervisor approval must be
1027           obtained and the supervisor must contact his/her Service coding
1028           representative prior to assignment.
1029
1030   As with all coding, it is important to select the correct 3rd, 4th, and 5th digits, as applicable.
1031   Use DoD-unique code extenders 0 (elective), 1 (therapeutic), 2 (elective, terminated
1032   elsewhere), or 9 (unspecified) with abortion codes 635 and 638.
1033
1034   Do not use unspecified abortion codes in DoD.
1035
1036   When using the code for abortions incomplete with other specified complications, an
1037   additional code is required to describe the other specified complication.
1038
1039   If a patient has an abortion at the MTF or elsewhere and returns for care after the abortion,
1040   with no problems present, the code is V58.49, after care, following surgery.
1041
1042   2. 2.13. Abortion with Live-Born Fetus
1043   When an attempted termination of pregnancy results in a live-born fetus, assign code
1044   644.21, Early Onset of Delivery, with an appropriate code from category V27, Outcome of
1045   Delivery. The procedure code for the attempted termination of pregnancy should also be
1046   assigned.
1047
1048   2.2.14. Closing Out an Encounter for Lack of Documentation
1049   When there is an indicator that an encounter occurred (e.g., documented technician
1050   screening, a prescription, laboratory test or radiology study associated with the
1051   encounter), but the provider’s documentation of the encounter is not available, code the
1052   encounter V68.89, unspecified administrative purpose. If there is no indication of an
1053   encounter within 45 days, cancel the appointment in CHCS.
1054
1055   2.2.15. HIV
1056   Return visit for results of HIV serology test will be assigned to code V65.44, HIV
                                                     2-15
                                              MHS Coding Guidance
                                                  March 2008
                                   DIAGNOSTIC CODING


1057   counseling. For inconclusive findings, an additional code of 795.71, Nonspecific
1058   serologic evidence of human immunodeficiency virus (HIV) would be used.
1059




                                              2-16
                                       MHS Coding Guidance
                                           March 2008
                          EVALUATION AND MANAGEMENT (E&M) CODING


1060   Chapter 3 EVALUATION AND MANAGEMENT (E&M) CODING
1061
1062   ALL CODING WILL BE SUPPORTED BY THE DOCUMENTATION IN THE MEDICAL
1063   RECORD.

1064                  DoD Rule
1065
1066                   AHLTA Documentation: Autocite information will not be considered when
1067                  determining the appropriate ICD-9-CM, E&M, and/or CPT code to be
1068                  assigned to the encounter, unless you assume the entire note or acknowledge
1069                  the pertinent findings within the body of the providers’ notes.
1070

1071
1072   NOTE: This section refers to coding collected in the second data collection screen of the ADM.
1073   Only E&M codes 99201–99499 may be entered in this screen. There are other E&M codes, most
1074   frequently used in mental health, optometry or ophthalmology, physical therapy, and occupational
1075   therapy. Refer to separate sections on E&M codes outside the 99201–99499 range.
1076
1077   Facilities should indicate in their compliance plan which set of CMS guidelines each clinical
1078   service will follow. Indicate how the encounter was audited—using the CMS 1995 or 1997
1079   E&M guidelines.
1080
1081   NOTE: Chapter 3 is organized as follows: Section 3.1. gives general information on E&M coding
1082   in the MHS. Sections 3.2. to 3.8. cover categories of E&M codes. The paragraphs follow the
1083   numbering sequence in the CPT. For instance, paragraph 3.2. provides MHS information on codes
1084   99201–99215; paragraph 3.3 gives MHS information on the next category in the CPT, codes
1085   99217–99236.
1086
1087   3.1. Evaluation and Management Coding – 99201-99499
1088   E&M codes, a subset of CPT codes, identify the location, type, and overall complexity of a
1089   patient encounter. Modifiers clarify the E&M services provided, but their use is limited by MHS
1090   systems.
1091
1092   3.1.1. Determination of Level of E&M Code
1093   The three key elements in selecting the appropriate complexity of the E&M code are history,
1094   examination, and medical decision making. These components must meet or exceed the minimum
1095   requirements specified in the E&M guidance of CPT. When determining the level of history for an
1096   E&M code, the documented elements in the History of Present Illness (HPI) may also be counted in
1097   the Review of Systems (ROS) and the Past Family Social History (PFSH) when appropriate. If
1098   nausea, vomiting, and diarrhea is documented in the HPI, it is not necessary to re-document
1099   ―nausea, vomiting, and diarrhea‖ in the ROS section in order to count it in both elements of the
1100   history component. There are four contributory factors: nature of presenting illness, coordination of

                                                       3-1
                                                MHS Coding Guidance
                                                    March 2008
                          EVALUATION AND MANAGEMENT (E&M) CODING


1101   care, counseling, and time. More E&M documentation guideline information is on the CMS
1102   website at http://www.cms.hhs.gov/.
1103
1104   3.1.1.1. Chief Complaint /HPI/ROS/PFSH
1105   The reason for the encounter, called the chief complaint, should always be noted in the encounter
1106   documentation. This requirement can be met by printing out the reason entered by the appointment
1107   clerk in the computer system. If the chief complaint is not what the appointment clerk entered, (e.g.,
1108   patient told clerk the appointment was for abdominal pain, but when the patient met the provider,
1109   the patient expressed concerns about a sexually transmitted disease), the correct chief complaint
1110   must be documented. All parts of the history (HPI, ROS, PFSH) and the chief complaint may be
1111   documented by other staff members or the patient. Only those parts of the HPI that are actually
1112   documented by the provider may be used in calculating the level of the encounter. Any
1113   documentation, from provider, staff member, or patient, may be used to calculate the level of the
1114   encounter for the ROS and PFSH.
1115
1116   To certify that the provider reviewed the information documented by others, there must be a
1117   notation supplementing or confirming the review.
1118
1119   In AHLTA, support staff can document subjective and objective information. Providers can take
1120   ownership of that documentation and modify it. When the provider takes ownership of another’s
1121   documentation, these elements are considered the provider’s documentation and are included in the
1122   calculation of the E&M code. When ROS and PFSH information are documented by support staff
1123   and the provider does not take ownership of that documentation, the provider must document his
1124   review of that information and agreement or disagreement with that information. When support
1125   staff document HPI information, the provider must take ownership of that documentation. Failure to
1126   do so will result in the AHLTA E&M calculator erroneously including the support staff HPI
1127   documentation in the E&M code calculation.
1128
1129   3.1.2. Coding E&M in ADM
1130   An E&M code is no longer required for each encounter. Up to three E&M codes may be entered.
1131   Use of 99499 is not auditable on TMA audits. Modifiers should be assigned where appropriate.
1132
1133   3.1.3. Privileged Providers
1134   A privileged provider may use any E&M code that accurately reflects the services rendered and
1135   documented. Privileged provider encounters with such limited documentation as to only support a
1136   99211 will be coded with a 99211. A privileged provider is an independent practitioner who is
1137   granted permission to provide medical, dental, and other patient care in the granting facility, within
1138   defined limits, based on the individual’s education, licensure, experience, competence, ability,
1139   health, and judgment. Resident physicians are not independent practitioners, although they are
1140   included in the scope of privileged providers for this document.
1141
1142   NOTE: Navy coding guidance for IDCs and Air Force coding guidance for IDMTs are in
1143   Appendix B.
1144
                                                       3-2
                                                MHS Coding Guidance
                                                    March 2008
                          EVALUATION AND MANAGEMENT (E&M) CODING


1145   3.1.4. Non-Privileged Providers (Nurses and Technicians)
1146   Non-privileged providers are normally restricted to using E&M code 99211 to document face-to-
1147   face encounters in which no procedure is performed (e.g., counseling or education by a technician
1148   or offering a service or supply item that does not have a specific code).
1149   The following clinic services are not considered codeable events:
1150
1151         TB test reading
1152         Patient who presents for an order for pregnancy test only
1153         Blood pressure checks per patient request
1154         Patient who presents to pick up a prescription refill
1155
1156   3.1.4.1. 5 Day BP Checks
1157   Nurses/technicians will use the vital signs module to collect the data for the 5 day blood pressure
1158   checks.
1159
1160      Day 1: Create encounter and document vital sign in vital signs module (use E&M 99211)
1161
1162      Day 2 - 5: Append day 1 encounter and update vital signs in the vital signs module
1163
1164   3.1.5. Encounter Duration
1165
1166   3.1.5.1. When Time Is Not a Dominant Factor
1167   Time is not a dominant factor for assigning the appropriate E&M code in most scenarios. The
1168   time frames identified in E&M code descriptions represent a general range of time that will vary
1169   depending on actual clinical circumstances. The severity of illness as documented by history,
1170   examination, and medical decision making should determine the choice of office visit or
1171   consultation E&M code.
1172
1173   3.1.5.2. Counseling and Coordination Exception
1174   Counseling and coordination are exceptions to the time factor in selecting the E&M code. Time is a
1175   determining factor when counseling or coordination of care consumes more than 50 percent of the
1176   time a provider spends face-to-face with the patient, the family, or both.
1177

1178                  DoD Rule
1179
1180                   AHLTA Documentation: When a provider selects greater than 50% of time
1181                  spent ―counseling and/or coordinating care‖ and also selects the appropriate
1182                  amount of floor time (face to face) then time in and time out requirement has
1183                  been met.
1184



                                                      3-3
                                               MHS Coding Guidance
                                                   March 2008
                          EVALUATION AND MANAGEMENT (E&M) CODING



1185                  Documentation must indicate specifics on the discussion of why the
1186                  additional time was necessary, what occurred during that time, and how
1187                  much time was spent.
1188
1189                  Note: ―counseled on condition‖ is not acceptable documentation.

1190
1191   3.1.5.3. Other Specific Exceptions
1192   Specific exceptions when time is always a factor are prolonged services, critical care, discharge
1193   services, and patient transport. Time plays a role in the extended duration of the encounter.
1194   Extended time may be identified in two ways, modifier -21 (Prolonged E&M Services), or E&M
1195   codes 99354–99357 (Prolonged Services). Modifier -21 is used to designate the total duration of
1196   provider–patient face-to-face time when it exceeds the typical time of encounter. Modifier -21 can
1197   only be used with the highest level E&M code (e.g., 99215, 99245). Codes 99354–-99357 are used
1198   when treatment exceeds the E&M code by more than 30 minutes. Codes 99354–99357 can be used
1199   as add-on codes with any level of E&M service. Modifier -21 and codes 99354–99357 cannot be
1200   used with the same encounter. Documentation must support the need for additional time, as well as
1201   the time of the encounter (e.g., time in and time out).
1202
1203   3.1.6. New and Established Patients
1204   To recognize the different levels of service between a patient who has not received care in a practice
1205   (and therefore needs more explanations about the operation of the practice) and an established
1206   patient (who is aware of the practice’s routines), there are different coding categories.
1207
1208   3.1.6.1. New Patient
1209   A new patient is one who has not received any professional services from the provider or another
1210   provider of the same specialty who belongs to the same group practice in the previous three
1211   years.
1212
1213   A new patient may receive initial professional services as an inpatient or outpatient.
1214   Subsequent professional services would be coded as an established patient. The
1215   encounter that determines a new patient is the first encounter a patient has that meets the
1216   criteria above and meets the requirements of a visit. Occasions of service are not coded
1217   as a new patient encounter. A common error in the DoD is coding a newborn as a new
1218   patient at its first well-baby visit with the pediatrician involved with the delivery and
1219   initial hospitalization. The first well-baby visit would be as an established patient.




                                                       3-4
                                                MHS Coding Guidance
                                                    March 2008
                          EVALUATION AND MANAGEMENT (E&M) CODING


1220
1221   3.1.6.2. Established Patient
1222   An established patient is one who has received professional services from the provider or another
1223   provider of the same specialty who belongs to the same group practice in the previous three
1224   years. A common error in DoD is an optometrist new to the facility coding all patients as new.
1225   The patients who had been seen in the clinic by the previous optometrists in the prior three years
1226   are all established patients to that optometry clinic.
1227
1228   3.1.6.3. Determining New versus Established based on Documentation
1229   New and established patients are determined based on documentation. If the documentation does
1230   not specifically indicate new or established and the record is not available to review for previous
1231   encounters, verify prior encounters in ADM. If, after research, the status of the patient cannot be
1232   determined, the encounter will be coded as an established patient.
1233
1234   3.2. Office Outpatient Services, 99201–99215
1235   These codes are used when a privileged provider collects a medically related history, performs an
1236   exam, and makes a medical decision in a DoD healthcare facility on a patient who is not admitted as
1237   an inpatient to a healthcare facility.
1238
1239   3.2.1. Shared Medical Appointments (SMA)
1240   SMAs are visits when multiple patients meet with the provider and a behaviorist at the same
1241   encounter. A list of chief complaints is compiled. All patients are present for those parts of the
1242   examination not requiring privacy. The provider examines each patient individually and addresses
1243   the patient’s issues. Immediately after completing the encounter with each patient, the provider
1244   documents the encounter while the behaviorist furnishes general education or counseling. When the
1245   provider completes the documentation, the provider starts the next patient’s exam. This continues
1246   until all patients are evaluated and treated. SMAs usually take 60–90 minutes to complete. SMAs
1247   are coded based on documentation. Only one encounter per patient will be completed. The
1248   appropriate E&M code will be assigned according to the documentation (i.e., prevention/office
1249   visit). The modifier TT, indicating individualized services with multiple patients present, is used
1250   when available in the ADM.
1251
1252   3.3. Hospital Observation Services 99217–99220 and 99234–99236
1253   Patients are in observation to determine whether they should be admitted to the hospital, transferred
1254   to another facility or sent home. This is an unplanned service. Patient stays in observation status
1255   should not exceed 48 hours. Follow MTF guidance for notification when observation exceeds 48
1256   hours.
1257
1258   3.3.1. Doctor’s Orders
1259   The doctor must specifically write an order to place a patient in observation. Observation cannot be
1260   initiated based on standing orders.
1261
1262
1263
                                                       3-5
                                                MHS Coding Guidance
                                                    March 2008
                          EVALUATION AND MANAGEMENT (E&M) CODING


1264   3.3.2. Observation Time
1265   Observation time begins at the clock time appearing on the nurse’s initial admission or observation
1266   note. Observation ends at clock time documented in the doctor’s discharge orders. If there is no
1267   time on the doctor’s discharge orders, the time the nurse signs off on the doctor’s orders is used.
1268
1269   NOTE: A SADR is required for each date of service.
1270
1271   The table below summarizes the appropriate use of E&M codes for observation care.
1272
1273                                 E&M Codes for Observation Services
         LENGTH OF OBSERVATION (CALENDAR                      DAY OF OBSERVATION E&M CODES
                  DAYS OR DATES)                             SERVICE       FOR ACUITY
                                                                     LOW MODERATE HIGH
       Initial observation care when length of stay exceeds    Day 1 99218    99219   99220
       calendar day of admission to observation.
       Observation care services provided when patient is       Day 1      99234     99235        99236
       admitted and discharged on same calendar day of
       service.
       Observation care on a day not the admission and not      Middle     99212   99213-99214   99214-
       the discharge day.                                        days                            99215
       Observation care services provided on day of discharge Day 2 or 3   99217     99217       99217
       (unless day of discharge is day of admission) across 2  (date of
       or more calendar days, but not exceeding a total of 48 discharge)
       hours of observation care.
1274
1275   The following G codes will not be used in the MHS at this time:
1276
1277        G0378 Hospital Observation Services, per hour
1278
1279        G0379 Direct admission of patient for hospital observation care in the result of a direct
1280        admission to ―observation status‖ without an associated emergency room visit, hospital
1281        outpatient clinic visit or critical care service on the day of initial observation services.
1282
1283   The following services are not qualified as outpatient observation services:
1284       Those that exceed 48 hours, unless an exception is deemed necessary after a medical
1285           necessity review.
1286       Those not reasonable or necessary for the diagnosis or treatment of the patient but
1287           provided for the convenience of the patient, his or her family, or a physician or provider
1288           (e.g., after an uncomplicated treatment or procedure; physician or provider is busy when
1289           patient is ready for discharge; patient awaiting placement in a long-term care facility).
1290       Inpatient services.
1291       Services associated with ambulatory procedure visits.
1292       Routine preparation services furnished prior to testing and afterwards during recovery
1293           (e.g., patients undergoing diagnostic testing in a hospital outpatient department).

                                                       3-6
                                                MHS Coding Guidance
                                                    March 2008
                           EVALUATION AND MANAGEMENT (E&M) CODING


1294         Observation concurrent with treatments such as chemotherapy.
1295         Services for postoperative monitoring.
1296         Any substitution of an outpatient observation service for a medically appropriate
1297          inpatient admission.
1298         Services ordered as inpatient services by the admitting physician or provider but reported
1299          as outpatient observation services by the hospital.
1300         Standing orders for observation following outpatient services.
1301         Discharges to outpatient observation status after an inpatient hospital admission.
1302
1303   NOTE: For OB observation see section 6.10.4.1.1.1.
1304
1305   3.3.3. Observation to Admission
1306   When a patient is admitted from observation status, the ADM record for the observation care should
1307   be closed out with a disposition type of admitted.
1308   3.3.4. Observation to Ambulatory Procedure
1309   When a patient is referred from observation to an ambulatory procedure unit (APU) or another
1310   MTF, the ADM record for the observation care is closed out with disposition type of immediate
1311   referral.
1312
1313   3.3.5. Admission from Clinic to Inpatient
1314   If a provider admits a patient to his/her service from the clinic, make a copy of the visit notes and
1315   add it to the inpatient record. The provider, or another provider from the same service, should
1316   document additional services (e.g., H&P, visits, procedures) performed on that date of service in the
1317   inpatient record. Combine the documentation from the clinic visit and the additional services
1318   performed to code the initial inpatient E&M visit in addition to any procedures (CPT-4 and/or
1319   HCPCS codes). To close out the clinic encounter, enter disposition ―admitted.‖ Enter appropriate
1320   diagnosis codes that represent the reason for the patient’s admission.
1321
1322   If a provider sends the patient from the clinic to the hospital and another service admits the patient,
1323   the clinic provider may code the clinic visit separately from the initial inpatient visit based upon the
1324   documentation in the clinic record only.
1325
1326   3.3.6. Admission from Emergency Department (ED)
1327   The emergency department provider codes the services provided. The emergency department
1328   physician’s services are not included in the initial inpatient E&M of the admitting service. The
1329   original emergency department notes and any additional services provided on that date of service
1330   should be combined in the inpatient medical record. The encounter should be closed out with
1331   disposition type ―admitted.‖ The emergency department E&M should be coded separately under
1332   BIAA for the initial ED visit.
1333
1334   3.4. Hospital Inpatient Services
1335   See Chapter 9. Professional Coding of Inpatient Consults and Rounds (RNDs).
1336

                                                        3-7
                                                 MHS Coding Guidance
                                                     March 2008
                          EVALUATION AND MANAGEMENT (E&M) CODING


1337   3.5. Emergency Department
1338   Code procedures performed by the emergency department staff, such as infusions, injections and
1339   medications, EKG tracings, in addition to professional services. For consultation or referral
1340   within the ED, see section 4.8. Not all services provided in the ED constitute use of an ED
1341   E&M code(Office visit).
1342
1343   The following G codes will not be used in the MHS at this time:
1344
1345   G0380 Level 1 hosp type B emergency visit
1346   G0381 Level 2 hosp type B emergency visit
1347   G0382 Level 3 hosp type B emergency visit
1348   G0383 Level 4 hosp type B emergency visit
1349   G0384 Level 5 hosp type B emergency visit
1350
1351   3.6. Telephone Services
1352
1353   NOTE: Code selection has changed and is now based on minutes of medical discussion.
1354
1355   The following (Do not assign) list applies to privileged and non privileged providers.
1356
1357   DO NOT ASSIGN TELEPHONE SERVICES CODES FOR:
1358      Telephone services referring to an E&M service performed and reported by the same
1359       provider occurring within the past 7 days
1360      Telephone services ending with a decision to see the patient within 24 hours or next
1361       available urgent visit appointment
1362      Telephone services occurring within the post operative period of the previously
1363       completed procedure
1364      New patient interaction
1365      Provider to provider interaction
1366      Provider to commander interaction
1367      Leaving messages on answering machines
1368      Scheduling/Billing/Administrative issues
1369      Communication of non-clinical information
1370      Telephone services completed by residents that are PGY-1’s
1371      Any other administrative issues
1372      Providing test results
1373
1374   3.6.1. Privileged Provider
1375   Telephone services are a patient initiated interaction between a privileged provider (to include
1376   IDC’s) and an established patient. Documentation must contain evidence of medical decision
1377   making by a licensed provider directly responsible for the management of the patient’s care. These
1378   encounters are reviewed for appropriate clinical documentation by Service audits. Privileged

                                                       3-8
                                                MHS Coding Guidance
                                                    March 2008
                          EVALUATION AND MANAGEMENT (E&M) CODING


1379   providers, including residents beyond post-graduate year one (PGY1), may choose from the three
1380   E&M codes for telephone services. (99441 – 99443)
1381
1382   Code telephone services with E/Ms for privileged providers and residents beyond PGY-1. Below
1383   are the new telephone services codes.
1384
1385   99441 Telephone evaluation and management service provided by a privileged provider to an
1386   established patient, parent, or guardian not originating from a related E/M service provided within
1387   the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest
1388   available appointment; 5-10 minutes of medical discussion
1389   99442          ; 11-20 minutes of medical discussion
1390   99443          ; 21-30 minutes of medical discussion
1391
1392   For online E&M service (99444), see section 8.5.6.
1393
1394   3.6.2. Non Privileged Provider
1395   Telephone services are a patient initiated interaction between a non privileged provider, (to
1396   include IDMT’s) and an established patient. Documentation must contain evidence of
1397   assessment and management of a patient’s care. These encounters are reviewed for appropriate
1398   clinical documentation by Service audits.
1399
1400   98996     Telephone assessment and management service provided by a non privileged
1401   provider to an established patient, parent, or guardian not originating from a related assessment
1402   and management service provided within the previous seven days nor leading to an assessment
1403   and management service or procedure within the next 24 hours or soonest available appointment;
1404   5-10 minutes of medical discussion
1405   98967          ; 11-20 minutes of medical discussion
1406   98968          ; 21-30 minutes of medical discussion
1407
1408   For online assessment and management service (98969), see section 8.5.6.
1409
1410   3.7. Provider (privileged and non privileged) Initiated Telephone Calls
1411   99499 is to be used for provider initiated telephone calls. Use 99499 as the E&M in the T-CON*
1412   module, and the diagnosis as the reason for the call.




                                                      3-9
                                               MHS Coding Guidance
                                                   March 2008
                                               CONSULTATION


1413   Chapter 4 CONSULTATION
1414
1415   THIS SECTION HAS CODING INFORMATION BASED ON THE SPECIALTY
1416   CLINIC THAT PROVIDES SERVICES.
1417
1418   4.1. Consultation Guidelines
1419   For consults, two providers are involved. The provider requesting the consult is the requesting
1420   provider. The provider furnishing the consult is the consulting provider.
1421
1422   4.2. Consult versus Referral
1423
1424   4.2.1. Consult
1425   A consult is a request for advice or opinion from a provider. This professional service may occur
1426   in both inpatient and outpatient settings. A consulting provider may initiate diagnostic or
1427   therapeutic services. Consults are coded from 99241 to 99255. For additional information on
1428   inpatient consults, see section 9.5.
1429
1430   4.2.2. Referral
1431   When the referring provider, in writing, transfers complete responsibility of treatment for a
1432   specific or suspected problem, the receiving provider may not code a consult. Outpatient
1433   referrals are coded using E&M codes for office visits as the new provider assumes full control of
1434   the patient. Inpatient referrals require the patient be transferred to the new service, at which time
1435   the new service begins using the appropriate Inpatient Hospital Services codes.
1436
1437      Example:
1438      Consult: A family practitioner asked a pulmonologist’s opinion about treatment
1439      options for a patient newly diagnosed with left lower-lobe pneumonia and cough.
1440
1441      Referral: A family practitioner requests that a pulmonologist take over treatment of a
1442      patient newly diagnosed with left lower-lobe pneumonia. The chart notes indicate the
1443      family physician will continue to manage the patient’s leukemia (initial reason for
1444      admission).
1445
1446   4.3. Documentation for Consultation
1447   Documentation in the medical records should list the following:
1448        The request for the consult from the attending provider.
1449        The reason for the consult, documented by the attending provider in the patient’s medical
1450          record.
1451        A written report to the requesting provider for opinion or treatment advice from the
1452          consulting provider. It is not necessary for an auditor to locate a separate report if there is
1453          documentation on the SF600 encounter that a report was sent to the requesting provider.
1454        Three elements required in any consultation documentation: the history, physical exam,
1455          and medical decision making.
1456
                                                       4-1
                                                MHS Coding Guidance
                                                    March 2008
                                                CONSULTATION


1457   4.3.1. Documentation for Consultation in a Shared Medical Record
1458   In an emergency department or inpatient or outpatient setting in which the medical record is shared
1459   between the referring physician and the consultant, the request may be documented as part of a plan
1460   written in the requesting physician’s progress note, an order in the medical record, or a specific
1461   written request for the consultation. In these cases, the report may consist of an appropriate entry in
1462   the common medical record.
1463
1464   4.3.2. Examples That Are Not Consults
1465   The following examples do not satisfy the criteria for consultation:
1466        Standing orders in the medical record for consultation.
1467        No order documented for a consultation by the requesting provider.
1468        No written report sent back to the requesting provider from the consultation.
1469        Statements in the medical record such as, ―Patient referred by Dr. Jones for consultation.‖
1470
1471   Use of the SF 513 Consultation does not, in and of itself, constitute a consultation service.
1472   Referrals are frequently made using the SF 513.
1473
1474                                  CONSULTATION VS REFERRAL
       CONSULTATION                                     REFERRAL
       Suspected problem or known problem               Known problem
       Opinion or advice only sought                    Transfer of partial or total patient care for the
                                                        specific problem
       Written request for opinion or advice received   Patient appointment made for the purpose of
       from attending provider, including specific      providing treatment, diagnostic, or therapeutic
       reason the consultation is required              services
       Primary (attending) provider will decide who     Provider is managing the known problem from
       will manage patient care                         the beginning
       Recommended documentation:              Please   Recommended documentation:                Patient
       examine patient and provide me with your         referred to your office for evaluation and
       opinion on his/her condition. The following      treatment of his/her condition
       diagnostic/therapeutic treatment has been
       initiated/recommended
1475
1476   4.4. Consultations That Require More Than One Encounter
1477   For outpatient coding, use the 9924x series for the initial visit and treatment. Any follow up care
1478   resulting from the initial consult will be coded as an established patient office visit. For inpatient
1479   coding use the 9925x series for the initial consult and subsequent hospital care codes (9923x) for
1480   all additional encounters.
1481
1482   4.5. Clearing Patients for Specialty Care
1483   When a consultation is requested to clear a patient for a specialty procedure (e.g., air
1484   evacuation), it is coded using the office consultation E&M codes, 99241–99245 when clearance
1485   is given in the clinic. If clearance is given during an inpatient stay, use codes 99251–99255 as
1486   applicable.
1487
                                                        4-2
                                                 MHS Coding Guidance
                                                     March 2008
                                               CONSULTATION


1488   4.6. Preoperative Consultation
1489   The appropriate consultation code (99241–99255) may be reported for a preoperative
1490   consultation performed by any provider, including a patient’s primary care provider, at the
1491   request of a surgeon, as long as all consultation requirements are met and the service is medically
1492   necessary.
1493
1494   In reporting the diagnosis, it is important to remember that the role of each code is to explain
1495   why a service was provided. In reporting preoperative clearance, the first diagnosis code would
1496   be the code for preoperative examination (e.g., V72.81–V72.84). Additional ICD-9 codes for the
1497   condition(s) that prompted surgery and for conditions that prompted the preoperative medical
1498   evaluation should also be documented and reported. The underlying condition determines the
1499   medical necessity for the preoperative clearance. Other diagnoses and conditions affecting the
1500   patient may also be documented and reported if appropriate.
1501
1502      Example:
1503      V72.81              Preoperative cardiovascular examination
1504      336.13              Anterior sub capsular polar senile cataract-Reason for surgery
1505      401.1               Essential hypertension benign-Underlying condition, why medical
1506                          clearance was needed.
1507
1508   4.7. Emergency Department
1509
1510   4.7.1. Referrals
1511   The emergency department provider requests the specialist take over care or a portion of care.
1512   The emergency department does not intend for the patient to receive follow-up care in the
1513   emergency department. To code emergency department services with separate specialist
1514   services, two ADM records will be created.
1515
1516   An appointment will be generated in the emergency department. The emergency department
1517   provider will document services provided. In the documented plan of care, the emergency
1518   department provider will indicate a portion or all of the care will be transferred to the specialist.
1519   The emergency department provider will generally use a code in the 99281–99285 series and
1520   collect the care in code BIAA of Medical Expense and Performance Reporting System
1521   (MEPRS).
1522
1523   The specialist will document services in a separate document. The specialist will have an
1524   appointment generated in the clinic, usually a walk-in. The appointment will be marked kept,
1525   which will generate a report to be completed in the ADM. This report will be separate from the
1526   ADM report generated in the emergency department. The specialist will usually code an office
1527   visit range of 99201–99215 in the specialist’s outpatient clinic MEPRS.
1528
1529   If the specialist admits the patient, there would not be a clinic appointment generated, but the
1530   documentation would become part of the inpatient record and collected in the inpatient
1531   professional service rounds appointment.
                                                       4-3
                                                MHS Coding Guidance
                                                    March 2008
                                              CONSULTATION


1532   4.7.2. Consultations
1533   For a consultation in the emergency department, see section 4.8. A separate encounter will be
1534   created when the emergency department physician requests a consultation.
1535
1536   Use codes 99241–99245 to document consultant services when the consultant is called to the
1537   emergency department to render a consultation at the request of the emergency department. The
1538   consultant will report his/her work in his/her specialty MEPRS clinic. The level of consultation
1539   is based on the documentation in the medical record. Documenting the problem(s) to be
1540   evaluated establishes the medical necessity for the consultation. The specialist will evaluate the
1541   patient and provide separate written documentation furnishing recommendations on the patient’s
1542   care.
1543
1544   4.8. Coding Consults in AHLTA
1545   In AHLTA, using the MEDCIN module, to code the consult correctly instead of a referral, the
1546   provider must switch the SERVICE TYPE from OUTPATIENT VISIT to OUTPATIENT
1547   CONSULT. Consultation results documented in AHLTA, are considered to meet the render and
1548   report requirements.
1549




                                                      4-4
                                               MHS Coding Guidance
                                                   March 2008
                                         PROCEDURAL CODING


1550   Chapter 5 PROCEDURAL CODING
1551
1552   ALL CODING WILL BE SUPPORTED BY THE DOCUMENTATION IN THE MEDICAL
1553   RECORD. Specific uses of procedural coding are listed under specialty chapters in Section 7.
1554
1555   5.1. Procedures
1556   The term procedures include E&Ms not in the 99201–99499 range, such as mental health, physical
1557   therapy, occupational therapy and optometry or ophthalmology evaluations. Procedures also
1558   include supplies and durable equipment. Procedure codes are entered in the CPT/HCPCS
1559   Description position on the ADM screen.                CPT procedure codes (00100–99199 and
1560   99500+,Category II and Category III) and all of the HCPCS Level II codes are entered in the
1561   CPT/HCPCS Description position. All procedure codes will be entered before the anesthesia code
1562   for APVs. The last code listed for the institutional component of the APV will always be 99199 .
1563
1564   ICD-9-CM procedure codes are not used when coding professional services. The ICD-9-CM
1565   diagnosis that shows the medical necessity for a procedure must be linked to the procedure. The
1566   codes for diagnostic radiology and laboratory procedures (other than those done and interpreted in
1567   the clinic such as obstetric ultrasounds and KOH tests) should only be added to the encounter when
1568   performed in the clinical setting.
1569
1570      Example: A child presents with ear pain. Because the tympanic membrane cannot be
1571      seen because cerumen is impacted, cerumen is removed. The primary diagnosis is otitis
1572      media (1). The secondary diagnosis is impacted cerumen (2). The procedure for
1573      removal of impacted cerumen, one or both ears, is coded with the CPT code 69210 and
1574      matched to impacted cerumen secondary diagnosis.
1575
1576   5.1.1. Minimize Use of Unlisted Procedure Codes
1577   Efforts should be made to minimize use of unlisted procedure codes. In CPT, unlisted codes
1578   usually end in 99. In HCPCS, unlisted codes are less consistent in their numbering and may
1579   have any numbering convention (e.g., Q4050 Unlisted Cast Supplies), though the terminal digit
1580   is frequently a 9.
1581
1582   5.1.2. Non-Privileged Provider Procedures
1583   When a non-privileged provider is granted permission by the MTF to do a procedure, the procedure
1584   code may be used to reflect nurse or technician services. Common examples are physical therapy
1585   technicians performing physical therapy procedures and technicians removing warts. In these cases,
1586   the technicians may only furnish the service if working under the written orders of a privileged
1587   provider.
1588
1589   5.2. Modifiers
1590   Modifiers are used to indicate a service or procedure has been performed, but was altered by some
1591   specific circumstance. Modifiers are two-character codes added to the E&M or CPT/HCPCS
1592   procedures. They are alpha, numeric, or alphanumeric codes. Modifiers and their associated
1593   nomenclature are derived from two sources—CPT and HCPCS. In CPT books, there are four
1594   groups of modifiers.
                                                      5-1
                                               MHS Coding Guidance
                                                   March 2008
                                           PROCEDURAL CODING


1595   5.2.1. CPT Modifiers
1596   The first list, usually referred to as Modifier starts with the modifier 21. These modifiers are for
1597   professional services. At this time, the MHS does not code the institutional component of services
1598   separately (except for the 99199 code for the institutional component of ambulatory procedure
1599   visits). All the modifiers in Appendix A are appropriate for MHS coding.
1600
1601   5.2.2. CPT Anesthesia Physical Status Modifiers
1602   The second group, usually referred to as Anesthesia Physical Status Modifiers starts with the
1603   modifier P1. These modifiers are now available for use.
1604
1605   5.2.3. CPT Modifiers Approved for Ambulatory Surgery Hospital Outpatient Use
1606   The third group of modifiers usually has a header something like Modifiers Approved for
1607   Ambulatory Surgery (ASC) Hospital Outpatient Use. This list starts with the modifier 25; modifier
1608   27 is in the list. In the civilian sector, coding for an ASC or for a hospital would be for the
1609   institutional component of the services. Modifiers 27, 73 or 74 are not to be used for professional
1610   services coding.
1611
1612   5.2.4. HCPCS Level II Modifiers
1613   The fourth list usually has a title such as Level II (HCPCS/National) Modifiers. These codes, found
1614   in Appendix A are used for professional services and should be used as applicable.
1615
1616   5.2.5. Unavailable Modifiers
1617   Not all modifiers are available at this time in ADM and AHLTA. Modifiers that can be used are in
1618   Appendix A. In general, modifiers in the Modifiers and Level II (HCPCS/National) lists in CPT
1619   books are available. Usually modifiers only found in the HCPCS book are not available. Up to
1620   three modifiers may be used for each procedure. Modifiers changing the amount of a service (e.g.,
1621   bilateral, professional component, surgical care only) should be sequenced before those describing
1622   the type of provider (e.g., anesthesiologist, certified registered nurse anesthetist [CRNA]), midwife).
1623   Modifiers describing anatomic locations (e.g., right, left) should be coded after modifiers describing
1624   type of provider. The most common modifier coding error in the MHS is missing an RT or LT
1625   finger, toe, or eyelid modifier.
1626
1627   5.2.6. Modifier -32 Mandated Services
1628   The intent of this modifier is to define when another entity has a mandate, not when an entity is
1629   following its own regulations. Therefore, it is inappropriate to use this code for encounters such
1630   as flying physicals, hearing conservation screenings or newborn hearing screenings and
1631   premarital laboratory testing.
1632
1633   5.3. Bundled Procedures and Global Procedures
1634
1635   5.3.1. Bundled procedure codes should be used whenever possible. Bundled services are a set of
1636   medical or surgical services wrapped in a group package. The components listed in a particular
1637   service are considered integral to the procedure and should not be billed separately. An example of
1638   this is a sigmoidoscopy with removal of foreign body. The code 45332 captures both procedures.
1639
                                                        5-2
                                                 MHS Coding Guidance
                                                     March 2008
                                           PROCEDURAL CODING


1640   5.3.2. Global and Bundled Procedures
1641   Global procedures are similar to bundled procedures. Global surgical packages have one code for
1642   all three parts: preoperative services, the procedure, and uncomplicated postoperative care--a
1643   package deal. The global package includes low-level patient monitoring and topical anesthesia. A
1644   common error is using an E&M to code uncomplicated postoperative services already included in a
1645   global procedure. The code 99024 reflects uncomplicated, routine postoperative care during the
1646   global period. When a patient has had surgery at another facility, the first follow-up at the new
1647   facility will be coded with the surgical procedure code and modifier -55 (postoperative care only).
1648   Code 99024 is for all subsequent uncomplicated encounters. Complicated postoperative services
1649   are coded to the appropriate postoperative complication codes and E&M services.
1650
1651   5.3.2.1. Obstetrical Coding.
1652   See section 6.9.
1653
1654   5.4. Clinical Pharmacists
1655

1656                  DoD Rule
1657
1658                  Anticoagulation INR lab tests review may be reported with appropriate diagnosis
1659                  code. E&M codes are reported only once at the end of the 90 day time frame.
1660                  Pharmacists will code 99363 or 99364 once the 90 day time frame has elapsed. If the
1661                  services performed occur for less than 60 days each encounter must be coded using
1662                  99211.
1663                  INR lab test will be reported on each encounter if performed in the B MEPRS clinic.
1664

1665
1666   Clinical pharmacists are privileged to provide patient care independently outside the pharmacy
1667   environment. These providers are usually doctors of pharmacy or pharmacists with extensive
1668   training that covers a particular range of disease processes for which they are credentialed to
1669   manage pharmacologically in a clinical setting. See Service-specific guidance for privileging
1670   procedures. Pharmacists will use Medication Therapy Management CPT codes (99605–99607) for
1671   patient treatment other than coagulation therapy. These are face-to-face timed codes that must
1672   include the following documented elements: review of the pertinent patient history; medication
1673   profile; recommendations for improving health outcomes and treatment compliance.
1674
1675   5.5. Chaplains and Pastoral Counselor
1676   Chaplain and pastoral counselor services will always be non-count. On occasion, chaplains
1677   document in the hard copy medical record to communicate with medical providers. In this case, it is
1678   inappropriate to code in ADM as only Defense Health Program (DHP) funded visits should be
1679   collected in CHCS or AHLTA. To document in AHLTA as a communication tool, the documenter
1680   must be able to enter the provider (usually with nurse or technician permission). Use the provider
1681   specialty code of 900 (technician) until the code Pastoral Counselor 076 is available. No workload
1682   will be credited for pastoral care. The usual diagnosis would be V62.89, Other, religious or spiritual
1683   problem or V62.6, Refusal of treatment for reasons of religion or conscience.
                                                       5-3
                                                MHS Coding Guidance
                                                    March 2008
                                          PROCEDURAL CODING


1684   5.6. Electrocardiogram (ECG or EKG) Services 93000–93042
1685   ECG/EKG has a global code (93000, 93040) when the tracing, interpretation, and report are
1686   completed in the same clinic. When the tracing (technical component) is performed in the
1687   cardiopulmonary lab or other clinic, code 93005 or 93041 for the tracing only. The provider
1688   privileged to interpret and report the ECG/EKG uses 93010 or 93042 after a report is completed to
1689   code the professional component. Interpretation only without a report is not a codeable event. An
1690   example of an interpretation would be an emergency department physician interpreting, but not
1691   creating a report for ECG tracing performed in the ED. This should be included in the medical
1692   decision-making portion of the E&M code.
1693
1694   NOTE: Although the interpretation does not have to be on a separate page, the summary of findings
1695   must contain sufficient detail that a conclusion of the significance of the findings can be made
1696   without the tracing itself being available. Documentation must include descriptive or tabular
1697   summary including information such as PR, QRS, QT intervals, rate, rhythm, axis, ST segment
1698   changes, along with an interpretation of these findings. Simple notations in the E&M visit notes,
1699   such as "EKG-neg" or "EKG-acute MI", are not adequate documentation.
1700
1701      Example: ECG/EKG ordered and read by the same provider in conjunction with a visit.
1702      The provider would capture the tracing, as well as the interpretation and report for the ECG
1703      along with the visit and code 93000 or 93040, as appropriate. The technician performing the
1704      test could be included as an additional provider in ADM.
1705
1706      Example: ECG/EKG performed in a central cardiopulmonary lab and interpreted by a
1707      provider. Currently there is no module to capture and code these procedures. NOTE: For
1708      ADM reporting, the MTF may establish a non-count clinic, non-count appointment
1709      type in CHCS using DDA and capture the CPT tracing only code. The interpretation
1710      and report will be captured by the provider doing the initial interpretation in their B
1711      MEPRS clinic.
1712
1713   5.7. Laser Tattoo and Hair Removal
1714   For laser removal of tattoos code to ICD-9-CM 709.09, use procedure code 17999. For laser hair
1715   removal of pseudofolliculitis barbae (shaving bumps) code to ICD-9-CM 704.8 and procedure code
1716   96999.
1717
1718   5.8. On Call
1719   On call codes will not be used. To enter an encounter in the ADM, a patient must be associated
1720   with the procedure code. On call is not for a specific patient.
1721
1722   5.9. Medical Evaluation Boards (MEB)
1723
1724   5.9.1. Board Participation Not Codeable
1725   Participation on the board is an administrative service and is not codeable. Time spent participating
1726   on an MEB is not collected in the B*** MEPRS, but in the FEDA MEPRS.
1727
1728
                                                       5-4
                                                MHS Coding Guidance
                                                    March 2008
                                           PROCEDURAL CODING


1729   5.9.2. MEB Services
1730   The MEB may originate from different sources; the privileged providers performing evaluations for
1731   a specific condition will be coded as an office visit, based on the documentation. The MEB
1732   initiating provider will assess the patient and request necessary consults. The consults (e.g., mental
1733   health evaluations, neurology, and orthopedics) will be coded based on the documentation. The
1734   package development by the MEB initiating provider, which incorporates all the consults and other
1735   documentation, will be coded with the 99455 or 99456 codes. The package development codes
1736   99455 or 99456 documentation will include the following: completion of a medical history,
1737   commensurate with patient’s condition; performance of an examination commensurate with the
1738   patient’s condition; formulation of a diagnosis, assessment of capabilities and stability and
1739   calculation of impairment; development of future medical treatment plan; and completion of
1740   necessary documentation/certificates or reports. When the MEB meets, the primary provider
1741   presents the case, and the board makes a recommendation. MEB services do not include ongoing
1742   treatment for any disability-related condition.
1743

1744                  DoD Rule
1745
1746                  If the package development which is coded using 99455 or 99456 takes more than 1
1747                  hour of the provider’s time, use the appropriate face to face prolonged services
1748                  99354-99357 or non face to face prolonged services 99358- 99359 codes.
1749
1750                  For inpatients receiving an MEB, generate an encounter in the provider’s B clinic.
1751

1752
1753   5.10. Records Review
1754   Records review for peer review and the Medical Record Review Committee are administrative
1755   activities. There are no CPT/HCPCS codes for administrative records review.
1756
1757   5.11. Injections and Infusions
1758   To capture the immunization administration for vaccines or toxoids, report the appropriate age-
1759   specific codes in cases where the physician provides face-to-face counseling of the patient or family
1760   during administration of the vaccine. For services provided by technicians or nurses, use the code
1761   range 90471–90474 and the immunization product code 90476–90749.
1762
1763   If a significantly identifiable E&M service is performed with a vaccine or toxoid procedure, the
1764   appropriate E&M service code should be reported in addition to the vaccine or toxoid
1765   administration.
1766
1767   For injections/immunization administration, documentation must include at a minimum, method of
1768   administration, unit(s), and substance.
1769
1770   For infusions, documentation must include at a minimum, start and stop times, method of
1771   administration, unit(s) and substance.

                                                       5-5
                                                MHS Coding Guidance
                                                    March 2008
                                          PROCEDURAL CODING


1772   It is insufficient to simply select corresponding CPT codes in AP section of AHLTA note. Although
1773   this information may be reported in a different system, documentation must be contained in the
1774   note.
1775
1776   5.12. Cast or Splint Application
1777   All casts and splints applied will be coded when not bundled with another procedure on the ordering
1778   privileged provider’s SADR, with the technician listed as a secondary provider. When applying
1779   other than the initial cast or splint, also use the casting and splint codes Q4001–Q4051.
1780
1781   5.13. Tobacco Use Cessation
1782   Use code 99406 for smoking and tobacco use cessation counseling visit; 3-10 minutes and 99407
1783   for smoking and tobacco use cessation counseling greater than 10 minutes. If an assessment of
1784   tobacco use was conducted, use 1000F. Use 1034F to report smoking use and 1035F for tobacco
1785   use. Use the appropriate ICD-9-CM diagnosis code 305.1.
1786
1787   5.14. Physician’s Voluntary Reporting Program Codes
1788   Codes G8006–G8186 were not available in AHLTA prior to publication of this edition of the MHS
1789   Coding Guidance.




                                                      5-6
                                               MHS Coding Guidance
                                                   March 2008
                                        SPECIALTY CODING
                                           6.1 Anesthesia

1790   Chapter 6 SPECIALTY CODING
1791
1792   THIS SECTION HAS CODING INFORMATION BASED ON THE SPECIALTY
1793   CLINIC THAT PROVIDES SERVICES.
1794
1795   6.1. Anesthesia
1796
1797   6.1.1. Basic Tenets of Professional Services Anesthesia Coding
1798   Anesthesia procedures are coded when local anesthesia is supplemented, or when
1799   regional, monitored anesthesia care or general anesthesia is performed by a person other
1800   than the provider performing the surgical procedure.
1801        Regional anesthesia is the use of anesthetic agents with or without sedation to
1802           provide pain relief or the loss of sensation to a specific area of the body, such as
1803           epidural anesthesia or a brachial plexus block.
1804        General anesthesia is the total loss of consciousness and reflexes caused by the
1805           administration of drugs and inhalation agents.
1806        Monitored anesthesia care (MAC) is intra-operative monitoring by an
1807           anesthesiologist or CRNA of the patient’s vital signs, in anticipation of possible
1808           need to transition to general anesthesia. The patient maintains an airway and
1809           responds to verbal stimuli, except possibly for brief periods of time (e.g., fewer
1810           than 60 seconds).
1811
1812   6.1.2. Reporting B MEPRS for Anesthesia Services
1813   The professional component of anesthesia services will be captured on the lead surgeon’s
1814   ADM encounter. The anesthesia code will be sequenced after all procedures performed
1815   by any surgeons and before the 99199 code for the institutional component of the APV.
1816   Procedures performed by the surgeon should be linked to the surgeon. Procedures
1817   performed by the anesthesia provider should be linked to the anesthesia provider.
1818

1819                  DoD Rule
1820
1821                  Anesthesia services will be reported in MTFs when performed by a
1822                  provider other than the surgeon using anesthesia procedure CPT
1823                  codes: 00100–01999.
1824
1825                  MTFs will list anesthesiologists or CRNAs as additional providers on
1826                  the surgeon’s record in the ADM.
1827
1828                  For Air Force specific guidance, contact the Service representative.

1829
1830   6.1.3. E&M Coding
1831
1832   6.1.4. Providers
                                                   6-1
                                           MHS Coding Guidance
                                               March 2008
                                       SPECIALTY CODING
                                          6.1 Anesthesia

1833   6.1.4.1. Anesthesia Performed by a Provider Other than the Surgeon
1834   When the provider administering and monitoring the anesthesia is a provider other than
1835   the surgeon (e.g., another physician, anesthesiologist, or CRNA), the anesthesia services
1836   will be reported using anesthesia procedure CPT codes: 00100–01999.
1837
1838   6.1.4.2. Anesthesia Performed by Provider Also Performing Surgical Procedure
1839   When the provider performing the surgical procedure also administers and monitors the
1840   anesthesia, a surgical CPT procedure(s) code and not an anesthesia code is applied.
1841   Append modifier -47 to the surgical procedure code.
1842
1843   6.1.5. Gathering Documentation
1844   Medical records will be reviewed for the anesthesia provider’s documentation
1845   supporting the use of regional, MAC, or general anesthesia. Generally, these
1846   anesthesia services can be found on DA Form 7389 for the Army or OF 517 for
1847   the Navy and Air Force.
1848
1849   6.1.5.1. When Not to Code for Anesthesia Services
1850
1851   6.1.5.1.1. Types
1852   Anesthesia services are NOT coded when the procedure is performed using the following
1853   types of anesthesia:
1854
1855         topical;
1856         local infiltration of anesthetic agents to a limited area, such as those used for
1857          minor procedures like biopsies, and the excision of skin tumors and lesions; or
1858         metacarpal, metatarsal, or digital block.
1859
1860   6.1.5.1.2. Procedures
1861   Anesthesia guidelines in the CPT coding manual and the National Correct Coding
1862   Initiatives (NCCI) provide guidance on the services that are inclusive to the provision of
1863   anesthesia, and therefore are not coded separately. They are:
1864
1865         normal pre- and post-anesthesia visits;
1866         provision of fluids or blood;
1867         normal monitoring of vital signs, EKG, pulse oximetry, capnography (blood
1868          carbon dioxide concentration), and mass spectrometry;
1869         laryngoscopy for placement of airway and placement; and
1870         nerve stimulation to determine level of consciousness.
1871
1872   6.1.5.1.3. Moderate Sedation (Previously Termed Conscious Sedation)
1873   Clinicians use moderate sedation to achieve a medically controlled state of depressed
1874   consciousness while maintaining the patient’s airway, protective reflexes, and ability to
1875   respond to stimulation or verbal commands. Review CPT code descriptions to avoid
1876   unbundling as some procedures (e.g., some endoscopies) include moderate sedation.

                                                  6-2
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                           6.1 Anesthesia

1877   Moderate sedation is reported when the physician performing the surgical procedure also
1878   provides the moderate sedation. Moderate sedation requires an independent observer be
1879   present to assist the physician in monitoring the patient’s level of consciousness and
1880   physiologic status. Report moderate sedation on the surgeon’s ADM entry in the
1881   appropriate MEPRS code.
1882
1883   6.1.6. Additional Anesthesia Procedures
1884   Other forms of monitoring by anesthesia personnel will be coded on the surgeon’s ADM
1885   encounter when they are done by an anesthesia provider. These codes should be linked to
1886   the anesthesia provider. For example:
1887
1888         Central venous puncture (CVP) line insertion,
1889         Intra-arterial lines,
1890         Swan–Ganz catheters,
1891         Emergency intubation,
1892         Critical care visits and
1893         Transesophageal echocardiography.
1894
1895   6.1.7. Coding Anesthesia
1896
1897   6.1.7.1. Coding with a Crosswalk
1898   Anesthesia can be coded in a number of ways. A crosswalk between surgical procedures
1899   and anesthesia is available from a variety of sources, including the American Society of
1900   Anesthesiologists (www.asahq.org) or the Coding Compliance Editor (CCE). When a
1901   crosswalk is not available, follow the steps below.
1902
1903   6.1.7.2. Coding without Crosswalk:
1904           1. Identify all surgical procedures performed.
1905           2. Refer to the main term, anesthesia, in the CPT index.
1906           3. Search for a sub-term to indicate the anatomic site of the procedure or
1907              the actual procedure performed.
1908           4. Reference the code or codes noted in the index’s tabular portion of the
1909              CPT codebook.
1910           5. Read and apply any notes in the index or in the tabular portion of the
1911              CPT codebook.
1912           6. If multiple anesthesia services are performed in the same session, the
1913              anesthesia procedure with the highest base unit will be determined (see
1914              the ―Relative Value Guide,‖ published by the American Society of
1915              Anesthesiologists).
1916           7. To calculate the base units for multiple anesthesia services, see section
1917              6.1.8 Base Unit in this document.
1918           8. At this time the MHS cannot accommodate modifiers for anesthesia.
1919              Therefore, the MHS does not report medical direction or supervision.


                                                   6-3
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                           6.1 Anesthesia

1920           9. Assign codes for any qualifying circumstances, if applicable. See section
1921              6.1.14. Reporting Qualifying Circumstances in this document.
1922
1923   6.1.8. Base Unit
1924   A base unit reflects the difficulty (or level of acuity) of the anesthesia service. The base
1925   unit includes the initial anesthesia assessment to determine if the patient is an anesthesia
1926   candidate. It also includes the following services, usually provided on the day of surgery:
1927
1928          preoperative visit,
1929          postoperative visit, and
1930          administration of fluids or blood products incident to the anesthesia care and
1931           interpretation of non-invasive monitoring.
1932
1933   Each anesthesiology CPT code is assigned a base unit value in the Medicare Relative
1934   Value Guide. It is available at the CMS Website:
1935   (http://www.cms.hhs.gov/center/anesth.asp) in Appendix A, Chapter 8, Medicare
1936   Carriers Manual, Part 3.
1937
1938   6.1.9. Single Code Exceptions for Anesthesia
1939   There are exceptions to the inclusion of all anesthesia procedures performed during the
1940   same surgical session under one code. The exceptions are the anesthesia add-on codes
1941   for the excision or debridement of burns (that accommodates percentage of body surface)
1942   and obstetrical anesthesia (that allows for time). The anesthesia add-on codes have
1943   separate base units. All add-on codes are reported in addition to the principal procedure
1944   code(s). They are never used as the first-reported or solo code.
1945
1946   6.1.10. Identifying Type of Provider
1947   When available in the MHS systems, an HCPCS level II modifier identifies the provider
1948   as an anesthesiologist or CRNA. The modifier indicates whether the CRNA provider is
1949   or is not under the medical direction or supervision of an anesthesiologist. Additionally
1950   the modifier indicates the number of cases directed or supervised by a provider. The
1951   physician or anesthesiologist and the anesthetist both report their services with the
1952   appropriate modifier.
1953
1954   6.1.11. Cancelled Procedure
1955   If the surgical procedure is cancelled or terminated prior to the induction of
1956   anesthesia or the administration of drugs or medication (e.g., day before or morning
1957   of the surgery), but there has been a pre-surgical anesthesia assessment, then the
1958   anesthesia clinic will create and complete the ADM record in the B MEPRS, then
1959   code the pre-anesthesia evaluation using a consult code (e.g., 99241) based on the
1960   documentation of the initial anesthesia assessment to determine if the patient was an
1961   anesthesia candidate.
1962
1963   If the surgical procedure is cancelled or terminated after preparation of the patient for
1964   anesthesia, assign the anesthesia code for the anticipated surgical procedure. At this time,
                                                    6-4
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                           6.1 Anesthesia

1965   the unit’s field automatically fills with a unit of 1 when a code in the 00100–01999 range
1966   is used. Therefore, minutes of service cannot be reported in the ADM. Anesthesia
1967   personnel do collect and report minutes of anesthesia service in MEPRS.
1968
1969   6.1.12. Aborted Procedure
1970   If the surgical procedure is cancelled or terminated (not patient elective) after the surgical
1971   procedure has started, assign the appropriate anesthesia code for the procedure in the
1972   routine manner, based on the actual procedure performed. Do not use modifier -53 on
1973   anesthesia codes. Modifier -53 would be used on the surgical procedure code.
1974
1975   6.1.13. Monitored Anesthesia Care (MAC)
1976   MAC entails intra-operative monitoring of the patient’s vital physiological signs in
1977   anticipation of the need for administration of general anesthesia or in the event the patient
1978   develops physical complications from the surgical procedure. To report MAC, the
1979   anesthesia provider must:
1980
1981         provide a pre-anesthesia evaluation and examination;
1982         prescribe the anesthesia plan;
1983         dispense any oral or parenteral anesthesia drugs to the patient;
1984         provide intra-procedural monitoring of patient’s vital signs, maintenance of the
1985          patient’s airway, and continual evaluation of vital functions;
1986         conduct any postoperative care needed; and
1987         maintain adequate medication and ensure pharmacological equipment is readily
1988          available at all times.
1989
1990   Because MAC requires at least the same level of monitoring as that of general anesthesia,
1991   it is treated the same as general anesthesia except that the appropriate modifiers should be
1992   coded when they become available in the DoD system. Medical necessity must be
1993   documented to support the need for MAC.
1994
1995   6.1.14. Reporting Qualifying Circumstances
1996   Additional codes are needed to report unusually difficult circumstances for anesthesia
1997   administration. The qualifying circumstances codes are in the Medicine Section of the
1998   CPT. They are also listed in the beginning of the Anesthesia Section of the CPT coding
1999   manual. These codes are not stand-alone codes. More than one qualifying circumstance
2000   code can be used if applicable.




                                                    6-5
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                          6.1 Anesthesia

        Qualifying Circumstances        Description
        +99100                          Anesthesia for patient of extreme age, under 1 year and over
                                        70 (List separately in addition to code for primary anesthesia
                                        procedure).
        +99116                          Anesthesia complicated by use of total body hypothermia
                                        (List separately in addition to code for primary anesthesia
                                        procedure).
        +99135                          Anesthesia complicated by use of controlled hypotension
                                        (List separately in addition to code for primary anesthesia
                                        procedure).
        +99140                          Anesthesia complicated by emergency conditions (specify)
                                        (List separately in addition to code for primary anesthesia
                                        procedure).
2001
2002   6.1.15. Postoperative Pain Management
2003
2004   6.1.15.1. Overview
2005   The most common techniques for postoperative pain control are patient-controlled
2006   analgesia (PCA), epidural analgesia, and nerve blocks. Postoperative pain management
2007   is only reported when the attending surgeon requests, in writing, that the anesthesia
2008   provider performs significant, separately identifiable services, such as ongoing critical
2009   care services, postoperative pain management services, or extensive unrelated ventilator
2010   management.
2011
2012   6.1.15.2. Patient Controlled Analgesia
2013   PCA therapy is a technique for pain management that involves self-administration of
2014   intravenous drugs through an infusion device. When PCA is initiated in the recovery
2015   room by an anesthesiologist as part of the anesthesia time, the initial set-up time for PCA
2016   may be incorporated into the total number of anesthesia time units reported.
2017
2018   6.1.15.3. Epidural
2019   Epidural analgesia involves the administration of a narcotics drug through an epidural
2020   catheter. Insertion of an epidural catheter should be reported as a separate procedure
2021   code. Management of epidural or subarachnoid drug administration (CPT code 01996) is
2022   reported on dates of service after the date of the surgery. Management of epidural or
2023   subarachnoid drug administration is limited to one unit of service per postoperative day,
2024   regardless of the number of visits necessary to control the catheter per postoperative day.
2025   Postoperative pain management services are generally provided by the surgeon, who is
2026   reimbursed under a global payment policy related to the procedure and is reported by the
2027   anesthesia provider only when separate, medically necessary services are required that
2028   cannot be rendered by the surgeon. The surgeon is responsible for documenting in the
2029   medical record the reason care is being referred to the anesthesia provider.
2030
2031   6.1.15.4. Nerve Block
2032   A nerve block injection involves injection of an anesthetic agent into or around a given
2033   nerve. When an injection or block is administered postoperatively by an anesthesia
                                                 6-6
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                           6.1 Anesthesia

2034   provider in the recovery room as part of the anesthesia time, any additional time required
2035   for the injection may be included in the total number of anesthesia minutes reported.
2036
2037   6.1.16. Physical status modifiers are used in the civilian sector but not currently used in
2038   DoD.
2039
2040   6.1.17. Anesthetic Agents
2041   Anesthetic agents, as well as other medications (e.g., anti-emetics, antibiotics) are part of
2042   the institutional component of the surgery. They are not coded separately.




                                                   6-7
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                          6.2 Audiology

2043   6.2. Audiology
2044
2045   6.2.1. Evaluation & Management (E&M) Rules
2046   E&M codes are not appropriate for routine audiology encounters for procedures. The
2047   medical E&M components of an outpatient office visit are already included in the special
2048   procedures codes listed in the Special Otorhinolaryngologic Services subsection.
2049
2050   Encounters with patients for whom no procedure is done are reported with an E&M code
2051   (99201–99205 or 99211–99215) based on the chief complaint, history, exam, and
2052   decision making documented in the medical record.
2053
2054   6.2.2. Diagnosis Coding Rules
2055

2056                 DoD Rule
2057
2058                 Deployment-related encounters will code one of the following: V70.5_4 for
2059                 pre-deployment, V70.5_5 during deployment, or V70.5_6 for post-
2060                 deployment related conditions. See section 2.2.8.2.

2061
2062   6.2.2.1. Extender Codes
2063
2064   See Appendix D for a complete list of all extender codes.
2065
2066   V72.1 Examination of Ears and Hearing
2067            V72.11* 0 Encounter for Hearing Examination Following Failed Hearing
2068                          Screening.
2069            V72.11* 1 Encounter for Hearing Examination Following Failed Hearing
2070                          Screening, Otoscopic Exam Done
2071            V72.11* 2 Encounter for Hearing Examination Following Failed Hearing
2072                          Screening, Otoscopic Exam Not Performed
2073            V72.19* 0 Other Examination of Ears and Hearing
2074            V72.19* 1 Other Examination of Ears and Hearing, Otoscopic Exam Done
2075            V72.19* 2 Other Examination of Ears and Hearing, Otoscopic Exam Not
2076                          Performed
2077   6.2.2.2. Hearing Conservation Program (HCP)
2078   HCP guidelines in DA Pam 40–501 or other Service guidelines require all military and
2079   civilian personnel who routinely work in noise-hazardous areas to have reference (base
2080   line), annual, and terminal audiograms.
2081
2082
2083
2084

                                                  6-8
                                          MHS Coding Guidance
                                              March 2008
                                         SPECIALTY CODING
                                            6.2 Audiology


2085                  DoD Rule
2086
2087                  Hearing Conservation Program services are coded in a Special Program
2088                  service in an F MEPRS clinic (FBN*).

2089
2090   Hearing tests performed in other than an audiology clinic or for HCP, are reported in the
2091   clinic where the test or procedure is performed. These examination encounters are coded
2092   according to the table below. The table includes only codes for HCP encounters leading
2093   to referral to an audiology clinic.
2094

2095                  DoD Rule
2096
2097                  Official ICD-9-CM coding guidelines state that both V70 and V72 codes are
2098                  only listed first. Code V72 excludes V70.5. However, for the DoD to identify
2099                  the specific type of HCP exam, particularly those with an identified
2100                  significant threshold shift (STS), or permanent threshold shift (PTS), both
2101                  codes are reported in the order shown for HCP exams.

2102
2103                HEARING CONSERVATION PROGRAM (HCP) TABLE
                                                    ICD-9-CM          E&M         CPT
        Encounter Type                              Diagnosis         Codes       Procedure
                                                    Codes                         Codes
        Accession exam in basic training with       V70.5_8 and          N/A      92552 (Individual),
        no abnormalities                            V72.1*                        92559**(Group)

        Accession exam in basic training with       V70.5_8 and          N/A      92552 (Individual),
        abnormalities                               V72.1*, plus                  92559**(Group)
                                                    794.15***
        Exam at start of routine employment         V70.5_3 and          N/A      92552 (Individual),
        involving hazardous noise with no           V72.1*                        92559**(Group)
        abnormalities
        Exam at start of routine employment         V70.5_3 and          N/A      92552 (Individual),
        involving hazardous noise with              V72.1*, plus                  92559**(Group)
        abnormalities                               794.15***
        Annual exam with no identified STS          V70.5_3 and          N/A      92552 (Individual),
                                                    V72.1*                        92559**(Group)

2104




                                                      6-9
                                                MHS Coding Guidance
                                                    March 2008
                                              SPECIALTY CODING
                                                 6.2 Audiology

        Annual exam with an initial STS                 V70.5_3 and                N/A         92552 (Individual),
        identification                                  V72.1* plus                            92559**(Group)
                                                        794.15***
        Annual exam with a previously                   V70.5_3 and                N/A         92552 (Individual),
        confirmed PTS                                   388.1X* or                             92559**(Group)
                                                        389.XX*

        Follow-up 1 or 2 for STS identified             794.15***                  N/A         92552 (Individual),
        during current annual or follow-up 1                                                   92559**(Group)
        exam
        Termination exam at end of                      V70.5_9 and                N/A         92552 (Individual),
        employment or separation from active            V72.1*                                 92559**(Group)
        duty
2105
2106   * Indicates there are various 4th and 5th digits or extender codes that may be assigned to indicate a specific
2107   condition or encounter
2108   ** For patients tested using Defense Occupational and Environmental Health Readiness System-Hearing
2109   Conservation (DOEHRS-HC).
2110   *** Code to be used by non-professionals (e.g., technicians, nurses, volunteers). Only physicians or
2111   audiologists may diagnose noise-induced hearing loss.
2112
2113   NOTE: 99078 may be used as an additional code if physician education services are
2114   provided in a group setting.
2115
2116   6.2.2.3. Hearing Loss Caused by Injury
2117   Initial encounters for hearing loss acquired from performance of duties, but not
2118   associated with physical trauma to the head will be identified with the appropriate E code
2119   as a secondary diagnosis. E codes are only used for the first encounter for the condition
2120   that was caused by the situation described by the E code. There is an injury or accident
2121   field in the ADM that should be answered yes each time the patient is seen for a condition
2122   caused by an accident or injury.
2123
2124            E923.8            Other Explosive Material—explosions not a result of war
2125                              operations
2126            E928.1            Exposure to Noise
2127            E993              Injury Caused by War Operations by Other Explosion—
2128                              including accidental explosion of own weapon
2129            E995              Injury Caused by War Operations by Other and Unspecified
2130                              Forms of Conventional Warfare—for hearing losses caused
2131                              by exposure to other noises during war operations
2132
2133   6.2.2.4. Early Hearing Detection and Intervention (EHDI)
2134   EHDI will not be coded on the SIDR. EHDI screening exams and interventions are coded
2135   according to the table below. The table includes only codes for EHDI encounters.
2136
2137
2138
                                                           6-10
                                                   MHS Coding Guidance
                                                       March 2008
                                         SPECIALTY CODING
                                            6.2 Audiology

2139          NEWBORN EARLY HEARING DETECTION AND INTERVENTION
2140
                     Encounter Type                    ICD-9-CM              CPT               CPT
                                                        Diagnosis            E&M            Procedure
                                                         Codes               Codes            Codes
       Newborn hearing screening with no            V72.1**                If            92586 or
       abnormalities performed in audiology                                applicable,   92587
       clinic***                                                           99xxx
       Newborn hearing screening with               V72.1** and               N/A        92586 or 92587
       abnormalities performed in audiology         794.15* or
       clinic***                                    389.XX**
       Follow-up with no abnormalities              794.15                    N/A        92585 and 92588
       Follow-up with abnormalities                 389.XX*                   N/A        92585 and 92588
       Intervention 1                               389.XX*                   N/A        92590, 92591, or
                                                                                         92700
       Intervention 2                               389.XX*                   N/A        92590, 92591, or
                                                                                         99002
       1st follow-up to intervention                389.XX*                   N/A        92590, 92591,
                                                                                         92594 or 92595
2141   * Code to be used by non-professionals (e.g., technicians, nurses, volunteers).
2142   ** Indicates there are various 4th and 5th digits that may be assigned to indicate a specific
2143   condition or encounter
2144   *** Initial screening exam for patients not tested in the hospital prior to discharge from birth
2145   episode.
2146
2147   6.2.3. Procedural Coding Rules
2148
2149   6.2.3.1. CPT procedure Codes for Audiology
2150   These services are in the Special Otorhinolaryngologic Services subsection of the
2151   Medicine section (92502–92700). Codes in the 92500 series do not require the
2152   supervision of a physician. Tests in this series can be performed by a qualified
2153   audiologist, but diagnostic procedures must be ordered by a physician.
2154
2155   6.2.3.2. Cerumen Removal
2156   Removal of cerumen is considered integral to audiology services. Instillation of drops,
2157   minor scraping, or simple irrigation is bundled into the evaluation portion of audiology
2158   service. If a physician removes impacted cerumen before audiology testing, the
2159   physician should use code G0268. In all other circumstances, use 69210 for removal of
2160   impacted cerumen. Removal of cerumen to see the tympanic membrane is included in
2161   the E&M component. The physician or audiologist may report separate E&M service
2162   with modifier -25.
2163
2164   6.2.3.3. Tinnitus
2165   Audiologists are qualified to evaluate, diagnose, develop management strategies, and
2166   provide treatment and rehabilitation for tinnitus patients. Diagnostic audiologic testing
2167   for tinnitus is reported with CPT code 92625.

                                                    6-11
                                              MHS Coding Guidance
                                                  March 2008
                                      SPECIALTY CODING
                                         6.2 Audiology

2168   6.2.3.4. Hearing Equipment Services
2169   Services related to fitting, providing or repairing hearing supplies and equipment,
2170   excluding implantable bone conduction devices, are reported with HCPCS Level II codes
2171   V5008–V5299.
2172
2173   6.2.4. Other Audiology Guidance
2174
2175   6.2.4.1. Documentation of Hearing Conservation
2176   The results of administering all aspects of monitoring audiometry with the DOEHRS HC
2177   equipment is documented by completion of the following:
2178
2179          DD Form 2215          Reference Audiogram
2180          DD Form 2216          Hearing Conservation Data
2181
2182   6.2.4.2. Dispositions or Referrals
2183   DOEHRS HC software will automatically determine if an Occupational Safety and
2184   Health Administration (OSHA)-reportable hearing loss (RHL) is present and will provide
2185   disposition instructions.
2186
2187   6.2.5. Modifiers
2188           TC    Technical Component is used by technicians who perform tests in a
2189                 different clinic than the one used by the audiologist who interprets
2190                 the test and renders a report.
2191           26    Professional Component is used by the audiologist who only
2192                 interprets tests performed elsewhere and provides a report.
2193           52    Reduced Service is used when audiologic function tests (except
2194                 92559) are performed on one ear only.




                                                6-12
                                          MHS Coding Guidance
                                              March 2008
                                          SPECIALTY CODING
                                         6.3 Chiropractic Services

2195   6.3. Chiropractic Services
2196
2197   6.3.1. E&M Rules
2198
2199   6.3.1.2. Initial Encounter for a Problem
2200   If chiropractic manipulative treatment (CMT) was furnished during the initial encounter,
2201   indicating the chiropractor accepted the patient for treatment of the problem, and a
2202   separately identifiable chiropractic evaluation was conducted, use an E&M code, usually
2203   in the new or established office visit codes (9920x/9921x) with a modifier -25, along with
2204   the CMT procedure code (98940–98943).
2205
2206   6.3.1.3. Referrals
2207   If there is a request for the chiropractor to evaluate and treat the patient, this is a referral.
2208   CMT covers pre- and post services, including an assessment specific to CMT. The
2209   documentation must reflect a history, exam or decision of something not related to the
2210   CMT to use a separate E&M code.
2211
2212   6.3.1.4. Consult When CMT Not Appropriate
2213   If there is a request for evaluation and advice, and the chiropractor determines that CMT
2214   is not appropriate for the patient, and sends advice back to the provider who requested the
2215   consult, and all other requirements for a consult are met, the consult codes (9924x)
2216   should be used.
2217
2218   6.3.1.5. Consult When CMT Is Appropriate
2219   When there is a request for evaluation and advice; the chiropractor determines that CMT
2220   would be appropriate but has not yet begun it; the chiropractor sends advice back to the
2221   consulting provider and meets all other requirements for a consult, the consult codes
2222   (9924x) should be used.
2223
2224   6.3.1.6. CMT
2225   When an encounter is for CMT and the evaluation is limited to reviewing data to ensure
2226   CMT is still appropriate, there is no separately identifiable E&M and only the CMT code
2227   should be used.
2228
2229
2230   6.3.1.7. Reevaluation
2231   When there are separately identifiable E&M services beyond those needed for CMT,
2232   such as when the chiropractor re-exams the patient to obtain objective measures of
2233   progress, and the treatment plan is modified as necessary, a separate E&M coded (usually
2234   from the established office visit range, 9921x) should be coded.
2235




                                                     6-13
                                             MHS Coding Guidance
                                                 March 2008
                                         SPECIALTY CODING
                                        6.3 Chiropractic Services

2236   6.3.1.8. The AT Modifier
2237   Use the AT modifier when the treatment is for active or corrective treatment, when the
2238   documentation shows that treatment is medically reasonable or necessary under Medicare
2239   rules. The AT modifier is not used for maintenance therapy, such as services that seek to
2240   prevent disease, promote health, maintain or prevent deterioration of a chronic condition,
2241   or enhance the quality of life.
2242
2243   6.3.2. Procedural Coding Rules
2244

2245                 DoD Rule
2246
2247                 The CMT procedure codes are 98940–98943. Use only one code per session
2248                 unless both spinal and extra spinal are performed.

2249
2250   6.3.2.1. Manual Therapy Techniques
2251   Manual therapy techniques are coded 97140. The provider uses his/her hands to perform
2252   soft tissue massage and joint mobilization, manipulation, manual traction, or manual
2253   lymphatic drainage to one or more areas. The code requires direct one-on-one contact
2254   with the patient.
2255
2256   See also HCPCS code S8990, physical manipulative therapy performed for maintenance
2257   rather than restoration.
2258
2259   6.3.3. Modifiers
2260                      25   Separate or distinct E&M services
2261                      51   Multiple procedures (when unrelated procedures are done at the
2262                           same encounter)
2263                      59   Distinct procedural service (when one code is usually included in
2264                           another but for an unusual reason both were done separately)




                                                   6-14
                                            MHS Coding Guidance
                                                March 2008
                                        SPECIALTY CODING
                                            6.4 Dialysis

2265   6.4. Dialysis
2266
2267   6.4.1. E&M Rules
2268   E&M services associated with or related to the performance of dialysis, performed on the
2269   same day as the dialysis, are included in the dialysis procedure; therefore, no separate
2270   E&M code is reported. If there is a separately identifiable E&M, unrelated to the dialysis,
2271   that E&M shall be coded based on documentation and appended with modifier 25.
2272
2273   6.4.2. Procedural Coding Rules. See 6.5.5 for a sample list of dialysis procedures.
2274

2275                   DoD Rule
2276
2277                   Dialysis, hemodialysis, and peritoneal dialysis are ancillary services. They
2278                   should be given the appropriate procedure code 90918–90999 and should be
2279                   coded in the D MEPRS.

2280
2281   6.4.2.1. Individual Dialysis Therapy Encounters
2282   In the MHS, each encounter is coded. Therefore, except for the first encounter of the
2283   month, each encounter is coded using an unlisted code of 90999 in the CPT/Procedure
2284   field
2285
2286   6.4.2.2. Monthly Dialysis Codes
2287   The monthly dialysis codes will always be used for the first dialysis of the new month to
2288   reflect the previous month’s treatment. For instance, it will reflect 31 days for January
2289   and 30 days for April.
2290

2291                   DoD Rule
2292
2293                   When a dialysis service is performed, no procedure codes will be reported,
2294                   except for the first encounter of the month to reflect the previous month’s
2295                   services.
2296
2297                   Hint: To determine the number of dialysis encounters during the month, use
2298                   the patient appointment history in AHLTA/CHCS.

2299
2300   6.4.2.3. Dialysis for Less than an Entire Month
2301   Dialysis does not always begin the first day of the month. On the first dialysis of the
2302   month following initial treatment, instead of the monthly code, use the per day codes to
2303   reflect services from the start of care through the end of the prior month. Code 90925
2304   should be reported for each day outside of inpatient hospitalization.
2305
2306          Example: A patient is admitted to the hospital on the 11th of the month and
2307          discharged on the 27th. On the first dialysis visit in the next month, code 90925
                                                  6-15
                                            MHS Coding Guidance
                                                March 2008
                                        SPECIALTY CODING
                                            6.4 Dialysis

2308          with a quantity of 13 for the days the patient was not an inpatient the prior month.
2309          (30 days in the month minus 17 days of hospitalization = 13 days). Report
2310          inpatient E&M services as appropriate. Dialysis procedures rendered during
2311          hospitalization are coded as part of the hospitalization.
2312
2313   6.4.2.4. Dialysis for Entire Month
2314   To code dialysis, the first visit of the month will be used to record the appropriate
2315   monthly or per day code for services the previous month. All other visits will use the
2316   unlisted dialysis code of 90999 for the procedure. If any of the encounters of the prior
2317   month were conducted by a non-privileged provider, the first encounter of the new month
2318   must be collected in the DGB or DGD MEPRS, with the individual performing the
2319   service that day listed as the provider.
2320
2321   6.4.2.5. Privileged Provider
2322   If a privileged provider performs the dialysis, the provider’s name should be listed as the
2323   primary provider. If a separately identifiable E&M service is performed, use the
2324   appropriate E&M code with modifier -25. When a privileged provider furnishes a
2325   dialysis service, the encounter will usually be collected in the BAJ MEPRS as a count
2326   encounter.
2327
2328   6.4.2.6. Non-Privileged Provider
2329   Dialysis procedures should only be conducted by a non-privileged provider following a
2330   written treatment plan of a privileged provider. When a non-privileged provider
2331   performs the dialysis, the non-privileged provider should be listed as the primary
2332   provider.
2333
2334   6.4.2.6.1. Dialysis treatment is usually done by non-privileged providers whose time is
2335   collected in the DGB or DGD MEPRS. Therefore, a ―clinic‖ must be created in the DGB
2336   or DGD MEPRS where appointments will be created and marked as kept and ADM
2337   reports will be collected. When a non-privileged provider performs the service, the
2338   encounter must be entered as a non-count encounter.
2339
2340   6.4.3. Diagnosis Coding
2341   The first listed diagnosis, when the patient is only being seen for ongoing dialysis
2342   treatment, is in the V56 category. A secondary diagnosis will be used to explain why the
2343   dialysis is necessary, such as chronic kidney disease.




                                                  6-16
                                            MHS Coding Guidance
                                                March 2008
                                      SPECIALTY CODING
                                    6.5 End Stage Renal Disease

2344   6.5. End Stage Renal Disease Services (ESRD) (90918–90925, G0308, G0327)
2345
2346   6.5.1. Included Services
2347   ESRD-related physician services include establishment of a dialyzing cycle, outpatient
2348   evaluation and management of the dialysis visits, telephone calls and patient management
2349   during the dialysis, provided during a full month. These codes are not used if a
2350   hospitalization occurred during the month.
2351
2352   6.5.2. E&M Rules
2353   The E&M services associated with or related to performance of dialysis for ESRD
2354   services, when performed on the same day as the dialysis, are included in the ESRD
2355   procedure. Therefore no separate E&M code is reported. If there is a separately
2356   identifiable E&M, unrelated to the dialysis procedure, that E&M shall be coded based on
2357   documentation and appended with modifier -25.
2358
2359   6.5.3. Procedural Coding Rules
2360   In general, using ESRD codes is similar to using the dialysis codes in section 6.4.
2361   Because ESRD is a Medicare-covered benefit there are specific HCPCS codes. These
2362   codes (G0308–G0327) are more detailed and are used when the code requirements are
2363   met. The HCPCS Level II codes are used in the same manner as the dialysis CPT
2364   (HCPCS Level I) codes. ESRD services are usually captured in the BAJ* MEPRS
2365   (Nephrology).
2366

2367                 DoD Rule
2368
2369                 When ESRD service is performed, no procedure codes will be reported,
2370                 except for the first encounter of the month, to reflect the previous month’s
2371                 services.
2372
2373                 Hint: To determine the number of ESRD encounters during the month, use
2374                 the patient appointment history in AHLTA/CHCS.

2375
2376   6.5.4. ESRD Diagnosis Coding
2377   Use ESRD 585.6. Use V42.0 as an additional code to identify kidney transplant status if
2378   applicable.
2379
2380   6.5.5. Dialysis and ESRD Procedure Code List.
2381   End Stage Renal Disease Services (90918–90925) (G0308–G0327)
2382
2383   90918 ESRD-related services per full month; for patients less than 2 years of age,
2384   including monitoring for adequacy of nutrition, assessment of growth and development
2385   and counseling of parents.
2386

                                                  6-17
                                           MHS Coding Guidance
                                               March 2008
                                      SPECIALTY CODING
                                    6.5 End Stage Renal Disease

2387   90919 ESRD-related services per full month; for patients from 2 to 11 years of age,
2388   including monitoring for adequacy of nutrition, assessment of growth and development
2389   and counseling of parents.
2390
2391   90920 ESRD-related services per full month; for patients from 12 to 19 years of age
2392   including monitoring for adequacy of nutrition, assessment of growth and development
2393   and counseling of parents.
2394
2395   90921 ESRD-related services per full month; for patients 20 years of age and older.
2396
2397   90922 ESRD-related services (less than full month), per day; for patients under 2 years
2398   of age.
2399
2400   90923 ESRD-related services (less than full month), per day; for patients from 2 to 11
2401   years of age.
2402
2403   90924 ESRD-related services (less than full month), per day; for patients from 12 to 19
2404   years of age.
2405
2406   90925 ESRD-related services (less than full month), per day; for patients 20 years of age
2407   and older.
2408
2409   G0308 ESRD-related services during the course of treatment, for patients under 2 years
2410   of age, including monitoring for adequacy of nutrition, assessment of growth and
2411   development and counseling of parents; with four or more face-to-face physician visits
2412   per month.
2413
2414   G0309 ESRD-related services during the course of treatment for patients under 2 years
2415   of age, including monitoring for adequacy of nutrition, assessment of growth and
2416   development and counseling of parents; with two or three face-to-face physician visits
2417   per month.
2418
2419   G0310 ESRD-related services during the course of treatment, for patients under 2 years
2420   of age including monitoring for adequacy of nutrition, assessment of growth and
2421   development, and counseling of parents; with one face-to-face physician visit per month.
2422
2423   G0311 ESRD-related services during the course of treatment, for patients between 2 and
2424   11 years of age, including monitoring for adequacy of nutrition, assessment of growth
2425   and development and counseling of parents; with four or more face-to-face physician
2426   visits per month.
2427
2428   G0312 ESRD-related services during the course of treatment for patients 2 to 11 years of
2429   age, including monitoring for adequacy of nutrition, assessment of growth and
2430   development and counseling of parents; with two or three face-to-face physician visits
2431   per month.
                                                 6-18
                                          MHS Coding Guidance
                                              March 2008
                                      SPECIALTY CODING
                                    6.5 End Stage Renal Disease

2432   G0313 ESRD-related services during the course of treatment, for patients 2 to 11 years
2433   of age, including monitoring for the adequacy of nutrition, assessment of growth and
2434   development, and counseling of parents; with one face-to-face physician visit per month
2435
2436   G0314 ESRD-related services, during the course of treatment, for patients between 12
2437   and 19 years of age, including monitoring for the adequacy of nutrition, assessment of
2438   growth and development, and counseling of parents; with four or more face-to-face
2439   physician visits per month.
2440
2441   G0315 ESRD-related services during the course of treatment, for patients between 12
2442   and 19 years of age to include monitoring for the adequacy of nutrition, assessment of
2443   growth and development, and counseling of parents; with two or three face-to-face
2444   physician visits per month.
2445
2446   G0316 ESRD-related services during the course of treatment, for patients between 12
2447   and 19 years of age, including monitoring for the adequacy of nutrition, assessment of
2448   growth and development, and counseling of parents; with one face-to-face physician visit
2449   per month
2450
2451   G0317 ESRD-related services during the course of treatment, for patients 20 years of
2452   age and older; with 4 or more face-to-face physician visits per month.
2453
2454   G0318 ESRD-related services during the course of treatment, for patients 20 years of
2455   age and over; with two or three face-to-face physician visits per month.
2456
2457   G0319 ESRD-related services during the course of treatment, for patients 20 years of
2458   age and over; with one face-to-face physician visit per month.
2459
2460   G0320 ESRD-related services for home dialysis patients per full month; for patients less
2461   than two years of age including monitoring for adequacy of nutrition, assessment of
2462   growth and development and counseling of parents.
2463
2464   G0321 ESRD-related services for home dialysis patients per full month; for patients two
2465   to eleven years of age including monitoring for adequacy of nutrition, assessment of
2466   growth and development and counseling of parents.
2467   G0322 ESRD-related services for home dialysis patients per full month; for patients 12
2468   to 19 years of age, including monitoring for adequacy of nutrition, assessment of growth
2469   and development and counseling of parents
2470
2471   G0323 ESRD-related services for home dialysis patients per full month; for patients 20
2472   years of age and older
2473
2474   G0324 ESRD-related services less than full month, per day; for patients under 2 years of
2475   age.
2476
                                                 6-19
                                          MHS Coding Guidance
                                              March 2008
                                      SPECIALTY CODING
                                    6.5 End Stage Renal Disease

2477   G0325 ESRD-related services less than full month, per day; for patients 2 to 11 years of
2478   age.
2479
2480   G0326 ESRD-related services less than full month, per day; for patients 12 to 19 years
2481   of age.
2482
2483   G0327 ESRD-related services less than full month, per day; for patients 20 years of age
2484   and older.




                                                 6-20
                                          MHS Coding Guidance
                                              March 2008
                                       SPECIALTY CODING
                                     6.6 Flight Medicine Services

2485   6.6. Flight Medicine Services
2486   NOTE: Referral to flying status includes air traffic control duty. Reference to air
2487   crew member includes air traffic controller.
2488
2489   6.6.1. E&M Rules
2490

2491                  DoD Rule
2492
2493                  Annual/periodic flight exams are reported as comprehensive preventive
2494                  medicine encounters (99384–99397). Treatment of conditions identified,
2495                  regardless of whether they are pre-existing or identified in the course of the
2496                  preventive medicine encounter, are coded separately per the instructions in
2497                  the Preventive Medicine Services subsection of the CPT manual. To use the
2498                  code range 99384–99397, an examination must be performed.

2499
2500   6.6.1.1. Encounters for Approval for Flying Status
2501   Encounters that do not meet the requirements of a comprehensive preventive medicine
2502   service are reported as either individual counseling preventive medicine services (no
2503   medical problems and meets the requirements of preventive medicine counseling, use
2504   codes 99401–99404) or as office visit or other outpatient services (for a medical issue,
2505   use codes 99201–99215). When documentation supports only the use of a 99211, it is
2506   appropriate for providers to use the 99211 code.
2507
2508   6.6.2. Diagnosis Coding Rules
2509

2510                  DoD Rule
2511
2512                  Annual flight exams are reported with V70.5_1 as the first listed diagnosis.
2513                  Any pre-existing or newly diagnosed conditions are listed as additional
2514                  diagnoses.
2515
2516                  Encounters for post-deployment conditions (confirmed or suspected) will
2517                  have the reason for the encounter listed in the primary diagnosis field with
2518                  V70.5_6 listed as a secondary code. This rule takes precedence over any
2519                  other diagnosis coding rule.
2520

2521
2522   6.6.2.1. The following information provides guidance on coding flight physicals:
2523
2524      1. Initial flight exam, no symptoms
2525             a. Diagnosis code:        V70.5 1           Aviation exam
2526             b. E&M:                   993xx             Age-appropriate prevention exam
2527             c. CPT procedures *:      92552/3           Pure tone audiometry tests, air
                                               6-21
                                            MHS Coding Guidance
                                                March 2008
                                      SPECIALTY CODING
                                    6.6 Flight Medicine Services

2528                                          93000**      EKG, interpretation & report
2529                                          93005        EKG, tracing only
2530                                          93010        EKG, interpretation & report only
2531              d. Visual Screening         99173        Visual Acuity Screen
2532                  *      Procedures are coded if performed and properly documented in
2533          flight medicine clinic note(s).
2534          **      Choose appropriate EKG test performed in flight medicine clinic
2535
2536       2. Annual flight exam, normal, no symptoms (return to flight status)
2537             a. Diagnosis code:        V70.5 1         Aviation exam
2538             b. E&M:                   993xx           Age-appropriate prevention exam
2539             c. CPT procedures *:      92552/3         Pure tone audiometry tests, air
2540                                       93000**         EKG, interpretation & report
2541                                       93005           EKG, tracing only
2542                                       93010           EKG, interpretation & report only
2543             d. Visual screening       99173           Visual acuity screen
2544                 *       Procedures are coded if performed and properly documented in
2545   Flight Medicine Clinic note(s).
2546                 **      Choose appropriate EKG test performed in Flight Medicine Clinic
2547
2548      3. Annual flight exam with symptoms, disease found, or acute exacerbation of
2549         chronic condition
2550            a. Diagnosis codes:      V70.5 1        Aviation exam
2551                                     xxxxx          Code the symptom/disease found on
2552                                                    examination
2553            b. E&M:                  993xx          Age-appropriate prevention exam.
2554                                     992xx          Appropriate office encounter. Add
2555                                                    modifier -25 to show a separate
2556                                                    E&M service was provided.
2557            c. CPT Procedure:       xxxxx           List any procedures performed for
2558                                                     the flight exam as outlined in Item
2559                                                    1. List any additional procedures
2560                                                     performed that relate to the s
2561                                                    symptom or disease found on
2562                                                    examination.
2563
2564      4. Flight exam, chronic condition (not active or influencing flight status)
2565             a. Diagnosis code:       V70.5 1         Aviation exam
2566                                      xxx.xx          Code chronic condition (e.g.,
2567                                                      hypertension)
2568             b. E&M:                  993xx           Age-appropriate prevention exam
2569             c. CPT Procedures:       xxxxx           List any procedures performed for
2570                                                      the flight exam as outlined in Item 1.
2571
2572      5. Flight exam, active condition or disease influencing flight status
                                                 6-22
                                          MHS Coding Guidance
                                              March 2008
                                   SPECIALTY CODING
                                 6.6 Flight Medicine Services

2573          a. Diagnosis code:        xxx.xx          Code active condition of
2574                                                    symptom/disease that removed
2575                                                    individual from flight status
2576          b. E&M:                    992xx          Appropriate office encounter
2577          c. CPT procedures:         xxxxx          List any procedures performed
2578                                                    during office visit
2579
2580   6. Return-to-flight status, (after illness/injury) currently no symptoms
2581         a. Diagnosis code:            V68.09          Medical certificate
2582         b. E&M:                       9921x           Appropriate E&M office visit
2583
2584   7. Flight Exam, waiver renewal (face-to-face)
2585          a. Diagnosis code:      V68.09            Medical certificate (waiver)
2586          b. E&M:                 992xx             Appropriate office visit code
2587                                  99358/9*          Prolonged services, non face-to-face
2588          c. CPT procedure:       99080             Special reports (service specific
2589                                                    waiver report)
2590
2591   Prolonged services code would be assigned when the provider reviews records, tests
2592   and communications with professionals and family. This would be in addition to
2593   time spent with the patient—99358-first hour of review of tests and communication
2594   with other professionals and family. Code 99359 identifies any additional 30
2595   minutes.
2596
2597   8. Ground testing, no adverse effects of drugs
2598         a. Diagnosis code:         V70.5 1       Aviation exam
2599         b. E&M code:               992xx         Appropriate office visit
2600                                                  (new/established)
2601         c. CPT procedure:                        None
2602
2603   9. Ground testing, with adverse effects of drugs
2604         a. Diagnosis code:        995.2            Adverse effect of correct drug
2605                                                    properly administered
2606                                   780-789.xx Symptom code or appropriate ICD
2607                                                    code to describe the drug interaction
2608                                   E930-E949.x Cause of injury code to identify the
2609                                                    drug reaction
2610         b. E&M code:              9921x            Appropriate Office Visit
2611         c. CPT procedure:                          List any procedures/counseling
2612                                                    performed
2613
2614   10. Incentive Flight/Chamber/Survival Training clearance encounters
2615          a. Diagnosis code:      V70.5_1        Aviation exam
2616                                  V65.43         Counseling on injury prevention
2617                                                  (survival training)
                                              6-23
                                       MHS Coding Guidance
                                           March 2008
                        SPECIALTY CODING
                      6.6 Flight Medicine Services

2618   b. E&M code:          99384/86      New patient preventive exam,
2619                                               OR
2620                         99394/96      Established patient prevention exam




                                 6-24
                           MHS Coding Guidance
                               March 2008
                                        SPECIALTY CODING
                                           6.7 Gynecology

2621   6.7. Gynecology
2622
2623   6.7.1. E&M Rules
2624
2625   6.7.1.1. Office Visit
2626   The most common type of E&M is the office visit for a symptom, condition, or disease.
2627   Office visits are coded 99201–99215.
2628
2629   6.7.1.2. Well Woman Exam
2630   If a complete general physical exam is performed, use preventive medicine E&M codes
2631   99384–99387 for new patients and 99394–99397 for established patients. When a patient
2632   is seen for a physical and has a separately identifiable symptom, condition, or disease that
2633   requires significant time or resources, it should be documented and coded separately.
2634   Append the modifier -25 to the appropriate office E&M. When a patient is seen for a
2635   physical and a screening Pap smear is collected at the time, code the E&M and collect
2636   Q0091 in the CPT/HCPCS field.
2637
2638   6.7.1.3. Counseling
2639   Visits specifically for initial contraceptive management are coded to preventive
2640   medicine. Should the encounter not include an exam, counseling is reported as 99401–
2641   99404. Subsequent visits for contraceptive management are reported as established
2642   patient office visits.
2643
2644   6.7.2. Diagnosis Coding Rules
2645

2646                  DoD Rule
2647
2648                  Well-Woman Exams
2649                  V72.31         Is reported for a complete physical exam with a gynecology
2650                                 component.
2651                  Use these codes in addition to V72.31 when appropriate:
2652                  V76.47         For post-hysterectomy patients
2653                  V45.77         Acquired absence of the uterus
2654                  Report the code(s) for any problem (s) also addressed during the encounter.

2655
2656   6.7.2.1. Screening Pap
2657   When a screening Pap smear is done, one of the following diagnosis codes is reported
2658   and linked to the HCPCS codes for the exam.
2659
2660      V67.01      Vaginal Pap Smear s/p hysterectomy for malignant condition
2661                  (use additional codes for acquired absence of genital organs V45.77_x)
2662      V76.2       Cervical Pap Smear (Routine)
2663      V76.47      Vaginal Pap Smear s/p hysterectomy for non-malignant condition

                                                  6-25
                                           MHS Coding Guidance
                                               March 2008
                                       SPECIALTY CODING
                                          6.7 Gynecology

2664                 (use additional codes for acquired absence of genital organs V45.77_x)
2665      V76.49     Special screening for malignant neoplasm, other sites.
2666      V15.89     Other specified personal history presenting hazards to health.
2667                 (Used for women considered to be at high-risk for cervical cancer.
2668                 Examples would be screenings for patients with early onset of sexual
2669                 activity, patients exposed to DES in the womb, patients with more than
2670                 five sexual partners in a lifetime, and patients who have had a sexually
2671                 transmitted disease.)
2672
2673   NOTE: If the original pap smear did not contain an adequate sample, and the patient
2674   returns to obtain a new smear, code 795.08 nonspecific abnormal Pap smear of cervix,
2675   unsatisfactory smear.
2676
2677   An additional diagnosis code may be used to identify the high-risk factor, such as V69.2
2678   ―High-Risk Sexual Behavior.‖
2679

2680                 DoD Rule
2681
2682                 Use Q0091 to code the collection of screening Pap smear. In the MHS, it is
2683                 appropriate to code the V76 screening code when using the Q0091, including
2684                 when this occurs during a well-woman visit, coded V72.31.
2685
2686                 The collection of a diagnostic Pap is part of the exam component of an office
2687                 visit and is not coded separately.
2688
2689                 When a patient receives a breast and pelvic exam only and not enough of the
2690                 health/preventive requirements to satisfy a physical, the G0101 continues to
2691                 be the most appropriate code.

2692
2693   6.7.2.2. Diagnostic Pap
2694   Pap smears completed on women who have had previous cancer of the female genital
2695   tract are diagnostic, not screening, Pap smears. They are for a medically necessary
2696   reason, regardless of the presence or absence of symptoms. The appropriate personal
2697   history diagnosis code is reported.
2698
2699      Example: V67.01 would be used for diagnostic vaginal pap smear s/p hysterectomy
2700      for malignant condition (use additional codes for acquired absence of genital organs
2701      V45.77_x)
2702
2703   6.7.2.3. Abnormal Followed by Normal Pap
2704   If a woman has an abnormal Pap smear and then a follow-up Pap smear is normal, two
2705   more Pap smears are usually done to confirm the normal result. These encounters will be
2706   coded V72.32.
2707
                                                 6-26
                                          MHS Coding Guidance
                                              March 2008
                                        SPECIALTY CODING
                                           6.7 Gynecology

2708   6.7.2.4. Contraceptive Management
2709   A code from V25 is used when a contraceptive management procedure or counseling is
2710   done during an encounter.
2711
2712   6.7.2.5. Pregnancy Testing
2713   Encounters for the purpose of pregnancy testing are to be coded as follows, based on the
2714   results of the test or exam known at the time of the encounter.
2715
                      Results of Test and/or Exam                             Code(s)
       Positive                                                    V72.42
       Negative without any related symptoms or diagnoses          V72.41
       Negative with any related symptoms or diagnoses             Codes for symptoms or
                                                                   conditions and V72.41
       Unconfirmed exam or test                                    V72.40
2716
2717   6.7.3. Procedural Coding Rules
2718
2719   6.7.3.1. No Coding for Contraceptives
2720   Contraceptive supplies or medications dispensed through the pharmacy are not coded.
2721
2722   6.7.3.2. Procedures for Implantable Contraceptive Capsules
2723   These are coded in the Integumentary subsection (e.g., 11975, 11976, and 11977) of the
2724   CPT manual. Non-implantable devices are in the Female Genital System subsection (e.g.,
2725   58300).
2726
2727   6.7.3.3. Pelvic Exam under Anesthesia
2728   This (57410) is commonly miscoded in the clinic setting. A pelvic is part of the exam
2729   component of an office visit and the preventive medicine service (e.g., physical). There
2730   is no separate code for a pelvic exam.
2731
2732   6.7.4. Modifiers
2733   A -25 modifier is appended to the E&M code when a procedure is preformed as well as a
2734   separately identifiable E&M. Do not use the -25 modifier with E&Ms done at the same
2735   time as laboratory tests (e.g., KOH, wet prep).




                                                  6-27
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                         6.8 Mental Health

2736   6.8. Mental Health
2737
2738   6.8.1. Evaluation & Management (E&M) Rule

2739                  DoD Rule
2740
2741                  Air Force will follow guidance in the Behavioral Health Coding Handbook.

2742
2743   6.8.1.1. Mental Health Consults
2744   Infrequently, mental health consults with only a history, exam, or decision (e.g., would
2745   you recommend mental health therapy for this patient at this time for this condition?)
2746   occur. If the encounter meets the requirements of a consult, use a consult code. See
2747   Chapter 4 for information on consults. There may also be infrequent instances of a
2748   ―mini-mental status exam,‖ when an entire initial diagnostic interview cannot be
2749   completed. These may be coded using an E&M.
2750
2751   6.8.1.2. Inpatient Treatment without Therapy
2752   When treating inpatients and not providing therapy at the same time, inpatient E&M
2753   codes are appropriate. See section 9 for other coding guidance on inpatient services.
2754
2755   6.8.2. Diagnosis Coding Rules
2756
2757   6.8.2.1. Diagnostic and Statistical Manual (DSM)
2758   Mental health diagnoses are based on terminology and codes in the Diagnostic and
2759   Statistical Manual of Mental Disorders (DSM IV). Although the terminology in ICD-9-
2760   CM or CHCS does not always match the terminology in DSM IV, most of the codes are
2761   the same. Most mental health codes are in the 290–320 range in ICD-9-CM.
2762
2763   6.8.2.2. Patients without Mental Disorder Diagnosis
2764   Some encounters are with patients or clients who do not have a mental disorder
2765   diagnosis. There are V codes that describe these encounters, such as:
2766        V40 Mental and behavioral problems
2767        V60.2 Financial problems
2768        V61 Other family circumstances, including
2769              o V61.10 Counseling for marital and partner problems
2770              o V61.49 Presence of sick or handicapped person in family or household
2771              o V62.82 Bereavement
2772        V71.09 Observation for other suspected mental condition
2773
2774
2775
2776


                                                  6-28
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                          6.8 Mental Health


2777                  DoD Mental Health Extender Codes
2778
2779                  Mental health diagnosis extender codes are a group of ICD-9 codes that have
2780                  been modified to meet the needs of the Services. The extender is paired with
2781                  an ICD code to acquire a unique meaning. Use the appropriate extender for
2782                  the type of service provided. DOD mental health diagnoses extender codes
2783                  can be used in any clinical setting.

2784
2785   6.8.2.3. DOD Mental Health Diagnoses with Extender Codes
2786
2787          V65.42_0        Alcohol education
2788          V65.42_1        Substance abuse counseling
2789          V65.49_1        Medication education
2790          V65.49_7        Occupational stress education
2791          V65.49_8        Mental health education
2792          V65.49_9        Other specified counseling
2793          V65.49_A        Stress education
2794          V65.49_B        Suicide education
2795
2796   6.8.3. Procedural Coding Rules
2797
2798   6.8.3.1. Four Code Groups for Mental Health
2799   There are four major groups of procedure codes commonly used by mental health and life
2800   skills providers. They are the psychiatry and biofeedback CPT codes 90801–90899; the
2801   central nervous system assessments/tests CPT codes 96100–96117; health and behavior
2802   assessment/intervention CPT codes 96150–96155; and the HCPCS H codes for alcohol
2803   and drug abuse treatment services.
2804
2805   6.8.3.2. Initial Psychiatric Diagnostic Interview
2806   These codes are used by all privileged mental health providers (e.g., social workers,
2807   psychologists, psychiatrists) for the initial evaluation. The initial psychiatric diagnostic
2808   interview codes will only be used on the initial encounter. If the privileged mental health
2809   provider was unable to complete the psychiatric diagnostic interview examination at the
2810   initial encounter, a code would be selected for the initial encounter specifically on the
2811   basis of what services/procedures were performed. If an established patient presents with
2812   a new mental health condition, a new psychiatric diagnostic interview may be required.
2813
2814   6.8.3.3. Therapy with E&M
2815   The therapy with E&M codes are usually used only by psychiatrists and psychologists.
2816   The E&M component should be documented separately and include the history, exam,
2817   and decision making. For therapy, the time that face-to-face therapy started and time
2818   ended should be documented, because the therapy codes are time based. Time spent
2819   conducting the E&M component is not included in the therapy time.

                                                  6-29
                                            MHS Coding Guidance
                                                March 2008
                                        SPECIALTY CODING
                                          6.8 Mental Health

2820   6.8.3.4. 90862 Pharmacologic Management
2821   This code is not used with any E&M or therapy code. It may be used by any provider
2822   prescribing and managing psychopharmacological medication. It would be rare for a
2823   non-mental health provider to use this code, as pediatricians managing a patient using
2824   Ritalin would usually do more than just review and adjust the amount of medication.
2825
2826   6.8.3.5. 90885 Psychiatric Evaluation of Records
2827   This code is included in the initial diagnostic interview and therapy codes and is not used
2828   if codes 90801–90857 are used. Evaluation of all available applicable data is always part
2829   of treatment. This code is for a paper review of the patient, without seeing or treating the
2830   patient, to make a diagnosis.
2831
2832   6.8.3.6. 90887 Advising Family and Others How to Assist Patient
2833   This code is used when a provider summarizes results to the family when the patient is
2834   unable to communicate. It is not used in conjunction with 90801–90857.
2835
2836   6.8.4. Documentation
2837   When both therapy and an E&M are provided in the same encounter, the E&M
2838   documentation should be noted separately, after the end of the therapy note or on a
2839   separate page.
2840
2841   6.8.5. Auditing and Coding
2842   Mental health documentation coding and auditing will be performed in the mental health
2843   clinic by coding professionals in order to meet privacy and disclosure requirements.
2844
2845   DoD 6025.18R, para DL1.1.29. defines psychotherapy notes as, ―Notes recorded (in any
2846   medium) by a healthcare provider who is a mental health professional documenting or
2847   analyzing the contents of conversation during a private counseling session or a group,
2848   joint, or family counseling session and that are separated from the rest of the individual’s
2849   medical record.‖
2850
2851   An entry in the hard copy outpatient medical record or AHLTA, about the mental health
2852   encounter should include items excluded from the psychotherapy note as defined in DoD
2853   6025.18R, para DL1.1.29. ―Psychotherapy notes exclude medication prescription and
2854   monitoring, counseling session start and stop times, the modalities and frequencies of
2855   treatment furnished, results of clinical tests, and any summary of the following items:
2856   diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to
2857   date.”
2858
2859   This documentation should be sufficient to code a psychotherapy counseling encounter.
2860   However, if E&M services are provided, additional documentation may be required for
2861   auditing purposes. When outpatient documentation is sufficient, access to the separate
2862   mental health record or psychotherapy note may not be necessary for auditing. When
2863   such documentation is not sufficient, further documentation substantiating the coding will
2864   be made available to the auditor.
                                                  6-30
                                            MHS Coding Guidance
                                                March 2008
                                    SPECIALTY CODING
                                   6.9 Nutritional Medicine
2865   6.9. Nutritional Medicine Encounters
2866
2867   6.9.1. Evaluation & Management (E&M) Rules
2868   Nutritional medicine does not generate E&M services.
2869
2870   6.9.2. Privileged Providers, Dieticians
2871
2872   6.9.2.1. Physicians and Other Privileged Providers Not Registered Dieticians.
2873   Privileged providers other than registered dieticians should use an office E&M (e.g.,
2874   99201–99245) when coding consulting on nutritional therapy or intervention. These
2875   privileged providers (not Registered Dieticians) should use the preventive medicine codes
2876   (e.g., 99401–99412) when counseling individuals or groups on nutritional topics when
2877   the patients do not have symptoms, conditions, or diagnoses related to the topics being
2878   addressed. These privileged providers should use the group education code (99078)
2879   when educating groups with symptoms, conditions or diagnoses related to the education
2880   topic.
2881
2882   6.9.2.2. Registered Dieticians
2883
2884   6.9.2.2.1. Preventive Medicine
2885   Registered dieticians may use the preventive medicine codes (99401–99412) when
2886   providing counseling or risk-factor reduction interventions. To use these codes, the
2887   patient should not have a symptom, condition, or diagnosis related to the topics covered.
2888   For example, registered dieticians may teach a Healthy Heart eating group.
2889
2890   6.9.2.2.2. Telephone Consultation
2891   Registered dieticians may use the appropriate telephone consultation code, as long as the
2892   documentation reflects the encounter was for a new issue, providing additional
2893   information on a nutrition-related topic. Telephone consults are not to be used for
2894   administrative encounters, such as reminding patients of appointments. Telephone
2895   consults are not to be used for continuations of previous encounters, such as providing
2896   websites for help groups when information was not available at the previous encounter.
2897
2898   6.9.2.2.3. Outpatient Consultation
2899   Both referrals and consults are requested using Standard Form (SF) 513. It is very
2900   infrequent when a provider requests advice (a consult) from a registered dietician on
2901   management of a medical condition (e.g., for this 211-pound male, which diet should I
2902   use to treat him?). Usually, the provider refers (a referral) the medical nutritional
2903   management of the patient to the registered dietician. The registered dietician’s medical
2904   nutritional therapy should be coded using the 97802–97804 codes.
2905
2906   6.9.2.3. Non-Privileged Providers or Diet Technicians
2907   All diet technician visits are coded with the procedure code. If the technician is involved
2908   in the patient appointment conducted by a dietician (e.g. assesses the food diaries prior to
2909   the group encounter, which the dietician will conduct), the technician is considered an

                                                  6-31
                                           MHS Coding Guidance
                                               March 2008
                                       SPECIALTY CODING
                                       6.9 Nutritional Medicine
2910   additional provider in ADM and the dietician is credited with the visit(s).       Merely
2911   checking a patient in does not meet the requirement of an additional provider.
2912
2913   6.9.3. Diagnosis Coding Rules
2914   An outpatient visit to a nutrition clinic is coded with the ICD-9-CM code V65.3, Dietary
2915   Surveillance and Counseling. Other existing conditions would be coded as a secondary
2916   or additional diagnostic code. With ADM version 3.0, up to four diagnosis codes may be
2917   entered.
2918
2919      Examples of codes include the following:
2920       Colitis—558.9
2921       Diabetes mellitus—250.0_ (5th digit sub-classification 0–3)
2922                    Requires an additional code for diabetic manifestations (e.g., acute
2923                       angle-closure glaucoma, 365.22; peripheral neuropathy, 355.8;
2924                       skin ulcer of lower extremity, 707.10)
2925       Dermatitis caused by food (allergies)—693.1
2926       Pure hypercholesterolemia—272.0
2927
2928   NOTE: Please review new BMI codes located in the 2007 ICD-9-CM: V85.0x-
2929   V85.5x.
2930
2931   When a patient is seen for the cause of his weight gain (thyroid, etc.), use code V77.8
2932   special screening for obesity in addition to the overweight/obese ICD codes.
2933
2934   6.9.4. Procedural Coding Rules
2935
2936   6.9.4.1. Medical Nutritional Therapy (MNT) CPT codes
2937
2938   6.9.4.1.1. MNT; Initial Assessment and Intervention
2939   97802 is to be used only once each year, for initial assessment of a new patient, unless
2940   the patient is seen for a different condition with different therapy requirements than the
2941   prior initial assessment. Documentation must reflect the amount of face-to-face time
2942   with the patient. Enter the number of units (each 15 minutes) in the unit field.
2943
2944   6.9.4.1.2. MNT, Reassessment, and Intervention
2945   97803 should be used when there is a change in the patient’s medical condition that
2946   affects the nutritional status of the patient. Documentation must reflect the amount of
2947   face-to-face time with the patient. Enter the number of units (e.g., if the reassessment
2948   took 45 minutes, code a quantity of 3) in the unit field.
2949
2950   NOTE: MNT CPT codes (97802–97804) cannot be used in conjunction with the
2951   preventive medicine E&M codes (99401–99412). If the patient is receiving
2952   medical nutritional therapy and risk-factor reduction nutritional guidance (e.g.,
2953   being briefed on low-sodium diet, but also receives counseling on general
2954   nutritional topics), the entire time would be coded for the MNT.
2955
                                                 6-32
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                        6.9 Nutritional Medicine
2956   6.9.4.1.3. Registered Dieticians
2957   These individuals should use the appropriate medical nutritional therapy code (97802–
2958   97804) when conducting nutritional assessments and specific diet training. As these
2959   codes are time sensitive, the documentation must reflect the amount of time spent face-to-
2960   face with the patient. Time spent reviewing the food diary with the patient would be
2961   coded as part of the MNT encounter.
2962
2963   6.9.4.1.4. Certified Diet Technicians
2964   These individuals should use the nutritional medicine codes 97802–97804 for MNT.
2965   Diet technicians are authorized to provide instruction on those diets on which they
2966   have been certified.
2967
2968   6.9.4.2. Education and Training for Patient Self-Management
2969   Services prescribed by a physician and provided by a qualified nonphysician
2970   healthcare professional designed to teach patients how to effectively self-manage
2971   illness(es) or disease(s) including asthma and diabetes may be coded as follows when
2972   a standardized curriculum is used:
2973           98960           Face-to-face with patient each 30 minutes; individual patient
2974           98961           2-4 patients
2975           98962           5-8 patients
2976
2977   6.9.4.3. Group Counseling Performed by a Non-Physician Provider (excludes
2978   certified technicians)
2979   Documentation of group counseling, per session, is required in each individual’s medical
2980   record, along with topics addressed and any specific patient-related issues.
2981
2982       S9449     Weight management classes
2983       S9451     Exercise class, non-physicians
2984       S9452     Nutrition class, non-physician
2985       S9455     Diabetic management program, group session
2986       S9460     Diabetic management program, nurse visit
2987       S9465     Diabetic management program, dietician visit
2988       S9470     Nutrition counseling, dietician visit
2989
2990   6.9.5. Units of Service
2991
2992   6.9.5.1. Time Spent as Unit of Service
2993   By marking the quantity column on the superbill, indicate the time spent with the patient
2994   as units of service for CPT code assignment. Example: One 30-minute reassessment
2995   visit equates to two units of service.
2996
2997
2998
2999
3000

                                                 6-33
                                           MHS Coding Guidance
                                               March 2008
                                     SPECIALTY CODING
                                     6.9 Nutritional Medicine
3001   6.9.5.1.1. Dietitian Outpatient Examples:
3002

3003                 DoD Rule
3004
3005                 Recording of documentation in AHLTA is not a separately codable event.
3006                 Encounters that do not meet minimum visit criteria are administrative and
3007                 are not a coded visit.

3008
3009   6.9.5.1.1.1. A dietitian teaches a 45 minute nutrition segment of a multidisciplinary
3010   team diabetes education program (following the American Diabetes Association
3011   standardized curriculum). The dietitian reviews the patient diet history questionnaire
3012   which includes meds, labs, and exercise history. An individualized meal plan is provided
3013   to each patient and explained during the class. All patients are scheduled to return for
3014   two more follow-up visits to complete the series of classes. Once the class is completed,
3015   the RD documents the patient condition/diagnosis, initial assessment, diagnosis,
3016   counseling provided, and goals/action plan. Codes for example:
3017        ICD-9-CM: V65.3, additional diagnosis of diabetes 250.00 or other diabetes
3018           related medical condition code, obese or overweight code and BMI code (if
3019           patient overweight/obese)
3020        E&M: N/A
3021        CPT: 97804 with 3 units of service
3022
3023   6.9.5.1.1.2. A dietitian spends 45 minutes reading about an uncommon medical
3024   condition and then develops a handout for a patient. The RD spends 30 minutes face-to-
3025   face with the patient, discussing the information on the handout and providing detailed
3026   diet instruction. After the appointment, the RD takes 15 minutes to input the note into
3027   AHLTA. Codes for example:
3028        ICD-9-CM: V65.3 and the condition/diagnosis code
3029        E&M: N/A
3030        CPT code 97802 with 2 units of service. Only the actual face-to-face time with
3031           the patient is part of the procedural (MNT CPT) code.
3032
3033   6.9.5.1.1.3.   A physician sends a request for assessment to the RD to see an
3034   obese patient for weight loss and consideration for bariatric surgery. The RD
3035   conducts a 60 minute in-depth assessment for the patient’s readiness for behavior
3036   change, usual diet and exercise habits, measures current height and weight, and
3037   provides diet education and written materials. Codes for example:
3038        ICD-9-CM: V65.3, obesity 278.02, V85.39 (BMI range 39.0-39.9)
3039        E&M: N/A
3040        CPT: 97802 with 4 units of service
3041
3042   6.9.5.1.1.4. A dietitian teaches a 90 minute class on sports nutrition to a group
3043   of eight. The patients’ height, weight, and BMI are calculated. The dietitian
                                                 6-34
                                           MHS Coding Guidance
                                               March 2008
                                       SPECIALTY CODING
                                       6.9 Nutritional Medicine
3044   works with each patient to determine estimated energy, protein, fluid, and
3045   carbohydrate needs. Individualized documentation for each patient is entered into
3046   AHLTA. Codes for example:
3047        ICD-9: V65.3 only
3048        E&M: 99412 preventive medicine group code
3049        CPT: no NMT CPT codes are used with a preventive medicine E&M code
3050
3051   6.9.5.1.2. Diet Technician Outpatient Examples
3052
3053   6.9.5.1.2.1.   A diet technician teaches a one-hour group cholesterol class. The
3054   technician has each patient fill out an information sheet, reviews each patient’s
3055   laboratory values, and documents the visit by assessing the patient condition,
3056   describing the education provided and educational materials, and the follow-up
3057   plan. Codes for example:
3058        ICD9-CM: V65.3, dietary surveillance and counseling
3059        E&M: N/A
3060        CPT: 97804 with 2 units of service
3061
3062   6.9.5.1.2.2. The diet technician has a 30-minute follow-up visit with a patient
3063   who attended the cholesterol class described above. The technician analyzes the
3064   patient’s food diary, reviews any new relevant labs, provides specific
3065   recommendations on dietary changes, and documents the visit. ICD9-CM code
3066   V65.3, dietary surveillance and counseling. Codes for example:
3067        ICD-9: V65.3, dietary surveillance and counseling
3068        E&M: N/A
3069        CPT: 97803, reassessment and intervention, with 2 units of service
3070
3071   NOTE: 99078 may be used as an additional code if physician education services are
3072   provided in a group setting.
3073
3074   6.9.5.1.2.3.      A diet technician teaches the 30-minute nutrition segment of an
3075   obstetrics orientation. The diet tech assesses self-reported data on an SF 600
3076   overprint for each attendee includes: current pregnancy weight, week’s gestation,
3077   total weight gain compared to expected weight gain, and usual diet intake or food
3078   frequently. The diet technician meets with each patient individually to ensure her
3079   understanding of the assessment and nutritional recommendations. Codes for
3080   example:
3081        ICD-9: V65.3 and applicable pregnancy code (e.g., V22.0, supervision of
3082           normal first pregnancy or V22.1, supervision of subsequent pregnancy)
3083        E&M: N/A
3084        CPT: 97804 with 1 unit of service
3085
3086
3087
3088
                                                 6-35
                                           MHS Coding Guidance
                                               March 2008
                                    SPECIALTY CODING
                                    6.9 Nutritional Medicine
3089   6.9.6. Inpatient Therapy Examples:

3090                  DoD Rule
3091
3092                  Inpatient nutrition consultation encounters are reported in ADM. When the
3093                  screen prompts, Are you from the attending service? select no. This will
3094                  create the encounter in ADM and will be reported in the B MEPRS.
3095                  Nutritional screenings are not codeable services and will not be brought
3096                  back as workload to the B MEPRS clinic.
3097

3098
3099   6.9.6.1.       A physician consults an RD to assess an ICU patient with COPD with
3100   acute exacerbation for alternate nutrition sources e.g. TPN (total parenteral nutrition).
3101   The RD reviews the patient medical record, conducts a brief interview with the patient
3102   and spouse, talks with the nursing staff about the patient’s usual oral intake, and then
3103   make a detailed recommendation for TPN in the medical chart. The RD completes the
3104   assessment in 45 minutes. Codes for this example:
3105        ICD-9-CM: V65.3, additional diagnosis code for current medical condition COPD
3106           491.21
3107        E&M: N/A
3108        CPT: 97802 with 3 units of service
3109
3110   6.9.6.2.         The diet technician screens a cardiac patient and indicates the patient is
3111   high nutrition risk due to post-CABG surgical procedure, recent weight loss and poor
3112   appetite/intake. The diet tech refers the patient to the dietitian for further assessment and
3113   intervention. The dietitian interviews the patient and family, reviews the medical record,
3114   assesses the patient current condition and calorie needs, and makes recommendations to
3115   the physician for a liberal diet. The nutrition screening and assessment process are
3116   integral to the inpatient stay and are considered an institutional component of care,
3117   therefore are not separately codeable.
3118
3119




                                                   6-36
                                            MHS Coding Guidance
                                                March 2008
                                        SPECIALTY CODING
                                        6.10 Obstetrics Services

3120   6.10. Obstetrics Services
3121
3122                   NOTE: When a patient’s pregnancy is incidental to other services
3123                   rendered, the provider must state the pregnancy does not affect care.
3124
                       Code the pregnant state with V22.2 diagnosis code. An incidental pregnancy
3125                   cannot be the reason for the encounter, so V22.2 will not be the first listed
3126                   diagnosis. Do not use the V22.2 code with obstetrical diagnostic codes from
3127                   630–677. Do not code the encounters with the 0500F or 0502F obstetrical
                       procedure codes.
3128
3129                   For instance, a three-months-pregnant patient breaks her wrist. This would be
3130                   coded with an office visit E&M; an E code for the fracture, the V22.2 code
3131                   for the diagnosis, and a procedure code for treatment of the fracture.
3132
3133   6.10.1. E&M Rules
3134

3135                 DoD Rule
3136
3137                 UNCOMPLICATED obstetric encounters do not have an E&M component
3138                 in the 99201–99499 series.
3139
3140                 Most obstetric encounters involving complications of pregnancy do have an
3141                 appropriate E&M in the 99201–99499 series and the appropriate E&M
3142                 should be entered in the E&M field.

3143

3144                 DoD Rule
3145
3146                 As policy, global OB codes that represent work in two different MEPRS
3147                 codes and the bundled ante partum visit codes (59425 and 59426) are not
3148                 coded in the ADM.

3149
3150   To account for workload, the MHS cannot use the global codes.
3151
3152   6.10.1.1. Do not use the following codes:
3153      59400 Routine obstetric care including ante partum care, vaginal delivery (includes
3154                services in both the outpatient and inpatient MEPRS codes)
3155      59410 Routine obstetric care including postpartum care (includes services in both
3156                outpatient and inpatient MEPRS codes)
3157      59425 Ante partum care only, 4–6 visits (use 0500F, initial prenatal care visit, and
3158                0502F subsequent prenatal care, for ante partum encounters)

                                                   6-37
                                            MHS Coding Guidance
                                                March 2008
                                        SPECIALTY CODING
                                        6.10 Obstetrics Services

3159      59426     Ante partum care, 7 or more visits (use 0500F, initial prenatal care visit, and
3160                0502F, subsequent prenatal care, for ante partum encounters)
3161      59510     Routine obstetric care including ante partum care—Cesarean delivery
3162                (includes services in both outpatient and inpatient MEPRS codes)
3163      59515     Cesarean delivery—postpartum care (includes services in both outpatient
3164                and inpatient MEPRS codes)
3165      59610     Vaginal birth after a previous C-section (VBAC) delivery including ante
3166                partum, delivery, and post partum (includes services in both outpatient and
3167                inpatient MEPRS codes)
3168      59614     VBAC delivery and postpartum care (includes services in both the
3169                outpatient and inpatient MEPRS codes)
3170      59618     Attempted VBAC ante partum, delivery and postpartum care (includes
3171                services in both outpatient and inpatient MEPRS codes)
3172      59622     Attempted VBAC delivery and postpartum care (includes services in both
3173                outpatient and inpatient MEPRS codes)
3174
3175   6.10.1.2. Billing vs. Data Collection Codes
3176   The codes listed above are a billing convention, as insurance companies do not want 13
3177   separate bills for the professional services associated with a full-term pregnancy. The
3178   codes listed above cannot be used for data collection when each encounter reflects
3179   services provided. By using the new category II CPT obstetrical codes, obstetrical
3180   encounters will be collected without unbundling the obstetrical global codes.
3181

3182                  DoD Rule
3183
3184                  Use the appropriate E&M for office visits/hospital when something other
3185                  than uncomplicated, routine obstetrical care is furnished.
3186
3187                  For first visit with nurse for screening, vaccinations and counseling, code
3188                  services as appropriate. Code 99211 for face to face visit with no procedures.

3189
3190   6.10.2. Diagnosis Coding Rules
3191
3192   6.10.2.1. Fifth Digit Requirement for Obstetric Diagnoses
3193   The range of diagnosis codes 640–648, complications mainly related to pregnancy,
3194   requires a fifth digit. Follow ICD-9-CM coding guidance for reporting obstetric
3195   diagnoses.
3196          Fifth Digits
3197          0        Unspecified episode of care
3198          1        Delivered this episode, may or may not have had ante partum condition
3199          2        Delivered the episode of care, had postpartum complication
3200          3        Ante partum care (patient still pregnant at end of this episode of care)
3201          4        Postpartum care (patient delivered during previous episode of care)

                                                  6-38
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                       6.10 Obstetrics Services

3202   6.10.2.2. Co-morbidities
3203   Some obstetric cases have co-morbidities that influence the pregnancy. Ensure that the
3204   pregnancy and manifestation codes are listed.
3205
3206   6.10.2.2.1. Example: A pregnant patient presents to the clinic with a diagnosis of
3207   Type I diabetes, which complicates the pregnancy. This encounter is coded in the
3208   following manner:
3209           Fifth Digits
3210           648.03 Current conditions in the mother classifiable elsewhere, but complicating
3211                  pregnancy, childbirth, or the puerperium, diabetes mellitus
3212
3213          250.01 Type I diabetes, without mention of complication
3214
3215   6.10.2.3. Diagnosis codes 647–649
3216   Coders unfamiliar with obstetrical coding should review the codes in the 647–649 range
3217   and understand their application. If a patient 3 months pregnant sprains her ankle while
3218   jogging, but it does not affect the pregnancy and the pregnancy does not affect the care,
3219   the code 648.7X would not be appropriate. However, smoking is a systemic issue with
3220   decreased oxygenization that will affect the pregnancy. A pregnant patient with tobacco
3221   use disorder would usually be coded with 649.0X.
3222
3223   6.10.2.4. Congenital Anomalies
3224   When the infant has a congenital anomaly, it is coded on the infant’s record, not the
3225   mother’s. Be careful with the codes 740–759. For the mother’s record, consider 655,
3226   known or suspected fetal abnormality affecting management of mother.
3227
3228   6.10.2.5. Outcome of Delivery Codes V27
3229   These codes are used on the mother’s record at delivery, which is usually an inpatient
3230   event. Therefore, the V27 codes would be in the A MEPRS SADR if delivered at an
3231   MTF. This would be coded in ADM and will appear on the inpatient rounds encounter at
3232   delivery.
3233
3234   6.10.2.6. Live-born Infants According to Type of Birth, Codes V30–V39
3235   These codes are not used on the mother’s record. They are used in the infant’s record.
3236
3237   6.10.2.7. Pregnancy Testing
3238   Encounters for the purpose of pregnancy testing are to be coded as follows, based on the
3239   results of the test or exam that are known at the time of the encounter.
3240




                                                 6-39
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                        6.10 Obstetrics Services

                       Results of Test and/or Exam                                 Code(s)
       Positive                                                         V72.42
       Negative without any related symptoms or diagnoses               V72.41
       Negative with any related symptoms or diagnoses                  Codes for symptoms or
                                                                        conditions and V72.41
       Unconfirmed exam or test                                         V72.40
3241
3242   6.10.3. Procedural Coding Rules
3243

3244                  Category II CPT obstetric coded 0500F, 0502F, 0503F and Level I CPT code
3245                  59430.
3246
3247                  0500F Initial prenatal care visit. Reported for those portions of the first
3248                  prenatal encounter that are routine for that point in the pregnancy, with
3249                  health care professional providing obstetrical care.
3250
3251                  0501F Prenatal flow sheet documented. Do not use, because the DoD will
3252                  use 0500F, initial prenatal care visit, when the prenatal flow sheet is initiated
3253                  and 0502F for each subsequent obstetrical encounter.
3254
3255                  0502F Subsequent prenatal visits (continuing care). Use for subsequent
3256                  obstetrical visits that are routine for that point in the pregnancy. This code
3257                  does not include complications or issues not related to the pregnancy.
3258
3259                  Use 0503F for one uncomplicated postpartum care encounter only. It is
3260                  usually done six to eight weeks postpartum. Code all other postpartum
3261                  complications with the appropriate established patient office visit E&M
3262                  code. Use this code if the delivery and postpartum visit are performed by
3263                  the same group practice.
3264
3265                  Use 59430 if postpartum care is provided by a group other than the group
3266                  practice that performed the ante partum care or delivery.

3267
3268   6.10.3.1. Obstetrical Services
3269   Included are: obstetric care (routine and non routine), ante partum care, vaginal delivery
3270   (with or without episiotomy or forceps) and postpartum care uses 0500F, 0501F, 0502F,
3271   0503F, and 59430.
3272
3273   6.10.3.2. Ante Partum Services
3274   To document ante partum services, indicate the following when given:
3275           Pap Smear
3276           Monthly visit up to 28 weeks’ gestation, biweekly visit to 36 weeks’ gestation
3277              and weekly visits until delivery
3278           Initial history and physical exam (code 0500F) and subsequent history and
3279              physical examinations (code 0502F)
                                                   6-40
                                            MHS Coding Guidance
                                                March 2008
                                        SPECIALTY CODING
                                        6.10 Obstetrics Services

3280             Recording of weight, blood pressures, and fetal heart tones. When routine
3281              chemical urinalysis is done and interpreted in the clinic and is not bundled
3282              with routine obstetrical care, it may be coded using a laboratory code (e.g.,
3283              81000 or 81002).
3284             For first visit with nurse for screening, vaccinations and counseling, code
3285              services as appropriate. Code 99211 for face-to-face visit with no procedures.
3286             0500F, initial prenatal care visit reported for the first prenatal encounter with
3287              healthcare professional providing obstetrical care. After confirmation of
3288              pregnancy, the 0500F code is the trigger code to indicate the start of the
3289              pregnancy episode. The code is not appropriate when the only prenatal
3290              service during an office visit is pregnancy test.
3291             0501F, prenatal flow sheet documented. Do not use.
3292             0502F, subsequent prenatal visits (continuing care)
3293             0503F, uncomplicated outpatient visit by the same group practice that
3294              performed the delivery until six weeks postpartum. The AMA uses this code
3295              to define the number of women who receive care on or between 21 and 56
3296              days after delivery.
3297             59430, uncomplicated outpatient postpartum follow-up by a group practice
3298              other than the group practice that performed the delivery.
3299
3300   6.10.3.3. The following is a list of services that reflect routine, uncomplicated care and
3301   are included in the routine codes.
3302
3303   Procedures outlined below, will not be coded separately. Positive findings during
3304   screening will be coded.
3305
3306         Prenatal risk assessment checklist—administering and history taking, ordering
3307          applicable tests
3308              o Auscultation of fetal heart tones
3309              o Screening fundal height
3310              o Screening for hypertension (HTN) disorders
3311              o Assessing inappropriate weight gain
3312              o Educate about symptoms of preterm labor
3313              o Review for development of contraindications
3314              o Assessment of fetal kick counts
3315              o Routine ultrasound (weeks 16–24)
3316         Interventions at all visits
3317              o Screening for HTN disorders
3318              o Breast feeding education
3319              o Exercise during pregnancy
3320              o Influenza vaccine (season-related, 6–20 weeks)
3321         First visit with nurse (6-8 weeks)–Screening for
3322              o Tobacco use, alcohol use, drug abuse
3323              o Domestic abuse
                                                   6-41
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                       6.10 Obstetrics Services

3324              o Anti-D/non-anti-D antibodies
3325              o Rubella, varicella, hepatitis B, syphilis (RPR), asymptomatic bacteriuria
3326              o HIV counseling
3327              o Immunization–TB booster (1st trimester), hepatitis B (1st trimester)
3328         First visit with provider (10–12 weeks)
3329              o Assessing weight gain (inappropriate)
3330              o Auscultation fetal heart tones
3331              o Screening fundal height
3332              o Screening for gonorrhea and chlamydia
3333              o Screening for cervical cancer
3334              o Counseling for cystic fibrosis screening
3335         Weeks 16–24
3336              o Assessing weight gain (inappropriate)
3337              o Auscultation fetal heart tones
3338              o Screening fundal height
3339              o Screen for domestic abuse
3340              o Maternal serum analyte screening
3341              o Counseling for family planning
3342              o Educate regarding preterm labor
3343         Weeks 28–37
3344              o Assessing weight gain (inappropriate)
3345              o Auscultation fetal heart tones
3346              o Screening fundal height
3347              o Screen for domestic abuse (week 32)
3348              o Assess for preterm labor
3349              o Daily fetal movement counts
3350              o Screening for gestational diabetes
3351              o Iron supplementation
3352              o Anti-D prophylaxis for Rh-negative women
3353              o Screening for group B streptococcal (week 36)
3354              o Assessment of fetal presentation (week 36)
3355         Weeks 38–41
3356              o Assessing weight gain (inappropriate)
3357              o Auscultation fetal heart tones
3358              o Screening fundal height
3359              o Weekly cervical check (stripping)
3360              o Post-dates antenatal fetal testing
3361
3362   6.10.3.4. Codes for Medical Problems Complicating Pregnancy
3363   All encounters for OB care will have a code from the 0500F series coded. Significant
3364   separately identifiable medical conditions complicating obstetric management may
3365   require additional resources and should be identified by using the E&M codes in addition
3366   to those codes for maternity. Modifier -25 will not be assigned to an E&M in this chapter
3367   only. These significant separately identifiable medical conditions will be coded when

                                                 6-42
                                          MHS Coding Guidance
                                              March 2008
                                       SPECIALTY CODING
                                       6.10 Obstetrics Services

3368   documented in the medical record. Documentation must meet minimal requirements.
3369   Procedures other than those routine procedures listed above should also be coded.
3370
3371   Examples of complicating conditions are:
3372         Pre-existing diabetes
3373         Gestational diabetes mellitus (GDM)
3374         Pregnancy-induced hypertension or pre-eclampsia
3375         Fetal anomaly or abnormal presentation (older than or equal to 36 weeks)
3376         Multiples
3377         Placenta previa
3378         Chronic hypertension
3379         Systemic disease that requires ongoing care (e.g., severe asthma, lupus,
3380         inflammatory bowel disease)
3381         Drug abuse
3382         HIV (or abnormal screen)
3383         Age (<16 or >40 years at delivery)
3384         Past complicated pregnancy
3385         Prior preterm delivery (<37 weeks)
3386         Prior preterm labor requiring admission (e.g., early cervical change)
3387         Intrauterine fetal demise—10 weeks after cardiac activity was first noted
3388         Prior cervical or uterine surgery
3389         Fetal anatomic abnormality (e.g., open neural tube defects in prior child or first-
3390         degree relative)
3391         Abnormal fetal growth
3392         Preterm labor requiring admission (i.e., regular uterine contractions and cervical
3393         change)
3394         Abnormal amniotic fluid
3395         2nd or 3rd trimester bleeding
3396         Relative BMI <16.5
3397         Hematologic disorders
3398         Severe anemia (<24 percent hematocrit)
3399         Cancer
3400         Seizure disorders
3401         Recurrent urinary tract infections or stones
3402         Substance use disorders (alcohol or tobacco)
3403         Eating disorders
3404         Surgery
3405         Abnormal screen—antibody, hepatitis, syphilis, and Pap
3406         Abnormal maternal triple screen
3407         Current mental illness requiring medical therapy
3408
3409      Examples of separately reportable services:
3410         Additional non-routine Ultrasound
3411         Echocardiography
3412         Fetal biophysical profile
                                                  6-43
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                        6.10 Obstetrics Services

3413          Amniocentesis, cordocentesis
3414          Chorionic villus sampling
3415          Fetal contraction stress test
3416          Fetal nonstress test
3417          Hospital admission and observation for preterm labor, except within 24 hours of
3418          delivery
3419          Management of surgical problems arising during pregnancy (e.g., appendicitis,
3420          incompetent cervix, ruptured uterus)
3421          Insertion of cervical dilator by physician
3422          External cephalic version, if done in the clinic
3423          Administration of Rh immune globulin
3424          Cerclage of cervix, during pregnancy—vaginal or abdominal
3425
3426   6.10.3.5. Postpartum Care
3427
3428   6.10.3.5.1. Routine Postpartum Care
3429   For postpartum encounters code 0503F/59430 in the CPT/HCPCS field code. Following
3430   is a list of services that reflect routine, uncomplicated postpartum care and are included in
3431   the routine codes. They will not be coded separately.
3432
3433      Postnatal tests—administering and history taking, ordering applicable tests
3434             o Pelvic exam
3435             o Breast exam
3436      Topics addressed:
3437             o Contraception
3438             o Postpartum depression, screening for
3439             o Sexual activity
3440             o Weight
3441             o Exercise
3442             o Woman’s assessment of her adaptation to motherhood
3443
3444   6.10.3.5.2. Non-routine Postpartum Care
3445   Collection of Pap smears is not included and should be documented and coded separately
3446   and appropriately with reason (e.g., high risk or not). Additional services may be
3447   provided during a postpartum visit.
3448
3449   Patients who present with a history of an abnormal Pap smear and are being seen for a
3450   diagnostic Pap will require an added E&M code. If the obstetric follow up code 59430 is
3451   used, then a modifier -25 will be required on the E&M code.
3452
3453   Code non-routine postpartum issues separately. Treatment of these would be coded using
3454   an E&M. A few examples:
3455                   Disruption of wounds
3456                   Infections of breast and nipples
3457                   Disorders of lactation
                                                 6-44
                                            MHS Coding Guidance
                                                March 2008
                                      SPECIALTY CODING
                                      6.10 Obstetrics Services

3458   6.10.4. Inpatient Obstetric Coding.
3459   For more guidance on inpatient coding, see section 9. This section addresses inpatient
3460   professional services, including OB rounds and appointments that generate automatically
3461   in the name of the attending provider.
3462
3463   6.10.4.1. Recording in MEPRS
3464   To record the delivery, code inpatient professional services in the ACxx, AGxx or AHxx
3465   MEPRS. After a patient is admitted, an inpatient rounds ADM record is generated each
3466   inpatient day under the name of the attending physician.
3467
3468   6.10.4.1.1. Hospital Days prior to Delivery
3469
3470   6.10.4.1.1.1. OB Observation Status
3471   Pre-term labor/Labor Observation
3472
3473           Patient is seen in the OB-GYN clinic or Emergency Department. The provider
3474   writes an order to place the patient in observation status. Changing the patient from
3475   observation status is a decision of the privileged provider.
3476
3477   For normal, uncomplicated pre-natal care (which could include some labor) use
3478   procedure code 0502F for encounters leading up to delivery.
3479
3480   For problems other than normal pre-natal and labor care:
3481
3482          IF THERE IS NO ORDER FOR OBSERVATION:
3483
3484         For clinic services, use E/M code 9921X based on documentation. For
3485          Emergency department services, use E/M 9928x based on documentation. In
3486          those instances when a non-emergency service is provided by a non-emergency
3487          provider (e.g., obstetrician treats patient in the Emergency Department on a
3488          weekend when the OB clinic is closed), code the services as clinic services.
3489         If more than 70 minutes (99215= 40 minutes, modifier 21 = 30 minutes) is spent
3490          face-to-face with the patient AND THE TOTAL TIME AND PROVIDER’S
3491          ACTIVITIES DURING THAT TIME ARE DOCUMENTED in the medical
3492          record, code 99215 and 99354-99355 for clinic OR 99285 only for Emergency
3493          Department.
3494         Code for fetal stress/non-stress/monitoring in addition to the E/M code.
3495
3496          IF THERE IS AN ORDER FOR OBSERVATION:
3497
3498         Provider documents written order for observation, no delivery on same date of
3499          service (99218-99220). Diagnosis will reflect medical necessity. Observation
3500          services are outpatient services. Therefore, if the patient is observed for a
3501          condition not verified, code the symptoms. Do not use the V71 Observation for
3502          Condition not found.
                                                  6-45
                                          MHS Coding Guidance
                                              March 2008
                                       SPECIALTY CODING
                                       6.10 Obstetrics Services

3503         To generate a codable encounter, an appointment must be created manually for
3504          each day of observation. Contact your Service Representative for guidance on
3505          manual creation of codable observation encounters.
3506
3507         Provider documents written order for observation, no delivery on subsequent date
3508          of service, use E/M 99218-99220.
3509
3510         Provider documents written order for observation, no delivery, discharged same
3511          date of service, use E/M 99234-99236.
3512
3513         Provider documents written order for observation, no delivery, discharged on
3514          subsequent date of service, use E/M 99217 for the last day of observation.
3515
3516   Scenarios:
3517   Admit from observation/trial labor
3518
3519          Patient is in observation, is admitted and delivers the same date.
3520          1. Observation: close out the observation using the 0502F for routine prenatal and
3521   labor. Complications are coded based on documentation.
3522
3523          2. Admission: the round (RND) encounter for this day may have an E/M based
3524   on documentation and the procedure will be the delivery (vaginal 59409; cesarean section
3525   59514). This is an MHS deviation from civilian standards of coding. Refer to DoD Rule
3526   for E/M in section 6.10.1.2.
3527
3528          Patient is in observation and is admitted and does not deliver during this
3529   admission.
3530          1. Observation: close out the observation using the 0502F for routine prenatal
3531   care and labor. Complications are coded based on documentation.
3532
3533           2. Admission: the RNDs encounter will be based on the documentation from the
3534   time of admission.
3535
3536           Patient delivers on the second date of observation status.
3537           1. Observation: code the observation encounter for day 1 using the 0502F for
3538   routine prenatal care and labor. Complications are coded based on documentation.
3539
3540          2. Code the observation encounter for day 2 using the 0502F for routine prenatal
3541   care and labor.
3542
3543           3. Admission: the RNDs encounter will be based on the documentation from the
3544   time of admission. Use appropriate delivery codes based on documentation.
3545
3546
3547
                                                  6-46
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                       6.10 Obstetrics Services

3548   6.10.4.1.1.2. Preterm Admission/Bed-Rest Admission
3549   For problem pregnancies that need inpatient monitoring (pre-mature labor, diabetic
3550   patient, toxemic, high blood pressure), the attending service will code one RNDs per day
3551   for admission until date of delivery or discharge as follows: admission date (99221-
3552   99223) subsequent days (9923X), date of delivery (59XXX).
3553
3554    NOTE: Inpatient days post delivery, that are uncomplicated post partum days will
3555   have the 99024 for the cesarean sections. For uncomplicated postpartum vaginal
3556   deliveries, code 0503F. For complications, code the appropriate subsequent hospital
3557   care code.
3558
3559   6.10.4.1.1.3. Labor
3560   All E&M services prior to labor are considered ante partum care. If the delivery does not
3561   take place until after the initial day of admission, delete the rounds encounter for the
3562   initial day. For example, when a healthy-term, uncomplicated singleton female is
3563   admitted at 1800 and delivers vaginally 12 hours later, the following codes are used:
3564   delete the automatically generated rounds appointment for the day of admission and code
3565   the delivery 59409 on the rounds appointment for the day of delivery.
3566
3567   6.10.4.1.1.4. Complicated
3568   For complicated inpatient ante partum care, use the appropriate initial hospitalization and
3569   subsequent hospitalization codes.
3570
3571   6.10.4.1.2. Delivery
3572   On the day of delivery, use
3573
3574         59409 for vaginal delivery
3575         59514 for C-section
3576         59612 for successful vaginal delivery after previous C-section
3577         59620 for an attempted vaginal delivery after a previous C-section when
3578          ultimately the newborn is delivered C-section
3579
3580   The delivery codes include:
3581       Management of uncomplicated labor, including fetal monitoring
3582       Placement of internal fetal or uterine monitors
3583       Catheterization or catheter insertion
3584       Preparation of perineum with antiseptic solution
3585       Forceps or vacuum extraction
3586       Delivery of placenta, any method
3587       Injection of local anesthesia
3588       Administration of intravenous oxytocin
3589
3590   Code any other appropriate procedures done.

                                                  6-47
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                        6.10 Obstetrics Services

3591   For complicated deliveries, use the appropriate procedure codes, e.g., surgical fixation for
3592   prolapsed uterus. For medical complications, e.g., asthma, the provider would use the
3593   appropriate E&M code.
3594
3595   6.10.4.1.2.1 Multiple Births
3596       For all newborns born vaginally, code 59409 (or 59612 for a vaginal birth after a
3597          previous C-section (VBAC) with a unit of the number of newborns. For instance,
3598          vaginally delivered twins would be coded 59409, unit of service 2.
3599       All newborns delivered C-section, code 59514 (or 59620 for a VBAC that results
3600          in a C-section), with a unit of service of 1. There is only one C-section.
3601       Multiple births with at least one vaginal and one C-section are coded with the
3602          appropriate type of vaginal birth code and the number of vaginal births using the
3603          unit’s field. Code the appropriate C-section code with a unit of service of 1 for all
3604          the infants delivered by the one C-section.
3605
3606   6.10.4.1.3. Associated C-section Procedures
3607   Code both the C-section and the associated procedure (e.g., hysterectomy, tubal ligation).
3608
3609   6.10.4.1.4. Routine Post Partum Days
3610   Code CPT 99024. For complications, code the appropriate procedure and E&M.
3611   Add diagnosis for post partum condition. (V24.x)




                                                  6-48
                                           MHS Coding Guidance
                                               March 2008
                                         SPECIALTY CODING
                                      6. 11 Occupational Therapy

3612   6.11. Occupational Therapy
3613
3614   6.11.1. E&M Rules
3615   E&M codes are not appropriate for occupational therapy. The evaluation and
3616   management components of routine outpatient office E&Ms are included in special
3617   occupational therapy evaluation (97003) and reevaluation (97004) procedural codes as
3618   indicated below.
3619
3620   6.11.2. Diagnosis Coding Rules
3621
3622   6.11.2.1. Outpatient Occupational Therapy
3623   All outpatient occupational therapy encounters for the purpose of receiving therapy are
3624   always coded with the V57.21 as the first listed diagnosis unless the need for therapy is
3625   related to a deployment. In that case, abide by the MHS Coding Guidance for
3626   deployment related issues.
3627
3628   6.11.2.2. Occupational Therapy Evaluation
3629   Occupational therapy encounters for the purpose of evaluation only or group educational
3630   classes (no therapy done during the encounter) are not identified by V57.21.
3631
3632

3633                  DoD Rule
3634
3635                  V57.21 will be the first listed code for all occupational therapy encounters
3636                  involving therapy only. The condition(s) for which the patient is receiving
3637                  therapy are listed in the second or third position. Occupational therapy
3638                  encounters for post-deployment therapy sessions have V70.5_6 as the third
3639                  or fourth listed code.
3640
3641                  If there is no therapy involved, V70.5_6 is still the first listed code with the
3642                  patient’s physical condition listed second.

3643
3644   NOTE: When a patient presents for evaluation and therapy is initiated on the same
3645   day, do not use V57.21. Code the condition as primary diagnosis.
3646
3647   6.11.2.3. E Codes for Occupational Therapy
3648   Occupational therapy encounters should not report E codes, as the occupational therapy
3649   encounter will not be the initial medical encounter at the MTF for the injury. If it is
3650   documented that the patient was initially seen for the injury at another MTF without
3651   occupational therapy, and this is the initial encounter at this MTF, then the E code(s)
3652   should be used. Most therapy encounters will not be for an acute injury (e.g., fracture).
3653   In rare instances, treatment will be to address the immediate resulting limitations from the
3654   injury (e.g., reduced movement of fingers following hand fracture).
3655
                                                    6-49
                                             MHS Coding Guidance
                                                 March 2008
                                         SPECIALTY CODING
                                      6. 11 Occupational Therapy

3656   6.11.3. Procedural Coding Rules
3657   CPT codes for occupational therapy procedures are in the Physical Medicine and
3658   Rehabilitation subsection of the Medicine Section (97003–97799). Activities of daily
3659   living (ADL) mock-ups for self-care home living are coded 97535 (and should not be
3660   used for education activities, like teaching the person to self-administer diabetic
3661   injections).
3662
3663   Osteopathic Manipulative Treatment codes may be used by Physical Therapist if
3664   authorized under their scope of practice (98925-98929).
3665
3666   6.11.4. Evaluations and Reevaluations
3667
3668   6.11.4.1. New vs. Established Patients
3669   There is no distinction for new or established patients. Code either an: evaluation 97003
3670   or reevaluation 97004 with or without modalities, or code just the modalities performed.
3671   The initial assessment of the problem is used to determine the appropriate therapy and
3672   prognosis. Various movements required for ADL are examined. Dexterity, range of
3673   motion, and other elements may also be studied. Reevaluations are for subsequent
3674   assessments to determine treatment success and make modifications as needed.
3675
3676   6.11.4.2. Reevaluation Is Part of Normal Service
3677   Reevaluation is part of the normal pre- and post-service. As with an E&M service, these
3678   evaluations should only be separately reported if the patient’s condition requires
3679   significant, separately identifiable E&M services.
3680
3681   6.11.5. Modalities
3682
3683   6.11.5.1. Modalities Included in Evaluation, Reevaluation
3684   Certain modalities (e.g., injection of anesthetic agents, range of motion measurements)
3685   are included in the evaluation and reevaluation procedural codes. For a list of these
3686   modalities refer to the National Correct Coding Initiative (NCCI) at the CMS Web.
3687   http://www.cms.hhs.gov/NationalCorrectCodInitEd/
3688
3689   6.11.5.2. One-on-One Contact
3690   Therapeutic procedures (97110–97546) require direct (one-on-one) patient contact by the
3691   provider. Basically, this means the provider must maintain visual, verbal, or manual
3692   contact with the patient throughout the procedure. For a technician to code an encounter,
3693   the technician must be working under a privileged provider’s plan of care. When the
3694   occupational therapist is actively involved in the therapy and assisted by a technician, the
3695   technician should be listed as an additional provider when coding the encounter.
3696
3697   6.11.6. Modifiers
3698   The HCPCS modifier GO is used in the civilian sector by occupational therapy to
3699   indicate that the therapy is being performed under an outpatient occupational therapy plan

                                                  6-50
                                            MHS Coding Guidance
                                                March 2008
                                         SPECIALTY CODING
                                      6. 11 Occupational Therapy

3700   of care. It does not specify a therapist furnished the care. The GO modifier is not used in
3701   the DoD system.
3702
3703   6.11.7. Documentation of Occupational Therapy
3704
3705   6.11.7.1. Requirements for CPT Code
3706   To support a CPT code, at a minimum each occupational therapy note needs to include
3707   therapist name, date, modality, treatment assessment (patient tolerated treatment), and
3708   adjustment to the therapy plan. Documentation based on a checklist alone is not
3709   sufficient for coding.
3710
3711   6.11.7.2. Required Elements
3712   The following elements need to be recorded by the therapist (or technician),
3713            The specific modalities or procedures (supervised or attended),
3714            The body area involved, and
3715            The start and stop times or total time for each treatment.
3716
3717   6.11.7.3. Coding for Pregnant Patients
3718   When a patient is pregnant, and the pregnancy affects the services provided (e.g., not
3719   pregnancy incidental, coded V22.2), the patient’s last menstrual period and estimated
3720   date of delivery need to be documented so they can be recorded in ADM.
3721
3722   6.11.8. Units of Service
3723
3724   6.11.8.1. Unit of Service Is 8-15 Minutes
3725   Constant attendance modalities and therapeutic modalities include ―each 15 minutes‖ in
3726   the code descriptions. Therefore, one unit of service is reported for each 15 minutes of
3727   therapy rendered per date of service. The table below is used to calculate units of service.
3728   A minimum of eight minutes must be performed to qualify for 1 unit of service.
3729
3730   6.11.8.2. Reporting Time Intervals
3731   For any single CPT procedure where unit of service is a factor, report time intervals for
3732   units of service as follows:
3733
             Unit of Service   Greater than or equal to   And fewer than
             1                 08 minutes                 23 minutes total for all
                                                          time-based modalities
             2                 23 minutes                 38 minutes total for all
                                                          time-based modalities
             3                 38 minutes                 53 minutes total for all
                                                          time-based modalities
             4                 53 minutes                 68 minutes total for all
                                                          time-based modalities
             5                 68 minutes                 83 minutes total for all
                                                          time-based modalities

                                                  6-51
                                            MHS Coding Guidance
                                                March 2008
                                         SPECIALTY CODING
                                      6. 11 Occupational Therapy

              6                83 minutes                  98 minutes total for all
                                                           time-based modalities
              7                98 minutes                  113-minutes total for all
                                                           time-based modalities
              8                113 minutes                 128-minutes total for all
                                                           time-based modalities
3734
3735   Units are calculated in the same manner for therapy that exceeds two hours.
3736
3737   6.11.8.3. Multiple CPT Procedures
3738   For multiple CPT procedures performed on the same calendar day, the total number of
3739   units does not equal the individual units of service for each service; rather, it equals the
3740   units of service for the total treatment time.
3741
3742   6.11.8.4. Group Therapy
3743   Multiple patients being given modalities or procedures during the same time are reported
3744   as group therapy. (See 97150)
3745
3746   6.11.9. Inpatient Therapy
3747

3748                  DoD Rule
3749
3750                  Inpatient therapy consults will be reported in ADM. When the screen
3751                  prompts Are you from the attending service? select NO. This will create the
3752                  encounter in ADM. Therapy related to the patient’s reason for admission is
3753                  not coded in the B MEPRS.




                                                    6-52
                                             MHS Coding Guidance
                                                 March 2008
                                   SPECIALTY CODING
                               6.12 Ophthalmology/Optometry
3754   6.12. Ophthalmology/Optometry
3755

3756                 DoD Rule
3757
3758                 Optometry clinic services are coded in an ambulatory service BHCx MEPRS
3759                 clinic. Ophthalmology clinic services, including services for pay patients are
3760                 coded in the ambulatory service BBDx MEPRS.
3761
3762
3763   6.12.1. E&M Rules
3764
3765   6.12.1.1. Optometrists
3766   An optometrist seldom uses an E&M office visit code in the 99201–99215 range.
3767
3768   6.12.1.2. Ophthalmologists
3769   Depending on the patient population and the number of associated optometrists,
3770   ophthalmologists commonly have 30 percent to 40 percent of their visits coded with
3771   E&M codes in the 99201–99499 range. Frequently, referrals are coded 99201–99215 and
3772   consults use 99240–99245 codes.
3773
3774   6.12.1.3. An E&M code may be used when a patient is seen for a medical reason that
3775   does not require any eye examination procedures. The most common instances when an
3776   E&M code is used are:
3777        Limited exams that do not meet the exam elements of an intermediate eye exam,
3778          but do meet the elements of a low-level E&M code (e.g., follow-up contact lens
3779          visit).
3780        Highly complex or risk-prone exams that meet the documentation elements of a
3781          99204/14 or 99215 E&M encounter.
3782        Examinations for medical reasons when no eye procedures are performed (e.g., an
3783          acute care visit for a subconjunctival hemorrhage).
3784
3785   6.12.2. Diagnosis Coding Rules
3786
3787   6.12.2.1. Routine Exams Active Duty (DoD Unique Visits)
3788   Encounters for DoD unique visits, such as aviation, military school screening, periodic,
3789   or termination exams, are reported using V70.5 with the appropriate extender (e.g.,
3790   Aviation exam V70.5_1). Any condition diagnosed during the examination is listed as an
3791   additional diagnosis.
3792
                    V CODES                          DESCRIPTION
                     V70.5 0            Armed Forces Medical Examination
                     V70.5 1            Aviation Examination
                     V70.5 2            Periodic Prevention Examination
                     V70.5 3            Occupational Examination
                     V70.5 4            Pre-Deployment Examination
                                                 6-53
                                          MHS Coding Guidance
                                              March 2008
                                        SPECIALTY CODING
                                    6.12 Ophthalmology/Optometry
                      V70.5   5          During Deployment Examination
                      V70.5   6          Post-Deployment Examination
                      V70.5   7          Fitness for Duty Examination
                      V70.5   8          Accession Examination
                      V70.5   9          Termination Examination
3793

3794                  DoD Rule
3795
3796                  Encounters for post-deployment related conditions have V70.5_6 as the
3797                  primary diagnosis and the patient’s physical condition listed second.

3798
3799   6.12.2.2. Routine Exams
3800
3801   6.12.2.2.1. Diagnosis Coding Based on Documentation
3802   Other than the DoD-required first-listed codes, diagnosis coding in optometry and
3803   ophthalmology is based on documentation. If the patient’s reason for the encounter is
3804   vision problems (e.g., myopia, presbyopia), that will be the first listed code. If the
3805   patient’s reason for the encounter is ―here for annual exam,‖ the most appropriate V code
3806   would be used.
3807
3808   6.12.2.2.2. Routine Eye Exams
3809   For non-active duty patients without any complaints or previously diagnosed
3810   ophthalmologic conditions, routine exams are coded V72.0, and any condition identified
3811   during the exam is an additional diagnoses.
3812           V 65.5        Feared Complaint—No symptoms
3813           V 67.59       Condition Resolved
3814           V 68.0        Driver’s Test
3815           V 72.0        Exam of Eyes and Vision
3816           V20.2         Routine infant or Child health check
3817
3818   6.12.2.2.3. Routine Exams with Complaints
3819   For routine exams (reason for encounter), with complaints or ophthalmologic conditions,
3820   the most appropriate V code would be the first-listed code with the applicable codes for
3821   the complaints or conditions listed as additional codes.
3822           367.1         Myopia
3823           367.21        Astigmatism, regular
3824           367.4         Presbyopia
3825           379.90        Disorder of the Eye—Unspecified
3826           379.91        Pain in or Around Eyes
3827           379.99        Other Ill-Defined Disorder of Eyes
3828
3829   6.12.2.2.4. Non-Routine Encounters
3830   Diagnostic codes are to be used at their highest level of specificity (fourth and fifth
3831   digits) and explicitness (e.g., chronic, acute, regular, irregular) to support medical
                                                   6-54
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                   6.12 Ophthalmology/Optometry
3832   necessity for procedures such as extended ophthalmology. Fourth and fifth digits should
3833   be used when available.
3834
3835   6.12.2.2.5. Special Screening for Glaucoma
3836   See glaucoma screening below for documentation requirements.
3837
3838   6.12.2.2.6. Diabetic Retinopathy
3839   Code 250.5x first, then use one of the following codes:
3840          362.01          Background diabetic retinopathy
3841          362.02          Proliferative diabetic retinopathy (NOS)
3842          362.03          Nonproliferative diabetic retinopathy (NOS)
3843          362.04          Mild nonproliferative diabetic retinopathy
3844          362.05          Moderate nonproliferative diabetic retinopathy
3845          362.06          Severe nonproliferative diabetic retinopathy
3846          362.07          Diabetic macular edema
3847
3848   6.12.3. Procedural Coding Rules
3849
3850   6.12.3.1. Optometrists
3851   Optometrists usually use the ophthalmology codes in the 92002–92396 range (e.g.,
3852   diagnosis and treatment) as well as the HCPCS codes V2020–V2799 and various other
3853   HCPCS codes. The most commonly used codes by optometrists are 92002–92014 for eye
3854   exams and 92015 for refractions. Optometrists associated with a refractive surgery program
3855   who do postoperative assessments will also frequently use 99024, postoperative follow-up
3856   visit.
3857
3858   6.12.3.2. Ophthalmologists
3859   Ophthalmologists also code a number of visits using the 92002–92014 ophthalmologic
3860   services codes, the diagnosis and treatment codes 92015–92396, and surgical eye and ocular
3861   adnexa codes 65091–68899. Ophthalmologists also frequently perform refractive surgery,
3862   coded S0800–S0830. Refractive surgery procedures tend not to have RVUs assigned by the
3863   CMS as they are not a CMS-covered benefit. It is very important that these services be
3864   coded correctly as they are specifically evaluated to determine the effectiveness of various
3865   refractive surgery programs.
3866
3867   6.12.3.3. Use of 92002–92499 Codes
3868   Usually optometrists and ophthalmologists use the 92002–92499 codes. When a technician
3869   does a simple acuity or visual function, the procedure codes 99172 and 99173 are
3870   appropriate. Dispensing glasses is a continuation of the visit when the glasses were
3871   prescribed or ordered and is not coded separately.
3872
3873   6.12.4. Eye Exams
3874
3875   6.12.4.1. CPT Codes for New and Established Patients
3876   CPT codes 92002, 92004, 92012, and 92014 for new and established ophthalmology or
3877   optometry patients include an evaluation and management of a patient. These codes are
                                                  6-55
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                   6.12 Ophthalmology/Optometry
3878   appropriate when the level of service includes several routine optometric or
3879   ophthalmologic examination techniques, such as slit lamp examination, keratometry,
3880   ophthalmoscopy, retinoscopy, tonometry, and sensorimotor evaluation that are integrated
3881   with and cannot be separated from the diagnostic evaluation.
3882
3883   6.12.4.2. Documentation Guidelines for 92 Series Eye Exam and Treatment Codes:
3884
3885   There is no specific history or medical decision-making guidelines for these codes.
3886   There are 13 exam elements that must be documented to validate a coding level:
3887               Testing visual acuity
3888               Gross visual fields
3889               Eyelids and adnexae
3890               Ocular motility
3891               Pupils
3892               Iris
3893               Conjunctiva
3894               Cornea
3895               Anterior chamber
3896               Lens
3897               Intra-ocular pressure
3898               Retina
3899               Optic disc
3900
3901      If three to eight of these elements are documented, an intermediate exam (92012 or
3902      92002) should be coded. If nine or more of these elements are documented, a
3903      comprehensive exam (92014 or 92004) should be coded
3904
3905      If fewer than three of these elements are documented, the lowest level E&M code
3906      (based on the documentation) should be coded along with the primary diagnosis
3907      (reason for visit or chief complaint).
3908
3909      Note that some procedures are bundled-included as part of / the 92 series exam codes.
3910      This means you would NOT put a separate CPT code for these procedures if done as
3911      part of the exam using a 92 series exam code. The bundled procedures are:
3912               Amsler grid
3913               Brightness acuity test (BAT)
3914               Corneal sensation
3915               Exophthalmometry
3916               General medical observation
3917               Glare test
3918               History
3919               Keratometry
3920               Laser interferometry
3921               Pachymetry

                                                6-56
                                          MHS Coding Guidance
                                              March 2008
                                         SPECIALTY CODING
                                   6.12 Ophthalmology/Optometry
3922                 Potential acuity meter (PAM)
3923                 Schirmer test
3924                 Slit lamp tear film evaluation and transillumination
3925
3926   NOTE: Corneal Pachymetry (76514) is separately reportable if a thorough
3927   evaluation of the cornea is performed along with image documentation,
3928   interpretation and report; no technical or professional modifiers should be
3929   reported. Code 76514 is reported only once, since it is considered a bilateral service.
3930   Therefore, if corneal pachymetry is performed on both eyes, modifier 50 would not
3931   be used.
3932
3933      All other services, tests, or procedures performed can be added as additional CPT
3934      codes, e.g., contact lens fitting, photography and foreign body removal, including
3935      refraction.
3936
3937   6.12.4.3. Refraction Code
3938   Any time refraction is performed, it is reported as an additional code, 92015 Refraction
3939   (can only use once, no multiple units).
3940
3941   6.12.4.4. Dilated Retinal Exams for Diabetics, S3000
3942   Diabetic indicator, retinal eye exam, dilated, bilateral. Diabetic patient exam encounters
3943   with a dilated, bilateral retinal eye exam as part of the comprehensive exam should be
3944   coded with additional code S3000 for the diabetic indicator.
3945
3946   6.12.4.5. Visual Screening
3947   When doing an occupational health screening use 99172 and 99173 (screening codes) for
3948   optometry. These codes are not to be used with 92002, 92004, 92012, and 92014 codes.
3949
3950   6.12.4.6. Fitting of Spectacles
3951   Minimal documentation requirements for optometrist or technician for the use of codes
3952   92340-92342 include: measurements of anatomical facial characteristics, records the
3953   laboratory specifications and performs the final adjustment of the spectacles to the visual
3954   axes and anatomical topography. If the final adjustment is performed on a later date, use
3955   V53.1. The supporting documentation must be contained within the medical record.
3956
3957   6.12.5. Glaucoma Screening (both military and nonmilitary)
3958
3959   6.12.5.1. Patients without a Primary Glaucoma Diagnosis
3960   For patients without a primary diagnosis of glaucoma, glaucoma screening is reported
3961   separately as V80.1. If this is part of an annual exam, list the annual examination V code
3962   of V70.5__2 followed by V80.1 as the second diagnosis.
3963
3964   6.12.5.2. Patients at High Risk for Glaucoma
3965   Charting documentation is specifically streamlined for the patient at high risk for
3966   glaucoma. The history will include the obvious risk factors for glaucoma (age, race,
3967   family history, trauma, corticosteroid use, and diabetes). Elements of the exam must be
                                                   6-57
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                    6.12 Ophthalmology/Optometry
3968   clearly documented if glaucoma screening is the only ophthalmologic or optometric
3969   service reported for high-risk patient’s code.
3970           G0117 Glaucoma screening for high-risk patients, furnished by an optometrist or
3971           ophthalmologist
3972           G0118 Glaucoma screening for high-risk patients, furnished under the direct
3973           supervision of an optometrist or ophthalmologist
3974
3975   6.12.5.3. Screening for Glaucoma
3976   Glaucoma screening is defined to include:
3977        A dilated eye examination with an intraocular pressure measurement; and
3978        A direct ophthalmoscopy examination, or slit-lamp biomicroscopic examination
3979
3980   6.12.5.4. Glaucoma Screening for Diabetics
3981   Glaucoma screening performed on diabetics during a general ophthalmologic exam is
3982   identified with an additional HCPCS Level II code, S3000, diabetic indicator, retinal
3983   eye exam, dilated, bilateral. This is for population health data collection purposes only,
3984   not for reimbursement.
3985
3986   6.12.6. Coding for the Optometric or Ophthalmology Technician
3987
3988   6.12.6.1. When the technician provides services for a patient in conjunction with an
3989   optometrist or ophthalmologist, the technician is reported in ADM as an additional
3990   provider using the designation paraprofessional. Additional codes for any procedures the
3991   technician performs (e.g., spectacle ordering, visual field) are to be reported.
3992
3993   6.12.6.2. When a technician provides services at a separate encounter, the correct
3994   procedures (e.g. 99173, visual acuity screening) are entered in the CPT/HCPCS field .
3995
3996          Example: Patient seen by technician for vision exam portion of routine physical
3997          V70.5_2      Routine annual physical
3998          99173        Screening test of visual acuity
3999
4000   6.12.7. Refractive Surgery
4001

4002                  DoD Rule
4003
4004                  S0800 will be used for both LASIK and LASEK procedures until a code is
4005                  created for LASEK procedures.
4006
4007                  When available, use modifier -54 and -55 with S0800 and S0810 codes.

4008




                                                  6-58
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                   6.12 Ophthalmology/Optometry
4009   Examples for lasik/lasek:
4010
4011   Pre-op:
4012         Diagnosis 1: V72.83 Other Specified Pre-Op Exam
4013         E&M N/A
4014         Procedure Code(s) as applicable:
4015                       92004 Comprehensive New
4016                       92014 Comprehensive Established
4017                       92015 Refraction (can only use once, no multiple units)
4018                       S0820 Computerized Corneal Topography (Has been replaced with
4019                              92025 and should be used if available.)
4020                       76514 Pachymetry (no 50 modifier, code is automatically bilat.)
4021
4022          Diagnosis 2: Hypermetropia 367.0, Myopia 367.1, Astigmatism 376.2, etc.
4023
4024   Procedure:
4025          Diagnosis: Hypermetropia 367.0, Myopia 367.1, Astigmatism 376.2, etc.
4026          E&M N/A
4027          Procedure Code(s) as applicable:
4028                        S0800 LASIK
4029                        S0810 PRK
4030                        Use 50 modifier for bilateral, use 54 modifier if all f/u at another
4031                        MTF
4032                        Cannot use 65760 Keratomileusis or 92070 Therapeutic CL
4033   Post-op:
4034          At same MTF:
4035          Diagnosis 1: V67.09 Follow-up Examination, Following Other Surgery
4036          E&M: N/A
4037          Procedure Code: 99024 (Exception: post-op complication, code diagnosis
4038                          first and code as 92014 Comprehensive Established
4039
4040          Diagnosis 2: V45.69 Postsurgical State of the Eye and Adnexa
4041
4042          At different MTF:
4043          Diagnosis 1: V67.09 Follow-up Examination, Following Other Surgery
4044          E&M: N/A
4045          Procedure Code: S0800 or S0810 with 55 modifier for first f/u encounter,
4046          subsequent encounters 99024 (Exception: post-op complication, code
4047          diagnosis first and code as 92014 Comprehensive Established
4048
4049          Diagnosis 2: V45.69 Postsurgical State of the Eye and Adnexa
4050
4051   Pre-op Exams:
4052       The primary Dx code should be V72.83 ―other specified pre-op exam‖.
4053         Secondary are things like myopia, etc. The referral exam should be coded as a
4054         comprehensive eye exam (92004 for new patient or 92014 for prior patient).
                                               6-59
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                    6.12 Ophthalmology/Optometry
4055         Corneal Topography: This actually had an ―S‖ code of S0820- Computerized
4056          corneal topography, unilateral (had .35 MHS RVUs). It now has its own CPT
4057          code, 92025- ―Computerized corneal topography, unilateral or bilateral, with
4058          interpretation and report. Intended to be reported when topography is not
4059          performed in conjunction with keratoplasty procedures (65710, 65730, 65750 and
4060          65755)‖. However, this code is not available in the current version of AHLTA, so
4061          S0820 must still be used (See AHLTA sample below). Use 50 modifier if
4062          bilateral until the new code is in place.
4063         Pachymetry: When this is documented with interpretation it can be coded as
4064          76514. The requirement does not specify the exact instrument used, and
4065          ―permanently recorded images are not required‖.
4066
4067   6.12.7.1. V72.83 Other Specified Preoperative Exam
4068   This code will be the first listed. The diagnosis that is the reason for the surgery will be a
4069   secondary code, followed by any conditions that may affect treatment.
4070
4071   6.12.7.2. Postoperative Care
4072   Postoperative care following eye surgery may be performed or shared between providers
4073   (e.g., when the surgery is done at another facility). When one provider performs the
4074   surgery, and postoperative care will be provided at a different MTF, the surgeon will
4075   code the procedure followed by modifier -54 to indicate only performance of
4076   intraoperative care, (e.g., S0810–54). The provider at a different MTF performing the
4077   first episode of postoperative care codes the encounter using modifier -55, (e.g., S0810–
4078   55) postoperative. Additional uncomplicated follow-up care for this service is coded
4079   with 99024, indicating subsequent visits within the 90-day global period. The provider
4080   may be entitled to code additional services performed in the evaluation of a new patient
4081   in accordance with procedural coding rules. When providing postoperative care, the date
4082   of procedure is included in the documentation.
4083
4084   6.12.8. Extended Ophthalmoscopy with Retinal Drawing
4085
4086   6.12.8.1. Ophthalmoscopy
4087   Extended (92225) and subsequent (92226) ophthalmoscopy are considered reasonable
4088   and necessary services for evaluation of tumors of the retina and choroid (the tumor may
4089   be too peripheral for an accurate photograph), retinal tears, detachments, hemorrhages,
4090   exudative detachments, and retinal defects without detachment, as well as other ocular
4091   defects when the patient’s medical record meets the documentation requirements set forth
4092   in this policy. These codes are reserved for the meticulous evaluation of the eye and
4093   detailed documentation of a severe ophthalmologic problem when photography is not
4094   adequate or appropriate.
4095
4096   6.12.8.2. Frequency of Service
4097   Frequency for providing these services depends on the medical necessity of each patient
4098   and this, of course, relates to the diagnosis. A serious retinal condition must exist or be
4099   suspected, based on routine ophthalmoscopy, which requires further detailed study.
4100
                                                   6-60
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                   6.12 Ophthalmology/Optometry
4101   6.12.8.3. Medical Necessity
4102   In all instances, extended ophthalmoscopy must be medically necessary. It must add
4103   information not available from the standard evaluation services or information that will
4104   demonstrably affect the treatment plan. It is not medically necessary, for example, to
4105   confirm information already available by other means.
4106
4107   6.12.8.4. Major Criteria
4108   These criteria must be met:
4109
4110         A serious retinal condition is present based on ophthalmoscopy, which
4111          requires further study, such as the detailed study of pre-retinal membrane, a
4112          retinal tear detachment, a suspected retinal tear with sudden onset of
4113          symptomatic floaters or vitreous hemorrhage.
4114         Another diagnostic technique in addition to routine direct and indirect
4115          ophthalmoscopy is necessary and documented; for example 360º scleral
4116          depression, fundus contact lens, or 90-diopter lens.
4117         The technique and findings of the extended ophthalmoscopy must be
4118          documented, including a three-dimensional representation or an extended
4119          colored retinal drawing. Sketches and templates are not acceptable. The
4120          documentation of follow-up services (92226) must include an assessment of
4121          the change from previous examinations.
4122         Documentation supporting the medical necessity of this item, such as ICD-9
4123          codes, must be submitted with each encounter.
4124
4125   6.12.9. Modifiers
4126   The most commonly used modifiers (and most frequently found to be missing in audits)
4127   in optometry or ophthalmology are the LT for left and the RT for right when unilateral
4128   codes are used; such as removal of foreign body. Many of the procedures for the eye are
4129   inherently bilateral. When one of these procedures is done on only one eye, add modifier
4130   -52, reduced services, as well as the modifier RT for right or LT for left.
4131




                                                6-61
                                          MHS Coding Guidance
                                              March 2008
                                         SPECIALTY CODING
                                          6.13 Physical Therapy

4132   6.13. Physical Therapy—Coding for Physical Therapist or Technician
4133
4134   6.13.1. E&M Coding Rules
4135   E&M codes are not appropriate for routine physical therapy (PT). The evaluation and
4136   management components of an outpatient office E&M are already included in special
4137   physical therapy evaluation and reevaluation procedural codes, as indicated below.
4138
4139   6.13.2. Diagnosis Coding Rules
4140
4141   6.13.2.1. Outpatient PT
4142   Outpatient PT encounters for the purpose of receiving therapy are always coded with
4143   V57.1 as the first listed diagnosis.
4144
4145   NOTE: When a patient presents for evaluation and therapy is initiated on the same
4146   day, do not use V57.1. Code the condition as primary diagnosis.
4147
4148   6.13.2.2. Evaluative PT
4149   PT encounters for evaluation only, or for attending runner’s clinics, or group educational
4150   classes, would not be identified by V57.1. Exercise counseling (e.g., runner’s clinic) is
4151   an education V code, V65.41. If the purpose of the encounter is evaluation, use the
4152   appropriate ICD-9-CM diagnosis or symptom code in the first SADR position.
4153

4154                  DoD Rule
4155
4156                  V57.1 will be the first listed code for all PT encounters involving therapy
4157                  only. The condition(s) for which the patient is receiving therapy will be listed
4158                  in the second or third position. PT encounters for post-deployment therapy
4159                  sessions will have V70.5_6 as the third or fourth code.

4160
4161   6.13.2.3. Injuries
4162   When functioning in the role of physician extender, physical therapists may render a
4163   diagnosis. If this is the first time the patient has been seen at the facility for the current
4164   injury, use the appropriate injury code followed by the appropriate E code. You must
4165   also document date of injury. PT services are only coded with aftercare, follow-up care,
4166   and pain-, muscle-, or joint-related diagnoses.
4167
4168   Example: A patient comes in with back pain that is the result of lifting a heavy item.
4169   The patient has not been seen in the ED or by any other provider for this pain. Physical
4170   therapist examines the back and determines there is a strained muscle. PT evaluation was
4171   done and therapy was not started that day.
4172           Codes: ICD-9 847.1 (thoracic back strain), E927 (lifting injury)
4173                  E&M N/A
4174                  CPT 97001 (evaluation)
                                                    6-62
                                             MHS Coding Guidance
                                                 March 2008
                                        SPECIALTY CODING
                                         6.13 Physical Therapy

4175   Example: Patient encounter for first PT session for a previously treated thoracic back
4176   sprain. PT evaluation was conducted at the previous visit. Modalities provided to the
4177   patient on this day were electrical stimulation and hot packs.
4178           Codes: ICD-9 V57.1, (physical therapy)
4179                          847.1 (thoracic back strain)
4180                   E&M N/A
4181                   CPT 97014 (electrical stimulation)
4182                          97010 (hot pack)
4183
4184   6.13.3. Procedural Coding Rules
4185   CPT codes for rehabilitation procedures are in the Physical Medicine and Rehabilitation
4186   subsection of the Medicine Section (97001—97799). A clinic visit for evaluation only
4187   with no therapy is given a CPT code of 97001. For education by a non-privileged
4188   provider (PT technician) the appropriate HCPCS S codes are S9451 exercise and S9454
4189   stress management.
4190
4191   6.13.4. Evaluations and Reevaluations
4192   There is no distinction for new or established patients. Code either an evaluation, 97001
4193   or reevaluation, 97002 with or without modalities, or code just the modalities performed.
4194   The initial assessment of the problem is to determine the appropriate therapy, the
4195   increments, frequency, duration, and other factors necessary to enhance healing.
4196   Reevaluations are for subsequent assessments to determine the success of the treatment
4197   and make modifications as needed.
4198
4199   6.13.5. Modalities
4200   Certain modalities are inclusive of the evaluation and reevaluation procedural codes. For
4201   a list of these modalities you may refer to the NCCI. NCCI edits are at:
4202   http://www.cms.hhs.gov/NationalCorrectCodInitEd/. Constant attendance modalities
4203   (97032–97039) and therapeutic procedures (97110–97546) require direct, one-on-one
4204   patient contact by the provider. Basically, this direct one-on-one contact requires that the
4205   provider maintain visual, verbal, or manual contact with the patient throughout the
4206   procedure. For a technician to code an encounter, the technician must be working under
4207   a privileged provider’s plan of care. When the physical therapist is actively involved in
4208   the therapy and assisted by a technician, the technician should be listed as an additional
4209   provider when coding the encounter.
4210
4211   6.13.6. Units of Service
4212
4213   6.13.6.1. Time as Unit of Service
4214   Constant attendance modalities and therapeutic modalities are each 15 minutes in the
4215   code descriptions. Therefore, one unit of service is reported for each 15 minutes of
4216   therapy rendered per date of service. The table below is used to calculate units of service.
4217   A minimum of 8 minutes must be performed to qualify for 1 unit of service.
4218
4219
                                                  6-63
                                            MHS Coding Guidance
                                                March 2008
                                        SPECIALTY CODING
                                         6.13 Physical Therapy

4220   6.13.6.2. Reporting Time Intervals
4221   For each CPT procedure where unit of service is a factor, report time intervals for units of
4222   service as follows:
4223
             Unit of Service       Greater than or equal to      Less than
             1                     08 minutes                     23 minutes
             2                     23 minutes                     38 minutes
             3                     38 minutes                     53 minutes
             4                     53 minutes                     68 minutes
             5                     68 minutes                     83 minutes
             6                     83 minutes                     98 minutes
             7                     98 minutes                    113 minutes
             8                     113 minutes                   128 minutes
4224
4225   Units are calculated in the same manner for therapy that exceeds two hours.
4226
4227   6.13.6.3. Treatment Time for Multiple Procedures
4228   For multiple CPT procedures performed on the same calendar day, the total amount of
4229   treatment time determines the number of units for the day. Each modality and amount of
4230   time needs to be documented, not a total time given for all modalities. A minimum of 8
4231   minutes for each modality provided is needed in order to report time.
4232
4233   6.13.6.4. Group Therapy Procedures
4234   Group therapy involves constant attendance by the physician or therapist, but by
4235   definition does not require one-on-one patient contact by the physician or therapist.
4236   Report code 97150 for each member of the group and provide documentation for the
4237   therapies the patients received, including minutes of activity.
4238
4239   6.13.7. Modifiers
4240   The HCPCS modifier GP is used in the civilian sector by physical therapy to indicate that
4241   the therapy is being performed under an outpatient physical therapy plan of care. It does
4242   not specify a therapist furnished the care. The GP modifier is not used in the DoD
4243   system.
4244
4245   6.13.8. Documentation of Physical Therapy
4246
4247   6.13.8.1. Note Requirements
4248   To support a CPT or HCPCS code, at a minimum each physical therapy note needs to
4249   include therapist’s name, modality, treatment assessment (patient tolerated treatment),
4250   and adjustment to the therapy plan. Documentation based on a checklist alone is
4251   insufficient.
4252
4253   6.13.8.2. Required Elements
4254    The following elements need to be recorded by the therapist or technician
4255        The specific modalities or procedures (supervised or attended),
                                                  6-64
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                                         6.13 Physical Therapy

4256         The body area involved,
4257         The start and stop times or total time for each modality,
4258         Access to a plan of care for reference to modalities and therapies being provided
4259          by the technician.
4260
4261   6.13.8.3. For pregnant patients, the date of the patient’s last menstrual period and
4262   estimated date of delivery must be recorded in ADM.
4263
4264   6.13.9. Inpatient Therapy
4265   Evaluations and Re-evaluations for physical therapy are coded in the B MEPRS.
4266   Physical therapy modalities related to the admission are not coded.




                                                   6-65
                                            MHS Coding Guidance
                                                March 2008
                                        SPECIALTY CODING
                                   6.14 Preventive Medicine Services

4267   6.14. Preventive Medicine Services
4268   There are two basic types of preventive medicine services, physicals or well-baby visits
4269   and counseling or risk-factor reduction intervention. Section 6.14.1 is about physicals
4270   and well-baby visits. Section 6.14.2 is about counseling and risk factor reduction
4271   intervention.
4272

4273                  DoD Rule
4274
4275                  If an additional problem or issue is identified and treated, an additional
4276                  office E&M code may be warranted.
4277
4278                  If the encounter intent is preventive (e.g., a physical), code the preventive
4279                  E&M encounter (e.g., 99384–7, 99394–7) first, even though problems or
4280                  issues addressed constitute an additional problem-oriented E&M code (e.g.,
4281                  99212) based on the separate problem-oriented documentation. Append
4282                  modifier -25 to the problem-oriented E&M (e.g., 99212-25).

4283
4284   6.14.1. Physicals and Well-Baby Visits
4285
4286   6.14.1.1. E&M Rules
4287
4288   6.14.1.1.1. Categorization
4289   Preventive medicine E&M services, such as physicals and well-baby checks, are
4290   categorized by patient age and status. These E&M codes include a comprehensive
4291   history and a comprehensive examination. The history obtained as part of the preventive
4292   medicine service is not problem oriented and does not involve a chief complaint or
4293   present illness.
4294
4295   6.14.1.1.2. Visit Comparisons
4296   The following table provides preventive medicine visit comparisons:
4297
                            Preventive         Problem Oriented      Preventive Medicine Visit with
                          Medicine Visit               Visit         Problem 993xx and 992xx with
                          99381–99397             99201–99215        modifier -25
       Chief          Healthy patient,         Chief complaint       Healthy patient with significant
       complaint      absence of               specified             complaint
                      complaints.
                      Insignificant or
                      trivial problem
       History        Not problem              Description of the    Include history 1) related to
                      oriented.                history of present    age/gender and 2) present illness
                      No description of        illness as
                      present illness.         appropriate for the
                      Assessment of            presenting problem
                      pertinent risk factors
                                                     6-66
                                               MHS Coding Guidance
                                                   March 2008
                                         SPECIALTY CODING
                                    6.14 Preventive Medicine Services

                             Preventive         Problem Oriented       Preventive Medicine Visit with
                           Medicine Visit              Visit           Problem 993xx and 992xx with
                            99381–99397            99201–99215         modifier -25
       Review of        Comprehensive           To the extent          Combine system review and
       systems—         system review.          appropriate for the    presenting problem
       past, family,    Comprehensive past,     presenting problem
       social history   family, and social
                        history
       Examination      Extent of the           Level of exam as       Level of exam as appropriate to
                        examination is based    appropriate to         evaluate the presenting problem
                        on the age of the       evaluate the           1) related to age/gender and 2)
                        patient and risk        presenting problem     present illness
                        factors identified
       Assessment       Screening for           Ancillary services     Combination of screening and
       and plan         ancillary services      ordered for specific   medical decision making
                        without complaint.      medical
                        Typically related to    problem(s).
                        counseling,             Medical decision-
                        anticipatory            making reflected
                        guidance, risk factor
                        reduction
4298
4299   6.14.1.1.3. Determining Proper Code Category
4300   The issue is not how healthy the patient is, but rather how much work the provider does.
4301   Use problem-oriented office visit codes when the documentation shows significant
4302   medical decision making.
4303
4304   Documentation points to preventive medicine codes when a patient presents for routine
4305   services (annual exam) and documentation does not show that a significant problem is
4306   addressed. Documentation points to preventive medicine codes when there are no patient
4307   complaints, no symptoms, and no significant problem or abnormality is recorded.
4308
4309   6.14.1.1.4. A Physical and a Condition
4310   Frequently, a patient will schedule an appointment but identify other issues at the
4311   encounter that require medical intervention. When the condition requires significant time
4312   and resources, it should be documented separately from the physical. There is usually a
4313   second SOAP (Subjective, Objective, Assessment, Plan) note after the physical
4314   documentation. Code the physical E&M (i.e., 99381–99397) linking the physical
4315   diagnosis to the physical E&M. Then code an office visit E&M (e.g., 99212) with a
4316   modifier -25, linking the medical condition to the office visit E&M.
4317
4318       Example: Well-baby visit with a second diagnosis of acute otitis media. The first
4319       E&M code, 993xx, would be linked to the well-baby visit (V20.2), while the 992xx-
4320       25 would be linked to the acute otitis media diagnosis (382.9).



                                                      6-67
                                                MHS Coding Guidance
                                                    March 2008
                                       SPECIALTY CODING
                                  6.14 Preventive Medicine Services

4321   6.14.1.2. Diagnosis Coding Rules
4322
4323   6.14.1.2.1. The V codes identify diagnoses when a person is not currently or acutely ill,
4324   but requires healthcare services. Some of the commonly used codes include:
4325
4326          V20.2           Well-baby examinations
4327          V68.09          Issue of medical certificate for full flying duties (FFD)/Return to
4328                          flight status (RTFS)
4329          V70.3           Sports physicals/ school physicals
4330          V70.5_ _ 1      Annual flight examinations
4331          V70.5_ _ 4      Pre-deployment prevention examinations
4332          V70.5_ _ 6      Post-deployment prevention examinations
4333          V72.31          Annual GYN examinations
4334
4335   6.14.1.2.2. Post-Deployment Visits
4336   The provider should assess if the visit is deployment related. All deployment-related
4337   visits must have the deployment code listed in one of the first four positions. See section
4338   2.2.8.2. of this manual. The deployment related codes are V70.5_4/5/6.
4339
4340   6.14.1.3. Procedure Coding Rules
4341
4342   6.14.1.3.1. Immunizations
4343   Those given at point of service (in the clinic performing the well-baby visit or other
4344   physical) are coded on the same encounter as the physical.
4345
4346   6.14.1.3.2. Vision Screening
4347   The 92xxx codes are inappropriate for vision screening in conjunction with a physical.
4348   Possible codes are 99172 or 99173.
4349
4350   6.14.1.3.3. Blood Pressure
4351   Measurement of blood pressure is a vital sign and collected as a part of the constitutional
4352   evaluation with other vital signs. It is inappropriate to use 93770 for arterial blood
4353   pressure measurement obtained at patient intake.
4354
4355   6.14.1.3.4. Codes to Assist in Population Health Management
4356   Consider using the category II codes for smoking if the MTF emphasizes smoking
4357   cessation (i.e., S9075and S9453).
4358
4359   6.14.2. Counseling and Risk Factor Reduction Interventions
4360   The second basic type of preventive medicine services is counseling or risk factor
4361   reduction intervention.
4362
4363   One of the more common coding errors in the DoD is using a preventive medicine,
4364   individual, or group counseling code, when an education code should have been

                                                  6-68
                                            MHS Coding Guidance
                                                March 2008
                                      SPECIALTY CODING
                                 6.14 Preventive Medicine Services

4365   used. Use a counseling or risk factor reduction intervention code when there is no
4366   condition, symptom, or disease.
4367
4368   For instance, a couple is considering having a child and the woman’s nephew has Tay-
4369   Sachs. The couple does not have a child with Tay-Sachs, but there is a risk they could
4370   since a nephew has it. This is therefore a counseling session. If the couple had already
4371   had a child with Tay-Sachs and was seeing a provider to learn more about the disease and
4372   how to manage their child, it would be education.
4373
4374   Another example: Discussion about having a prophylactic mastectomy because a
4375   woman’s mother and sister both had breast cancer is counseling. Discussion on treatment
4376   options for a woman diagnosed with breast cancer is an office visit. Occupational
4377   therapy to improve ADL after the mastectomy is occupational therapy. Classes
4378   addressing post-mastectomy issues are education. Prenatal, obesity, and diabetes classes
4379   are education.
4380
4381   NOTE: When an applicable education class code is not available in HCPCS (many
4382   are around S9436), use the 99078 CPT code, if applicable. These are procedure
4383   codes and would be coded in the procedure field of the ADM.
4384
4385   6.14.2.1. E&M
4386   The appropriate E&M codes should be assigned based on the documentation of the
4387   services performed: Counseling or risk factor reduction E&M codes include 99401–
4388   99404 and 99411–99412. To determine if the counseling or risk factor reduction codes
4389   are appropriate, ask: Was the encounter for an examination, education, or counseling?
4390
4391   If the provider sees the patient for a problem, reviews the patient’s health assessment
4392   form as part of the visit, and does risk factor reduction intervention (e.g., noticed on
4393   health assessment form that the patient does not wear sunscreen and has been sunburned
4394   a number of times), assign the office-outpatient codes 99201–99215. If the counseling
4395   (e.g., about protection from the sun) takes more than 50 percent of the time of the
4396   encounter, and it is documented, the encounter may be coded based on time instead of the
4397   history, exam and decision making. Office visits not documented as a new visit should
4398   be coded for established patients.
4399
4400   Diagnosis coding is based on the provider’s assessment of problems or illnesses and any
4401   counseling provided. It is also based on the type of exam or counseling performed and
4402   any problems or illnesses assessed as part of the examination.
4403
4404   If the provider is conducting preventive medicine counseling or risk factor reduction
4405   counseling, (e.g., counseling on safe sex) the 99401–99404 codes should be assigned.
4406
4407   NOTE: These codes are not to be used to report counseling and risk factor
4408   reduction interventions provided to patients with symptoms or established illness.
4409   The code selection is based on time. Documentation must support the reason for the
                                                 6-69
                                          MHS Coding Guidance
                                              March 2008
                                       SPECIALTY CODING
                                  6.14 Preventive Medicine Services

4410   amount of time used. For instance: Counseled on safe sex, 30 minutes would not
4411   adequately explain the amount of time involved.
4412
4413      Example: The 99411–99412 codes are appropriate for all students when the
4414      provider is teaching a healthy heart class for a general audience, even if one of
4415      the participants is diabetic, another is hypertensive, and a third is obese.
4416
4417   6.14.2.2. Diagnosis Coding for Preventive Encounters
4418   Diagnosis coding is based on the type of counseling provided. When counseling is
4419   provided, frequently used ICD-9-CM codes include:
4420
4421          V16.X          Family history of malignant neoplasm
4422          V17.X          Family history of certain chronic disabling diseases
4423          V25.09         Family planning (counseling for contraceptive mgt)
4424          V65.3          Dietary surveillance and counseling
4425          V65.40         Other counseling, no other symptoms
4426          V65.41         Exercise counseling
4427          V65.42         Counseling on substance use and abuse (this is a root code, use the
4428                         appropriate DoD extender code)
4429          V65.43         Counseling on injury prevention
4430          V65.44         HIV counseling
4431          V65.45         Counseling on other sexually transmitted diseases
4432          V65.46         Encounter for insulin pump training
4433          V65.49_x       Other specified counseling (this is a root code, use the appropriate
4434                         DoD extender code)
4435          V69.0          Lack of physical exercise
4436          V69.1          Inappropriate diet and eating habits
4437          V69.2          High-risk sexual behavior
4438          V69.3          Gambling and betting
4439          V69.8          Other lifestyle-related problems
4440          V69.9          Problem related to lifestyle, unspecified
4441
4442   6.14.2.3. Procedures
4443   Separate procedures for counseling or risk factor reduction are rarely done during an
4444   encounter.
4445
4446   6.14.3. Modifiers
4447           -25   Append to any separate office visit E&M services provided.
4448                 Reported in addition to the preventive medicine service codes.
4449
4450   6.14.4. Documentation
4451   For counseling, the amount of time spent with the patient as well as the time counseling
4452   the patient must be included in the documentation in addition to the date (e.g.. 12 Oct 04,
4453   0900–0930, counseling 20 minutes). Additional documentation guidelines are:
4454        Patient presents for annual physical when using preventive medicine codes.
                                                 6-70
                                           MHS Coding Guidance
                                               March 2008
                                  SPECIALTY CODING
                             6.14 Preventive Medicine Services

4455      Patient presents for multiple concerns as well as health maintenance when using
4456       both a low-level office visit and a preventive medicine code.
4457      When reporting preventive medicine counseling codes, document the nature of
4458       the counseling and any education provided during the encounter.
4459      Do not document patient presents for yearly exam when using a problem-
4460       oriented visit code.




                                             6-71
                                      MHS Coding Guidance
                                          March 2008
                                    SPECIALTY CODING
                               6.15 Radiation Oncology Services
4461   6.15. Radiation Oncology Services
4462
4463   6.15.1. E&M Coding Rules
4464   E&M codes are used in radiation oncology for services such as consultation, pre-
4465   treatment evaluations, and non-routine follow-up visits. Select the appropriate code from
4466   the documentation in the E & M section. For example, an inpatient might be evaluated
4467   by the therapeutic radiologist to determine treatment options before a decision for
4468   treatment is made. This visit would be coded as an initial inpatient consultation or
4469   subsequent hospital care, as appropriate.
4470
4471   6.15.2. Diagnosis
4472   Code the reason for the encounter. For instance, if the patient is being seen for radiation
4473   therapy, the first code will be:
4474
4475   V58.0 Radiotherapy. However, coding convention holds that this therapy is conducted if
4476   the malignancy still exists. Therefore, the malignancy should also be coded. The
4477   neoplasm table in the ICD-9-CM book is simple to use and codes may be taken directly
4478   from it without referring to the tabular.
4479
4480   6.15.3. Procedural Treatment Planning Rules
4481
4482   6.15.3.1. Radiation Oncology
4483   This treatment is used to destroy tumors and has professional and technical components.
4484   Procedure codes are for initial consultation through patient management of the entire
4485   course of treatment.
4486
4487   6.15.3.2. Treatment and Planning Codes
4488   Privileged providers document treatment and planning using codes 77261, 77262 and
4489   77263. These codes include the initial consultation, so there is no separate E&M.
4490
4491   6.15.3.3. Clinical Treatment, Planning, and Tumor Mapping
4492   This is used to identify the location, extent, volume of tumor(s) to be treated, and all
4493   critical structures surrounding them. The privileged provider plans an individualized
4494   course of radiation therapy that allows maximum benefit while protecting surrounding
4495   tissues and structures. These codes include clinical treatment planning, which may
4496   involve interpreting special tests. These professional services are usually provided once
4497   during the course of treatment and include a follow-up period of up to three months
4498   after treatment, unless a separate plan is implemented.
4499
4500   6.15.3.4. Simulation (77280–77295)
4501
4502   6.15.3.4.1. Simulation
4503   The purpose of simulation is to determine treatment options and the placement of ports
4504   for radiation treatment. It does not include the administration of radiation. The
4505   complexity of a simulation is based on the number of ports, volumes of interest, inclusion
4506   and type of treatment devices.
                                                  6-72
                                            MHS Coding Guidance
                                                March 2008
                                       SPECIALTY CODING
                                  6.15 Radiation Oncology Services
4507
4508   6.15.3.4.2. Simulations Not Reported Separately
4509   Simulations that are not to be reported separately are: (1) portal changes based on
4510   unsatisfactory initial simulations, (2) minor changes in port size without changes in beam
4511   and simulation set up. The simulation set up is part of a period of treatment management,
4512   usually in units of five.
4513
4514   6.15.3.4.3. Additional Simulations
4515   These may be necessary during treatment to account for changes in port size, boost dose,
4516   or tumor volume. Simulations need to be ordered by the privileged provider and
4517   documentation should be completed and signed with the results. Documentation should
4518   include the date, reason (initial, block check, subsequent, etc.), and a summary of the
4519   procedure.
4520
4521   6.15.3.4.4. Teletherapy Isodose
4522   If the documentation of the simulation supports CPT 77295, then teletherapy isodose
4523   (77305–77315) plans are also reported.
4524
4525   6.15.3.4.5. Level of Complexity of Treatment Planning and Simulation Services
4526   The levels of complexity for these services are clearly identified in the CPT code. All
4527   criteria do not have to be met to establish the level of complexity. For example, three
4528   or more separate treatment areas with simple blocking or no blocking would qualify as a
4529   complex service.
4530
4531   6.15.4. Medical Radiation Physics
4532
4533   6.15.4.1. Basic Dosimetry 77300
4534   The calculation of the radiation dose and placement is called dosimetry. The radiation
4535   oncologist must order these services as part of the treatment plan. These are reported
4536   once per port and may be repeated if documentation supports the reason for the new
4537   calculation.
4538
4539   6.15.4.2. IMRT-Intensity Modulated Treatment Delivery
4540   IMRT Planning—77301
4541
4542   6.15.4.3. Teletherapy Isodose Plans 77305–77315
4543   Teletherapy Isodose plans are coded once for a specific treatment area. An additional
4544   plan maybe coded if documentation supports that it was medically necessary to change
4545   fields or equipment, or if clinical variations are made during the course of treatment.
4546   6.15.4.4. Special Therapy Port Plan 77321
4547   This should be coded only once per treatment area (volume of interest) and not in
4548   conjunction with 77300.
4549



                                                 6-73
                                           MHS Coding Guidance
                                               March 2008
                                       SPECIALTY CODING
                                  6.15 Radiation Oncology Services
4550   6.15.4.5. Special Dosimetry 77331
4551   This service is the measurement of the actual amount of radiation a patient has received
4552   at any given point. The radiation oncologist must order this service. This code may be
4553   used more than once per day per treatment course.
4554
4555   6.15.4.6. Treatment Devices 77332–77334
4556   Multiple devices may be coded if documentation substantiates. If two devices of separate
4557   levels of complexity are documented, code only the one of the higher level.
4558
4559   6.15.5. Radiation Physics Consultations
4560
4561   6.15.5.1. Continuing Medical Physics Consultation 77336
4562   CPT clearly identifies the documentation requirements. This code may be reported
4563   weekly.
4564
4565   6.15.5.2. Special Medical Radiation Physics Consultation 77370
4566   This code may only be reported once per course of treatment. This is used when a
4567   problem or situation arises during treatment. It requires a written analysis or report of the
4568   course of treatment, and is done at the direct request of the radiation oncologist.
4569
4570   6.15.6. Radiation Treatment Delivery Codes 77401–77416
4571   Radiation treatment delivery codes are used for the actual delivery of the radiation and
4572   consist of the technical component only. This code is chosen by level of service and
4573   energy used. Multiple treatment sessions on the same day may be coded when there is a
4574   break in sessions. The record should document a distinct break in therapy.
4575
4576   6.15.7. Radiation Treatment Management 77427–77499
4577
4578   6.15.7.1. Radiation treatment management codes consist of the professional component
4579   only. CPT identifies documentation requirements for these services. This includes review
4580   of port films and dosimetry, dose delivery, and treatment parameters, review of treatment
4581   set up, and examination of patient for medical evaluation and management. The
4582   documentation must clearly identify that the radiation oncologist examined the patient.
4583   Nursing notes that the doctor adds, agree or patient doing well will not qualify as the
4584   examination of the patient for this management.
4585
4586   6.15.7.2. 77427 Reporting
4587   This is done every five treatments. For the first, second, third, and fourth treatment, use
4588   diagnosis V58.0 and the code for the neoplasm. Do not code 77427 until the fifth
4589   treatment. 77431 is reported if the course of treatment consists of one or two fractions.
4590
4591   6.15.8. Final Note
4592   Some radiation oncology services may be bundled and may be modified under Correct
4593   Coding Initiative, as discussed previously.
4594   References:
4595   CPT 2004 Professional Edition
                                                   6-74
                                            MHS Coding Guidance
                                                March 2008
                                    SPECIALTY CODING
                               6.15 Radiation Oncology Services
4596   ‖Cancer Care Network—
4597   A User’s Guide For Radiation Oncology Management & Billing Procedures.‖
4598   Coding Strategies, Inc.
4599   The Medical Management Institute—CUB All-In-One Coding Utility Book—Coding and
4600   Medicare for Radiation Oncology
4601   ‖AETC Radiation Oncology Training Modules,‖ by Patricia Bridges RHIT, CCS, CCS-P
4602   and Victoria Flisk BHA, CPC




                                             6-75
                                       MHS Coding Guidance
                                           March 2008
                                         SPECIALTY CODING
                                      6.16 Radiology, Intervention

4603   6.16. Radiology, Interventional
4604   Interventional radiology is used to describe the use of cross-sectional imaging
4605   techniques, such as ultrasound, CT and MRI, and digital processing of fluoroscopy.
4606   These techniques are used not only for diagnostic but also therapeutic applications.
4607
4608   6.16.1. E&M Coding Rules
4609
4610   6.16.1.1. No Separate E&M Codes
4611   Usually there is no separately identifiable E&M associated with an interventional
4612   radiology encounter.
4613
4614   6.16.1.1.2. Coding E&M Separately
4615   To code an E&M separately from a procedure, there must be a separately identifiable
4616   reason. For instance, a provider determines the need for a procedure. At that encounter,
4617   there would be a discussion of risks and benefits, informed consent would be obtained,
4618   and there would be an evaluation to determine contraindications and other issues
4619   affecting the procedure (such as allergies, previous adverse issue, or review of lab tests).
4620   If it is a major procedure (usually with a global post-operative period of 90 days), there
4621   would be a preoperative physical. In this case, there would be an E&M code. For minor
4622   procedures (usually with a global postoperative period of 0–10 days), the pre-procedural
4623   assessment is a component of the procedure. The postoperative encounter, usually for a
4624   suture removal, does not have an E&M, but is coded with 99024 in the CPT field.
4625
4626   6.16.2. Diagnosis
4627
4628   6.16.2.1. First-Listed Diagnosis
4629   The first-listed diagnosis is the reason the patient is having the procedure. If a definitive
4630   diagnosis is not available by the end of the encounter and there will not be a pathology
4631   report, code what is known. Do not code rule out. Code any additional diagnoses that
4632   affect the encounter, such as diabetes, pregnancy, or a history of carcinoma.
4633
4634   6.16.2.2. Diagnosis Contingent on Pathology Report
4635   When the diagnosis is contingent on a pathology report, wait to code the encounter until
4636   the pathology report is available. For example, if the provider’s pre-procedure diagnosis
4637   is mass and after the procedure, it is the provider’s assessment that the mass is benign, it
4638   would be coded as a benign neoplasm. If after the procedure, the provider suspects the
4639   mass may be malignant, the provider should wait to code the diagnosis and procedure
4640   until the pathology results are available. For instance, if a patient presents for rule out
4641   neoplasm of breast, but all that is known is that there is a mass in the breast, code a mass,
4642   not a neoplasm.
4643
4644   6.16.3. Procedures
4645
4646   6.16.3.1. Interventional radiology usually involves two components: the imaging
4647   procedural component and the therapeutic or diagnostic procedural component. In this
                                                   6-76
                                            MHS Coding Guidance
                                                March 2008
                                        SPECIALTY CODING
                                     6.16 Radiology, Intervention

4648   section, the term imaging guidance usually indicates a procedure in the 7xxxx range of
4649   CPT codes. The term procedural component usually indicates a procedure from the
4650   10000–69999 or 9xxxx CPT codes.
4651
4652   6.16.3.2. When performing the procedural component, (e.g., 19102, biopsy of breast;
4653   percutaneous, needle core, using imaging guidance), collect the procedural component in
4654   ADM. Collect the imaging guidance used in conjunction with the procedure (e.g., 76095,
4655   stereotactic localization guidance for breast biopsy or needle placement, each lesion,
4656   radiological supervision and interpretation) in the radiology module.
4657
4658   6.16.4. Modifiers
4659
4660   6.16.4.1. Modifier -26
4661   Most procedures in the 10000–69999 and 9xxxx ranges do not have a professional and
4662   technical component. Usually, the procedures are performed by a privileged provider in
4663   one setting. Therefore, it is not necessary to use the modifier -26 for the professional
4664   component.
4665
4666   6.16.4.2. Technical Component Modifier
4667   Most procedures in the 10000–69999 range do not have a separate technical component.
4668   There are a few in urology, but these would not usually be involved with interventional
4669   radiology. In those cases when there is a technical component, the appropriate modifier
4670   would be TC. The urology procedures may be performed by a urology technologist or
4671   nurse but the data must be interpreted by the urologist. A radiology imaging exam
4672   performed by a radiological technologist (imaging of the patient) must also have the data
4673   interpreted by the radiologist.
4674
4675   6.16.4.3. MEPRS
4676   Collect the procedural component of interventional radiology for procedures that do not
4677   require medically supervised recovery (e.g., patient is able to respond to verbal stimulus
4678   for the entire procedure and is able to depart upon termination of the procedure), in the
4679   BBMA MERPS account. Collect the procedural component of interventional radiology,
4680   for procedures requiring medically supervised recovery (e.g., patient needs to be
4681   supervised in the post-anesthesia care unit), in the BBM5 MEPRS account when the
4682   radiologist is AD or civil service.




                                                  6-77
                                           MHS Coding Guidance
                                               March 2008
                                               SPECIALTY CODING
                                             6.17 Readiness Assessment

4683   6.17.    Health Exams of Defined Subpopulations, V 70.5_x
4684
4685   6.17.1. E&M Guidance
4686
        ENCOUNTER TYPE                                                                        E&M
        Encounter with exam, <1 years                                                         99391
        Encounter with exam, 1-4 years                                                        99392
        Encounter with exam, 5-11                                                             99394
        Encounter with exam, 12-17                                                            99395
        Encounter with exam, 18-39                                                            99396
        Encounter with exam, 40-64 years                                                      99397
        Encounter no exam, counseling provided to an individual, 15 minutes (with provider)   99401
        Encounter no exam, counseling provided to an individual, 30 minutes (with provider)   99402
        Encounter no exam, counseling provided to a group, 30 minutes (with provider)         99411
        Encounter no exam, counseling provided to a group, 60 minutes (with provider)         99412
        Encounter record review only (face to face), no exam, no Counseling, reviewed by      99420
        provider (physicians, NPs, PAs or IDCs)
        Encounter record review, no exam, no Counseling, reviewed by provider (physicians,    Do not code
        NPs, PAs or IDCs)
        Encounter Office Consultation                                                         99241-99245
        Encounter Tech Visit, face to face, no privileged provider contact                    99211
4687
4688   6.17.1.1. Privileged Provider Performs Assessment
4689   The appropriate E&M codes should be assigned based on the documentation. Was the
4690   encounter for a DoD evaluation of the patient’s ability to perform his mission? Was the
4691   encounter for counseling or an examination? The definition of counseling is a dialogue
4692   with patient or family on one or more of the subsequent areas:
4693        diagnostic results, impressions, or recommended diagnostic studies
4694        prognosis
4695        risks and benefits of management (treatment) options
4696        instructions for management (treatment) or follow-up
4697        risk factor reduction
4698        patient and family education (CPT Assistant, January 1998, p. 6)
4699
4700   6.17.1.2. Assessing Ability to Perform Mission
4701   If the provider is evaluating the patient’s ability to perform the mission, there is no
4702   appropriate CPT code. If the provider is providing education (training about a symptom,
4703   condition, or disease), there is no appropriate CPT code.
4704   If the provider is conducting preventive medicine counseling or risk factor reduction
4705   counseling, (e.g., counseling on safe sex so long as the patient is not doing anything that
4706   could be considered unsafe sex) use codes 99401–99404.
4707
4708   NOTE: These codes are not to be used to report counseling and risk factor
4709   reduction interventions given to patients with symptoms or established illness. The
4710   code selection is based on provider counseling time. Time spent on risk-factor
4711   reduction must be documented. Time spent evaluating the patient for ability to
4712   perform the mission or educating the patient is not included in the time used to
4713   determine a preventive medical counseling or risk factor reduction.
                                               6-78
                                                    MHS Coding Guidance
                                                        March 2008
                                       SPECIALTY CODING
                                     6.17 Readiness Assessment

4714          99401 Preventive medical counseling or risk factor reduction
4715                intervention(s) given to an individual (separate procedure): 15
4716                minutes
4717          99402 Preventive medical counseling or risk factor reduction
4718                intervention(s) given to an individual (separate procedure): 30
4719                minutes
4720          99403 Preventive medical counseling or risk factor reduction
4721                intervention(s) given to an individual (separate procedure): 45
4722                minutes
4723          99404 Preventive medical counseling or risk factor reduction
4724                intervention(s) given to an individual (separate procedure): 60
4725                minutes
4726
4727      Example: The privileged provider is rendering individual counseling on lifestyle
4728      modifications for risky behavior, preventive counseling based on family history and
4729      occupational exposure. The duration of this visit is 60 minutes with 15 for evaluation
4730      to perform the mission (do not include this time), 15 minutes discussing why the
4731      patient should stop smoking, exercise, and lose weight (education, do not include this
4732      time), and 30 minutes for counseling or risk-factor reduction. Code this as 99402 —
4733      counseling
4734
4735      If the provider is conducting a wellness or screening exam (e.g., pelvic examination
4736      for women or prostate examination for men) during the PHA, the preventive medicine
4737      codes are to be used. A pelvic exam or prostate examination by itself does not justify
4738      use of these codes. The appropriate comprehensive history, comprehensive exam and
4739      risk factor reduction must be completed.
4740
       Patient Age (Years)           New Patient                   Established Patient
       18–39                         99385                         99395
       40–64                         99386                         99396
4741
4742      If the provider sees the patient for a problem (e.g., patella femoral syndrome for
4743      physical fitness waiver or profile), and reviews the patient’s medical record (e.g. DD
4744      Form 2766) as part of the visit, assign the office or outpatient codes 99201–99215.
4745
4746   NOTE: Code selection is based on documentation and new vs. established patient
4747   status.
4748
4749   6.17.2. Non-privileged Provider Performs the Assessment
4750   Code selection is based on what takes place during the encounter.
4751
4752   If a review of the medical record and DD Form 2766 results in preventive medicine or
4753   risk factor reduction counseling, assign E&M code 99211. Diagnosis coding is based on
4754   the type of counseling provided. (See the ICD-9-CM counseling code listing below.)
4755
                                                 6-79
                                          MHS Coding Guidance
                                              March 2008
                                       SPECIALTY CODING
                                     6.17 Readiness Assessment

4756   If a review of the medical record and DD Form 2766 does not result in preventive
4757   medicine or risk-factor reduction counseling, assign code V68.89 for the diagnosis.
4758
4759   6.17.3. Diagnosis Coding Rules
4760
4761   6.17.3.1. Use of V70.5 is located in Section 2.2.8.
4762
4763   6.17.3.2. Diagnosis coding is based on the type of counseling given. When counseling is
4764   provided, refer to the following series of ICD-9-CM codes:
4765
4766          V25.09         Family planning (counseling for contraceptive management)
4767          V65.3          Dietary surveillance and counseling
4768          V65.40         Other counseling, no other symptoms (NOS)
4769          V65.41         Exercise counseling
4770          V65.42         Counseling on substance use and abuse (this is a root code; use the
4771                         appropriate DoD extender code)
4772          V65.43         Counseling on injury prevention
4773          V65.44         HIV counseling
4774          V65.45         Counseling on other sexually transmitted diseases
4775          V65.49_x       Other specified counseling (this is a root code, use the appropriate
4776                         DoD extender code)
4777          V69.0          Lack of physical exercise
4778          V69.1          Inappropriate diet and eating habits
4779          V69.2          High-risk sexual behavior
4780          V69.3          Gambling and betting
4781          V69.8          Other problems related to lifestyle
4782          V69.9          Problem related to lifestyle, unspecified
4783
4784   6.17.3.3. Hearing Conservation and Hearing Loss
4785
4786   DoD unique extender tracking codes:
4787         V41.2_1 Hearing Conservation (HC), PH-1
4788         V41.2_2 HC, PH-2
4789         V41.2_3 HC, PH-3
4790         V41.2_4 HC, PH-4
4791         V41.2_0 Other and Unspecified problems with hearing
4792
4793   Hearing loss caused by injury:
4794          E923.8 Other Explosive Materials
4795          E928.1 Exposure to Noise
4796
4797   6.17.4. Documentation—What to Document
4798   For counseling, the amount of time spent with a patient must be included in the
4799   documentation, with the date (e.g., 12 Oct 04, 0900–0930).
4800    Patient presents for annual physical: use preventive medicine codes.
                                                  6-80
                                          MHS Coding Guidance
                                              March 2008
                                           SPECIALTY CODING
                                         6.17 Readiness Assessment

4801      Patient presents for multiple concerns as well as health maintenance: use both a low-
4802       level office visit and a preventive medicine code.
4803      When reporting preventive medicine counseling codes, document the nature of the
4804       counseling and any education provided during the encounter.
4805
4806   6.17.5. Procedural Coding
4807
4808   6.17.5.1. Education and Training for Patient Self-Management
4809   Services prescribed by a physician and provided by a qualified nonphysician
4810   healthcare professional designed to teach patients how to self-manage illness(es) or
4811   disease(s) effectively. The following codes may be reported when a standardized
4812   curriculum is used:
4813           98960          Face-to-face with patient each 30 minutes; individual patient
4814           98961          2–4 patient
4815           98962          5–8 patients
4816
4817   6.17.5.2. Procedures in Conjunction with Readiness Encounter
4818
       Immunizations, 90465–90749                     Prostate cancer screening, G0102
       Venipuncture, 36415                            Pap smear collection, Q0091
       Audiometry:                                    KOH, 87210–86220
       Pure tone (threshold), 92252
       Testing of groups, 92559
       Tympanometry, 92567                            Guaiac Test, 82270
       Visual acuity and color vision,                Dip Stick US, 81002
       99172–99173
       EKG, 9300093010                                Pulmonary Function Test (PFT), 94010–60




                                                   6-81
                                             MHS Coding Guidance
                                                 March 2008
                                      SPECIALTY CODING
                               6.18 Reconstructive/Cosmetic Surgery

4819   6.18. Reconstructive and Cosmetic Surgery
4820   Cosmetic procedures improve the patient’s appearance by plastic restoration, correction,
4821   and removal of blemishes. Many cosmetic procedures are coded with the same procedure
4822   codes as a reconstructive procedure.
4823
4824   Reconstructive procedures are not cosmetic. Reconstructive procedures are performed on
4825   abnormal structures, generally to improve function and to approximate normal
4826   appearance. Reconstructive procedures are coded using codes in CPT.
4827

4828                 DoD Rule. Regardless of training or skills maintenance for the provider, the
4829                 patient must pay for all cosmetic procedures through the Medical Services
4830                 Accounts (MSA) office and present a paid bill for the services prior to
4831                 receiving services.

4832
4833   6.18.1. Diagnosis Coding Rules
4834
4835   6.18.1.1. Cosmetic Procedure
4836   The provider determines if a procedure is reconstructive (e.g., to improve function) or
4837   cosmetic (e.g., to improve the patient’s appearance or self-esteem). When a provider
4838   documents that a procedure is cosmetic, use codes:
4839
4840      V50.0 Hair transplant
4841      V50.1 Other plastic surgery for unacceptable cosmetic appearance
4842      The term plastic surgery in this case includes cosmetic procedures such as laser tattoo
4843      removal and hair removal.
4844      V50.3 Ear piercing
4845      V50.8 Other. This includes piercing other than the ear.
4846      V50.9 Unspecified
4847
4848   6.18.1.2. Post-Procedure Services
4849   For routine follow up for cosmetic procedures, use the appropriate V codes, such as
4850   V58.3, attention to surgical dressings and sutures, V67.9, follow-up exam following other
4851   surgery, and V67.59, follow-up exam following other treatment—other.
4852
4853   6.18.2. Procedural Coding Rules
4854
4855   6.18.2.1. Many procedures can be reconstructive or cosmetic, such as blepharoplasty.
4856   Others are only cosmetic, such as hair transplant or lipectomy. When there is a CPT or
4857   HCPCS code that accurately reflects the service provided, use the CPT or HCPCS code.
4858
4859   6.18.2.2. Post-Procedure Services
4860   Routine post-procedure services are coded with 99024 for each visit within global period
4861   in the CPT/HCPCS field. Complications are coded based on the documented
4862   complication and procedures.
                                                6-82
                                          MHS Coding Guidance
                                              March 2008
                                      SPECIALTY CODING
                               6.18 Reconstructive/Cosmetic Surgery

4863   NOTE: See section 5.3.2. for a detailed explanation of global period.
4864
4865   6.18.2.3. Botox for Cosmetic Surgery
4866   Code J0585. The number of injections involved is not considered in coding. The
4867   physician is required to document the number of units administered to the patient. The
4868   number of units is entered in the unit’s field. Units feed to TPOCS and reside on the
4869   local server. Units are not a field in the SADR and are not transmitted to a central
4870   database injection codes are not used in coding Botox used for cosmetic reasons. There
4871   is an injection code for therapeutic use of Botox.




                                                6-83
                                          MHS Coding Guidance
                                              March 2008
                                       SPECIALTY CODING
                          6. 19 Social Work and Family Advocacy Services

4872   6.19. Social Work and Family Advocacy Services
4873   Social workers in the mental health and life skills clinic should refer to section 6.8,
4874   Mental Health.
4875
4876   6.19.1. E&M Coding Rules
4877   Social work providers do not use outpatient office E&M codes in addition to their
4878   procedural services. When social work providers furnish diagnostic interviews,
4879   psychotherapy, assessments, counseling, and other social work services, the services
4880   should be coded as procedures.
4881
4882   6.19.2. Diagnosis Coding Rules
4883

4884                  DoD Rule
4885
4886                  Encounters for post-deployment related conditions will have V70.5_6 as the
4887                  second code and the patient’s mental health condition listed first.

4888
4889   6.19.2.1. Diagnostic and Statistical Manual (DSM IV)
4890   Mental health diagnoses are based on terminology and codes found in the Diagnostic and
4891   Statistical Manual of Mental Disorders (DSM IV). Although the terminology in ICD-9-
4892   CM or CHCS does not always match the terminology in DSM IV, the majority of the
4893   codes are the same.
4894
4895   6.19.2.2. Coding for Clients Without Mental Disorder Diagnosis
4896   Use V codes for encounters with patients or clients who do not have a mental disorder
4897   diagnosis. For example:
4898
4899      V60.2       Financial problems
4900      V61.10      Counseling for marital and partner problems
4901      V61.49      Presence of sick or handicapped person in family or household
4902      V62.82      Bereavement
4903   Any conditions that may contribute to the patient’s mental condition, affect treatment
4904   (e.g., depression, anxiety) are coded as additional diagnoses.
4905
4906   6.19.2.3. Suspected Conditions
4907   Encounters for suspected conditions, including abuse or neglect, that do not have any
4908   reportable physical signs, symptoms, or conditions when the suspected condition is ruled
4909   out are to be coded:
4910           V71 Observation and Evaluation for Suspected Conditions not found.
4911
4912   6.19.2.4. HIV-Related Conditions
4913   Patients who have been diagnosed with HIV or AIDS may be evaluated to determine if
4914   they are experiencing depression or anxiety that needs the services of a psychiatrist (e.g.,
                                                 6-84
                                           MHS Coding Guidance
                                               March 2008
                                        SPECIALTY CODING
                           6. 19 Social Work and Family Advocacy Services

4915   pharmacological management of the mental problem). HIV will be reported as the reason
4916   for the encounter, then the mental condition, because the mental condition being
4917   evaluated is related to the HIV.
4918
4919   6.19.2.5. Family Advocacy Encounters
4920
4921   NOTE: For Air Force, AD and Defense Health Program-funded civilians, report
4922   family advocacy program (FAP) encounters. Refer to ―Behavioral Health Coding
4923   Handbook.‖
4924
4925   Initial domestic violence encounters for crisis intervention are reported with a code from
4926   995.5 Child Maltreatment Syndrome or 995.8 Other Specified Adverse Effects, not
4927   elsewhere classifiable (NEC). The code(s) for any physical injuries sustained, plus the
4928   appropriate E codes for external cause of injury, will be additional codes. Subsequent
4929   encounters for counseling will be reported with a V code such as:
4930
4931       V61.10      Counseling for marital and partner problems
4932       V61.12      Counseling of perpetrator of spousal and partner abuse
4933       V61.21      Counseling of victim or child abuse
4934       V61.22      Counseling for perpetrator of parent or child abuse
4935       V62.83      Counseling for perpetrator of physical or sexual abuse (used for a
4936                   perpetrator who is not a parent, spouse, or partner of the victim)
4937
4938   6.19.3. Procedural Coding Rules
4939
4940   6.19.3.1. Social workers will use 90801, the CPT psychiatric diagnostic interview
4941   examination codes for many initial encounters.
4942
       Description                        ICD-9-CM               E&M        CPT
       Initial FAP assessment; no         V71.9                    N/A      90801
       evidence or allegation
       Initial FAP assessment; evidence   995.80                   N/A      90801
       or allegation present; adult
       maltreatment
       Initial FAP assessment; evidence   995.50                   N/A      90801
       or allegation present; child
       maltreatment
       Individual follow-up for           995.80or 995.50 and      N/A      90804 20—30 min
       maltreatment                       V61.10                            90806 45—50 min
                                                                            90808 75—80 min
       Group treatment                    995.80 or 995.50 and     N/A      90853
                                          V61.20 or V61.22
       Marital or family treatment        995.80 or 995.50 &       N/A      90847
                                          V61.20 or V61.22
4943
4944
                                                   6-85
                                             MHS Coding Guidance
                                                 March 2008
                                       SPECIALTY CODING
                          6. 19 Social Work and Family Advocacy Services

4945   6.19.3.2. Use of HCPS Level II Codes
4946   Social workers will also use HCPCS Level II codes. For example, an initial encounter
4947   for domestic violence is coded S9484, crisis intervention mental health services, per hour.
4948
4949   6.19.3.3. Health and Behavior Assessment/Intervention (96150–96155).
4950   Health and behavior assessment or intervention codes are to be used by social workers
4951   and other non-physicians. These codes are not intended for use by physicians. Non-
4952   physician providers assess patients with acute or chronic medical illnesses who might
4953   benefit from counseling. Patients have psychiatric issues that may affect their illness or
4954   hinder treatment. Patients treated for psychiatric diagnoses are not coded using the
4955   Health and Behavior Assessment/Intervention.
4956
4957   6.19.3.4. Modifiers
4958   The following modifiers are used to identify the type of provider or to provide more
4959   specificity about a service than is listed in the CPT or HCPCS Level II coding manuals.
4960
          MODIFIER       DESCRIPTION           PROVIDER             APPEND   EXPLANATION
                                                                    TO
               22             Unusual          Mental/behavioral    CPT &    Indicates the service
                         procedural service     health provider     HCPCS    was more than is
                                                                    codes    normally provided for
                                                                             the reported procedure
                                                                             (usually at least 25%
                                                                             more work involved).
               32        Mandated services     Mental/behavioral    CPT &    Services mandated by
                                                health provider     HCPCS    law, or regulation other
                                                                    codes    than DoD regulations.
               AJ          Clinical social      Clinical social     HCPCS    Indicates type of
                              worker                worker          codes    provider.
               H9          Court-ordered       Mental/behavioral    HCPCS    Indicates the service
                                                health provider     codes    was ordered by a court,
                                                                             a probation officer, or a
                                                                             parole officer.
              HE           Mental health       Mental/behavioral    HCPCS    Designates that a
                            program             health provider     codes    procedure is associated
                                                                             with a program
                                                                             specifically designed to
                                                                             provide mental health
                                                                             services.

              HO          Master’s degree      Mental/behavioral    HCPCS    Provider’s education is
                               level            health provider     codes    master’s degree level


               HP          Doctoral level      Mental/behavioral    HCPCS    Provider’s education is
                                                health provider     codes    doctoral level

                                                    6-86
                                              MHS Coding Guidance
                                                  March 2008
                                       SPECIALTY CODING
                          6. 19 Social Work and Family Advocacy Services

          MODIFIER       DESCRIPTION            PROVIDER             APPEND EXPLANATION
                                                                     TO
              HQ            Group setting       Mental/behavioral    HCPCS  Reported services are
                                                 health provider     codes  provided to two or
                                                                            more clients who have
                                                                            no definite relationship
                                                                            during a single
                                                                            treatment encounter.


              HR          Family/couple         Mental/behavioral    HCPCS     Reported services are
                         with client present     health provider     codes     provided to two or
                                                                               more clients who have
                                                                               a familial or significant
                                                                               other relationship,
                                                                               during a single tx
                                                                               encounter


               HS          Family/couple        Mental/behavioral    HCPCS     Reported services are
                           without client        health provider     Codes     provided to two or
                              present                                          more clients who have
                                                                               a familial or significant
                                                                               other relationship,
                                                                               during a single
                                                                               treatment encounter
4961   * HCPCS II modifiers are not available in AHLTA.
4962
4963   6.19.4. Documentation of Time-Based Encounters
4964   The actual start and stop time or the total amount of time spent with a patient must be
4965   documented to support coding for encounters based on time.
4966
4967   6.19.5. Case Management Services
4968   The Case Management coding and reporting framework can be found in Appendix E.
4969
4970
4971
4972
4973
4974
4975
4976
4977
4978
4979
4980

                                                     6-87
                                               MHS Coding Guidance
                                                   March 2008
                                      SPECIALTY CODING
                              6. 20 Substance Abuse Program Services

4981   6.20. Substance Abuse Program Services
4982   How to Report
4983

4984                  Workload performed by Non-Defense Health Program-funded personnel is
4985                  NOT captured in ADM.
4986
4987                  Air Force Rule
4988
4989                  Air Force substance abuse rehabilitation services provided by AD and
4990                  Defense Health program-funded civilians will begin coding for ambulatory
4991                  services provided. See ―Behavioral Health Coding Handbook.‖
4992
4993                  Navy and Army Rule
4994
4995                  Navy Substance Abuse and Rehabilitation Program (SARP) and Army
4996                  Substance Abuse Program (SAP) encounters will be reported in an
4997                  ambulatory service B MEPRS clinic in the ADM. Workload performance is
4998                  measured in visits for this service.
4999
5000                  *Army, contact the Service representative for specific guidance on use of
5001                  HCPCS II and CPT codes.

5002
5003   6.20.1. E&M Coding Rules
5004   Behavioral health evaluation services related to substance abuse programs should not be
5005   reported with E&M codes. HCPCS Level II codes will be used to report these
5006   encounters. However, an encounter solely for the purpose of reviewing laboratory results
5007   will be reported with an E&M code.
5008
5009          99408          Alcohol and/or substance (other than tobacco) abuse structured
5010                         abuse structured screening (eg, AUDIT, DAST), and brief
5011                         intervention (SBI) services; 15-30 minutes
5012          99409                 ; greater than 30 minutes
5013
5014   6.20.2. Diagnosis Coding Rules
5015
5016   6.20.2.1. Reporting Substance Abuse Disorders
5017   Substance abuse disorders are never to be reported as dependence without specific
5018   documentation of the dependence. Licensed chemical dependency counselors (LCDC) or
5019   certified alcohol drug abuse counselors (CADAC) can diagnose a substance abuse
5020   problem, but a privileged provider must evaluate the patient for a diagnosis of
5021   dependence to be established.
5022
5023
5024
                                                  6-88
                                           MHS Coding Guidance
                                               March 2008
                                     SPECIALTY CODING
                             6. 20 Substance Abuse Program Services

5025   6.20.2.2. Coding for Patients Without Substance Abuse Diagnosis
5026   Patients who present to the clinic seeking program information or advice without a
5027   diagnosed substance abuse problem are coded V65.42—a root code—with the
5028   appropriate DoD extender). Encounters with a person seeking information or advice for
5029   someone else (e.g., for a family member) are coded V65.19, person consulting on behalf
5030   of another.
5031
5032
5033

5034                 DoD Rule
5035
5036                 Encounters for post-deployment related conditions have V70.5_6 as the first
5037                 listed code and the patient’s mental health or physical condition listed
5038                 second.

5039
5040   6.20.2.3. Medical Treatment for Physical Condition
5041   Medical treatment for an acute physical condition caused by substance abuse or
5042   dependence is coded and sequenced as a poisoning, with the E code for the substance and
5043   circumstance. The abuse will be an additional diagnosis.
5044
5045   6.20.3. Procedural Coding Rules
5046   Most encounters by CADAC, including evaluation for eligibility for a SAP, will be
5047   reported using H codes from the HCPCS Level II coding manual.
5048
       H CODES-
       *H0001        Alcohol, drug assessment (initial screening)
       *H0002        Behavioral health screening to determine eligibility for admission to
                     treatment program
       H0004         Behavioral health counseling and therapy, per 15 minutes
       H0005         Alcohol, drug services; group counseling by clinician or counselor
       H0006         Alcohol, drug services; case management (documenting any indirect
                     services rendered on behalf of patient, i.e. referral, follow-up, continuum
                     of care)
       H0007         Alcohol, drug services; crisis intervention (outpatient)
       H0012         Alcohol, drug services; sub-acute detoxification (residential addiction
                     program outpatient) (level II)
       H0013         Alcohol, drug services; acute detoxification (residential addiction program
                     outpatient)
       H0015         Alcohol, drug services; intensive outpatient (treatment program that
                     operates at least 3 hours/day at least 3 days/week, based on individualized
                     treatment plan), including assessment, counseling; crisis intervention, and
                     activity therapies or education (level I)
                                                6-89
                                          MHS Coding Guidance
                                              March 2008
                                      SPECIALTY CODING
                              6. 20 Substance Abuse Program Services

       H0017          Behavioral health; residential (hospital residential treatment program),
                      without room and board, per diem
       H0018          Behavioral health; short-term residential (non-hospital residential
                      treatment program), without room and board, per diem
       *H0021         Alcohol, drug training service (for staff and personnel) not used by
                      providers)
       H0022          Alcohol, drug intervention service—planned facilitation (family
                      intervention)
       *H0023         Behavioral health outreach service (planned approach to reach a target
                      population)
       *H0024         Behavioral health prevention information dissemination service (one-way
                      direct or non-direct
       *H0025         Behavioral health prevention education service (delivery of services with
                      target population to affect knowledge, attitude, or behavior)
       *H0026         Alcohol, drug prevention process services, community-based (delivery of
                      services to develop skills of impactors)
       *H0028         Alcohol, drug prevention problem identification and referral (e.g., student
                      and employee assistance programs), does not include assessment
       *H0029         Alcohol, drug prevention alternatives services (for populations that
                      exclude alcohol and other drug use, e.g., alcohol-free social events)
       *H0047         Alcohol, drug abuse services, not otherwise specified
       H0048          Alcohol, other drug testing: collection and handling only, specimens other
                      than blood
5049
       CPT Codes
       82075 Breath analyzer
       99082 Transportation
       90885 Psychiatric evaluation of records, tests, etc.
       90887 Fitness for evaluation
       90889 Prepare reports for agencies
5050
5051   6.20.4. Modifiers Used in Substance Abuse Programs
5052   The following modifiers are used to identify the type of provider or to provide more
5053   specificity to a service than is listed in the CPT or HCPCS Level II coding manuals.
5054
5055                       Modifiers Used in Substance Abuse Programs
        MODIFIER       DESCRIPTION          PROVIDER               APPEND          EXPLANATION
                                                                     TO
        22             Unusual procedural   Mental/behavioral     CPT &       Indicates service was more
                       service              health provider       HCPCS       than is normally provided
                                                                  codes       for the reported procedure
                                                                              (usually at least 25% more
                                                                              work involved).
        32             Mandated service     Mental/behavioral     CPT &       Services mandated by law or
                                            health provider       HCPCS       regulation other than DoD.
                                                  6-90
                                            MHS Coding Guidance
                                                March 2008
                           SPECIALTY CODING
                   6. 20 Substance Abuse Program Services

MODIFIER   DESCRIPTION            PROVIDER              APPEND        EXPLANATION
                                                          TO
                                                       codes
AH         Clinical               Clinical             HCPCS     Indicates type of provider.
           psychologist           psychologist         codes
AJ         Clinical social        Clinical social      HCPCS     Indicates type of provider.
           worker                 Worker               codes
H9         Court ordered          Mental/behavioral     HCPCS    Indicates the service was
                                  health provider      codes     ordered by a court,
                                                                 probation officer, or parole
                                                                 officer.
HE         Mental          health Mental/behavioral     HCPCS    Designates a procedure is
           program                health provider        codes   associated with a program
                                                                 specifically designed to
                                                                 provide mental health
                                                                 services.
HF         Substance abuse        Mental/behavioral    HCPCS     Designates a procedure is
           program                health provider      codes     associated with a program
                                                                 specifically designed to
                                                                 provide substance abuse
                                                                 services.
HG         Opioid addiction       Mental/behavioral    HCPCS     Designate a procedure is
           treatment program      health provider      codes     associated with a program
                                                                 specifically designed to
                                                                 provide opioid treatment
                                                                 services, including but not
                                                                 limited to the provision of
                                                                 methadone and
                                                                 levo-alpha-acetylmethadol
                                                                 (LAAM).
HO         Master’s degree        Mental/behavioral    HCPCS     Provider’s education level is
           level                  health provider      codes     a master’s degree
HP         Doctoral level         Mental/behavioral    HCPCS     Provider’s education level is
                                  health provider      codes     a doctorate
HQ         Group setting          Mental/behavioral    HCPCS     Reported services are
                                  health provider      codes     provided to two or more
                                                                 clients who have no definite
                                                                 relationship during a single
                                                                 treatment encounter.
HR         Family/couple with     Mental/behavioral    HCPCS     Reported services are
           client present         health provider      codes     provided to two or more
                                                                 clients who have a familial
                                                                 or significant other
                                                                 relationships during a single
                                                                 treatment encounter
HS         Family/couple          Mental/behavioral    HCPCS     Reported services are
           without client         health provider      codes     provided to two or more
           present                                               clients who have a familial

                                        6-91
                                 MHS Coding Guidance
                                     March 2008
                                      SPECIALTY CODING
                              6. 20 Substance Abuse Program Services

        MODIFIER      DESCRIPTION          PROVIDER             APPEND           EXPLANATION
                                                                  TO
                                                                            or significant other
                                                                            relationships during a single
                                                                            treatment encounter
5056
5057      Examples: A master’s level LCDC conducts substance abuse counseling with
5058      an AD patient and his wife as part of the soldier’s treatment program.
5059
5060      A patient in the SAP who is being treated by a psychiatrist with Antabuse is
5061      seen for management of the medication. 90862 Pharmacological management
5062      modifier HF indicates this is being done for a patient in an SAP.
5063
5064   6.20.5. Documentation of SAP Treatment
5065   Documentation of SARP treatment is governed by Navy regulations. Referral of patients
5066   to the SARP or SAP through medical channels is documented on an SF 513. Military
5067   health records (HREC) and outpatient treatment records (OTR) will only contain the
5068   following notation for outpatient mental health treatment: ―Patient seen, refer to file
5069   number 40-216k1‖ for adults or ―Patient seen, refer to file number 40-216k2‖ for minors.
5070   The referenced file will contain the actual documentation of any mental health treatment.
5071
5072   6.20.6. Documentation of Time-Based Encounters
5073   The actual start and stop time or the total amount of time spent with a patient must be
5074   documented to support coding for encounters based on time.
5075




                                                 6-92
                                          MHS Coding Guidance
                                              March 2008
                     CODING AMBULATORY PROCEDURE VISIT (APV)


5076   Chapter 7 CODING AMBULATORY PROCEDUREVISIT (APV) ENCOUNTERS
5077
5078   Coding audits indicate that the DoD needs to improve coding of APV procedures in five
5079   areas: procedure or service not coded, code(s) not supported by documentation,
5080   appropriate use of modifiers, appropriate use of quantity, and future focus on coding
5081   improvement (codes not matched to correct diagnosis, sequencing, and application of
5082   ancillary services). APV procedures can occur in the ambulatory procedure unit,
5083   emergency department, clinic, or outpatient activities on a ward. Diagnostic radiology
5084   and laboratory procedure codes should not be coded in the ADM, since that workload is
5085   reported in other MHS systems. Administration of local anesthesia is not reported
5086   separately because it is considered part of the procedure.
5087
5088   7.1. Definitions
5089   The definition of APV per Department of Defense Instruction (DoDI) 6025.8, Subject:
5090   APV, dated September 23, 1996, was modified by the UBU effective 01 Oct 2004. The
5091   complete list of CMS-approved ambulatory surgical center (ASC) procedures is at
5092   http://www.cms.hhs.gov/ASCPayment/04f_CMS-1392-FC(ASC).asp#TopOfPage
5093
5094   7.1.1. Ambulatory Procedure Visit
5095   APVs are defined as procedures or surgical interventions that require pre-procedure care,
5096   a procedure, and immediate post-procedure care, directed by a qualified healthcare
5097   provider. Minor procedures performed in an outpatient clinic that do not require post-
5098   procedure care by a medical professional are not considered APVs. The nature of the
5099   procedure and the medical status of the patient combine to require short-term, but not
5100   inpatient care. These procedures are appropriate for all types of patients (obstetrical,
5101   surgical, and non surgical) who, by virtue of the procedure or anesthesia, require post-
5102   procedure care or monitoring by medical personnel. Requiring an individual to remain in
5103   the area for a period of time, such as 20 minutes after an injection, is not post-procedure
5104   care.
5105
5106   7.1.2. Ambulatory Surgery Program
5107   A facility program for the performance of elective surgical procedures is defined as an
5108   APV in DODI 6025.8. APV care is not to exceed 23 hours and 59 minutes, measured
5109   from the time patient care begins in the MTF to the time the patient no longer requires
5110   medical supervision. Being checked in CHCS does not begin patient care. Frequently,
5111   care begins a significant amount of time after the nurse activates the encounter in CHCS.
5112   An APV patient who stays beyond 24 hours past actual patient care start time must be
5113   admitted to a hospital as an inpatient, if medically necessary. APV patients staying
5114   beyond 24 hours after start of care are not automatically admitted. As with any
5115   admission, there must be a written order from a provider to change an APV to an
5116   admission.
5117   Observation is not an APV.
5118
5119
5120
                                                   7-1
                                           MHS Coding Guidance
                                               March 2008
                      CODING AMBULATORY PROCEDURE VISIT (APV)


5121   7.1.3. Ambulatory Procedure Units (APUs)
5122   APUs are designated MTF-approved locations or areas that are specially equipped and
5123   staffed to perform the level of care associated with APV services. APUs provide a
5124   coordinated program of care for patients usually requiring care that lasts less than 24 hours.
5125
5126   7.2. Coding Pre- and Post-Procedure APV Encounters
5127
5128   7.2.1. Global Surgery Coding
5129   Global surgery coding for DoD does not necessarily follow civilian guidelines. In the
5130   DoD, each privileged provider-patient encounter that involves medical decision making
5131   and is documented, is collected in the ADM. The encounter when a decision for surgery
5132   is made is coded as an E&M. If the decision for surgery is made within 24 hours of a
5133   procedure with a 90-day postoperative period, the E&M is appended with the -57
5134   modifier. If the decision for surgery is made at the same encounter as a procedure with a
5135   0-or 10-day postoperative period, the E&M is appended with a -25 modifier.
5136
5137   7.2.2. Uncomplicated Post-Operative Encounters
5138   Code these with a 99024 procedure code
5139
5140   7.2.3. History and Physical
5141   Usually a preoperative history and physical is done a few days prior to the scheduled
5142   surgery to ensure the patient is a candidate for surgery. The history and physical is coded
5143   based on documentation. It becomes part of the APV record. If a pre-op is done within 24
5144   hours of a major operation (having a 90-day global postoperative period), it is not coded
5145   unless the decision for surgery was made at that time. In that case, use modifier –57 to
5146   indicate the decision for surgery was made during that E&M. Preoperative encounters to
5147   check that there have been no significant changes in the patient’s condition are not coded. If
5148   there is a significant change that requires medical intervention or a completely different
5149   issue is addressed, the encounter should be coded.
5150
5151   7.2.4. Complications
5152   Unlike some civilian coding guidance, all complications (conditions not expected at that
5153   time after the surgery) must be documented and coded with an E&M based on the
5154   complication documentation.
5155
5156   7.2.5. Postoperative Visits
5157   Visits during the postoperative period that are unrelated to the surgery should be coded and
5158   appended with the modifier -24.
5159
5160   7.2.6. Preoperative Appointments
5161   If visits the day before major surgery involve a nurse, but no independent medical judgment
5162   (although perhaps following medical staff-approved decision tables), they are usually
5163   performed outside the clinic visit and are not collected in the ADM.
5164

                                                    7-2
                                            MHS Coding Guidance
                                                March 2008
                      CODING AMBULATORY PROCEDURE VISIT (APV)


5165   7.3. Patient Admitted from APV
5166   If a patient is admitted from an APV, the ADM record should be coded and closed out with
5167   disposition type admitted. The procedure codes associated with the APV will not be
5168   included in the inpatient stay.
5169
5170   7.4. Consultation for APV
5171   When an APV patient requires a consultation, the consulted provider will code the
5172   consultation services in his or her specialty clinic.
5173
5174   7.5. Assistant at Surgery
5175   When coding an APV, capture the additional providers (assistant surgeons) in the Provider
5176   field of the ADM screen. The assistant surgeon should be linked to the same CPT code as
5177   the operating physician. Code the anesthesia provider on the same ambulatory data record as
5178   the surgeon. For anesthesia coding, see section 6.1.
5179
5180   7.5.1. Co-Surgeon
5181   The individual operative report submitted by each surgeon should indicate the distinct
5182   service each surgeon provided.
5183
5184   7.6. Code 99199: Institutional Component of an APV
5185
5186   7.6.1. Coding APV’s Institutional Component
5187   There is no CPT or HCPCS code for the institutional component of an APV. To bill, the
5188   MHS will use the CPT code 99199 to indicate the institutional component of an APV.
5189
5190   7.6.2. Discontinuance of Code 99199
5191   All MTFs discontinued using the CPT code 99199 as an unlisted code by 30 September
5192   2004. CPT defines 99199 as ―unlisted special service, procedure or report.‖ Most MTFs do
5193   not use the CPT code 99199. A few have used it to track unlisted services that currently do
5194   not have a code, such as a pediatrician sedating a patient so a radiologist can do a diagnostic
5195   imaging procedure.
5196
5197   7.6.3. No RVU with Code 99199
5198   As of 1 October 2004, to ensure correct billing, the MHS only uses the CPT code 99199 for
5199   APV data collection and billing. As the code is only for billing, no RVU is associated with
5200   it. Using the CPT code 99199 in the MHS now means Institutional Component, APV. Code
5201   99199 will be reported as the last procedure on the lead surgeon’s SADR.
5202
5203   7.7. Cancelled APVs
5204
5205   7.7.1. Coding Cancelled APVs
5206   A patient may present for an APV, but the procedure is cancelled because:
5207        Patient develops a condition that contra-indicates surgery (V64.1). For example,
5208           patient experiences arrhythmia that causes the procedure to be terminated.
5209        Patient decides not to have the planned surgery (V64.2).
                                                    7-3
                                             MHS Coding Guidance
                                                 March 2008
                     CODING AMBULATORY PROCEDURE VISIT (APV)


5210         The provider is unavailable to perform the APV, or
5211         Supplies or necessary resources are not available to support the APV (V64.3).
5212
5213   7.7.1.2. Additional Coding
5214   Mark the appointment or encounter as kept. Code 2000F (blood pressure, measure) as a
5215   placeholder.
5216
5217   7.7.1.3. Coding Presenting Medical Conditions
5218   It may also be necessary to code presenting medical conditions (e.g., fever, elevated
5219   hypertension) that prevented the procedure from being carried out. The first diagnosis
5220   coded should be the preoperative diagnosis, secondary diagnosis should be the conditions
5221   that prevented the procedure to be performed, then the appropriate V64*.
5222
5223   7.7.1.4. Incomplete Procedures
5224   If a scheduled procedure was started but not completed, use the appropriate surgical CPT
5225   code with appropriate modifier;
5226           -52    Reduced Services: Service or procedure partially reduced or eliminated at
5227                  provider’s discretion.
5228           -53    Discontinued Procedure: Anesthesia has been started or the patient has been
5229                  prepped in the operating room suite.
5230
5231   7.7.1.5. Anesthesia Cancellations
5232   See Anesthesia section 6.1.13 for coding anesthesia procedures that are cancelled.
5233
5234   7.8. Procedures Not Performed in the APU
5235   Since DoD only reports four procedures in the SADR, the highest risk or most resource-
5236   intensive procedure needs to be listed first. Examples of procedures that are not APVs
5237   are services associated with a magnetic resonance imaging (MRI), suturing a laceration,
5238   wart removal, removal of wisdom teeth, or unlisted dental procedures. The list of office
5239   procedures excludes the DoD ambulatory surgical procedures.




                                                  7-4
                                           MHS Coding Guidance
                                               March 2008
        OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
                                SCENARIOS


5240
5241   Chapter 8 OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR
5242   CLINICAL SCENARIOS
5243
5244   This section provides coding guidance for specific functions and situations.
5245
5246   8.1. Use of the MAIL Function
5247   In the menu across the bottom of the ADM entry screen, mail permits providers with coding
5248   questions to forward them to the MTF. The coder who receives this mail determines the
5249   most appropriate code for the condition or encounter and replies in a timely manner. This
5250   relieves providers from spending excessive amounts of time determining appropriate codes.
5251   The provider may also elect to have the coder complete the ADM encounter documentation,
5252   according to the policies of the clinic or facility.
5253
5254   8.2. For Clinic Use Only, an ADM function
5255   This function permits each clinic to collect data unique to that clinic. These data are not part
5256   of the SADR and remain at the facility level.
5257
5258   8.3. Additional Providers
5259   This function permits data collection of names and categories of personnel who assist with
5260   an encounter. It is especially useful to indicate when a second provider assists in performing
5261   a procedure. The second privileged provider may bill a percentage of the procedure in
5262   which he/she assists. For nurses and paraprofessional personnel, this function should be
5263   used when the data collected justify the time and effort involved in data collection. The
5264   categories for additional providers are:
5265        Attending
5266        Assisting
5267        Supervising
5268        Nurse
5269        Paraprofessional
5270        Operating provider #1 (will only appear if APV field is YES)
5271        Surgeon
5272        Anesthesia
5273        GME (resident)
5274
5275   8.4. Telehealth Services
5276   A subset of e-Health, telehealth is the use of electronic information and telecommunications
5277   technologies to provide or support clinical healthcare, patient and professional health-related
5278   education, public health, and health administration when distance separates participants. It
5279   embraces several related areas, including electronic consultation and e-mail. Coding of
5280   telephone encounters is covered under the E&M section. Coding for telehealth does not
5281   encompass provider-to-provider interaction (such as provider-to-provider e-mail).
5282

                                                     8-1
                                             MHS Coding Guidance
                                                 March 2008
        OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
                                SCENARIOS




5283                  DoD Rule
5284
5285                  Telehealth services are coded in the ambulatory care service B MEPRS
5286                  clinic, where workload performance is measured in visits.
5287

5288
5289   NOTE: Provider-to-provider telephone calls, images transmitted via facsimile
5290   machines and text messages without visual images (e-mail) are not considered
5291   telehealth.
5292
5293   8.4.1. The following types of providers may code for telehealth encounters:
5294        Physician
5295        Nurse practitioner
5296        Physician assistant
5297        Nurse midwife
5298        Clinical nurse specialist
5299        Clinical psychologist*
5300        Clinical social worker*

5301      *Clinical psychologists and clinical social workers cannot code for psychotherapy
5302      services that include medical E&M services. These practitioners may not use the
5303      following CPT codes: 90805, 90807, and 90809.

5304   8.4.2. Documentation of Telehealth
5305   Coders should look for telehealth encounters to be documented on an SF513
5306   (Consultation Sheet), an approved substitute form or in AHLTA. For tele-radiology, the
5307   SF 519 (Radiographic Report) or AHLTA are used. Telehealth encounters must meet the
5308   same documentation requirements as face-to-face encounters.
5309
5310   8.4.3. How to Report
5311
5312   8.4.3.1. Real-time Communications
5313   Telehealth may be reported for interactive audio, video, or other electronic media
5314   telecommunications permitting real-time communication between the distant site
5315   provider and the patient.
5316
5317   8.4.3.2. Store and Forward Telecommunications
5318   Telehealth may also be reported for store-and-forward telecommunication that permits
5319   asynchronous transmission of medical information to be reviewed later by a provider at


                                                  8-2
                                           MHS Coding Guidance
                                               March 2008
        OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
                                SCENARIOS



5320   the distant site. The type of telehealth is identified by a modifier (see section 8.5.5
5321   Modifiers ).
5322
5323   8.4.3.3. Hospital Inpatients
5324   Telehealth encounters for hospital inpatients will be reported in ADM as outpatient
5325   encounters.
5326
5327   8.4.3.4. Photographs
5328   Photographs, (e.g., of a skin lesion) must be specific to the patient’s condition and show
5329   enough detail for interpretation or confirmation of a diagnosis or treatment regimen.
5330
5331   8.4.4. Site (MTF) Definitions
5332
5333   8.4.4.1. Originating Site
5334   The originating site is the location where the patient is at the time the service is furnished.
5335   The originating site will not use an E&M code for the telehealth encounter unless a
5336   separately identifiable E&M service is documented on the same day. For encounters
5337   involving patient-provider interaction, the visit will be entered as an office visit (e.g.,
5338   99201 or 99211).
5339
5340   8.4.4.2. Remote (Distant) Site
5341   The remote site is the location where the consultant is at the time the service is furnished.
5342   Services at the receiving facility are coded based on the documentation of the encounter.
5343   Consultation services (e.g., 99241 or 99242) for the receiving facility are coded in
5344   ADM/AHLTA under the provider’s outpatient clinic (B MEPRS). Mental health, CPTs
5345   90804–90809 and 90862 (medication management) are available for telemedicine. A
5346   provider at the originating site is not required to present the patient to a physician or
5347   practitioner at the remote site unless medically necessary. This decision will be made by
5348   the physician or practitioner located at the remote site. However, the provider must be in
5349   the facility and available to take part in the teleconference if needed.
5350
5351   8.5. Remote Professional Services
5352   A provider at one facility performing an interpretation of results, consultation or referral
5353   (office visit code with modifier) for another facility is an example of remote professional
5354   services. Interpretation would be coded using the appropriate code, such as 59051.
5355   Consultations should be coded with a consultation code, such as 99241–99245 or 88321–
5356   88325. Referrals should be coded with an office visit code, such as 99201–99215 with
5357   modifier (GQ or GT). Other types of encounters include mental health, in the code
5358   ranges 90801 and 90804–90809, and nutritional counseling, with codes 97802, 97803,
5359   and 97804.
5360
5361   8.5.1. Types of Remote Professional Services: Interpretations, Referrals, Consults,
5362   and E-Mails.
                                                    8-3
                                             MHS Coding Guidance
                                                 March 2008
        OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
                                SCENARIOS



5363   8.5.1.1. Interpretations
5364   An interpretation is made on limited clinical data and the finding(s) documented. The
5365   data could be transmitted electronically, via e-mail or facsimile, or by mail. If an EKG is
5366   done at one facility and transmitted to another for interpretation, the facility where the
5367   EKG was done would code 93005 and the facility where the EKG was interpreted would
5368   code 93010. Another common example would be radiology. For radiology, one facility
5369   would code the 7xxxx-TC (technical component) and the other would code the 7xxxx-26
5370   (professional component).
5371
5372   8.5.1.2. Referrals
5373   When a provider at the remote site evaluates a patient for a specific problem or condition,
5374   this is called a referral. The most common example is a family practice physician at the
5375   originating MTF who refers the patient to a remote MTF for care. The referral includes
5376   history, vital signs, and photographs of the involved tissue and the contra-lateral tissue.
5377   The dermatologist at the remote site reviews the collected data, makes a diagnosis,
5378   develops a patient care plan, writes a prescription if necessary, and communicates the
5379   plan to the patient and patient’s physician, usually through the technician. The technician
5380   at the originating site would code a 99211 for each episode of care. The remote provider
5381   would code a referral (office visit) and any applicable procedure codes, such as
5382   interpretations.
5383
5384   8.5.1.3. Consult
5385   When a provider at the remote site is asked for advice on a patient, this is called a
5386   consult. As with all consults, there must be a written request and written report. The
5387   most common example is a family practice provider at the originating site e-mailing a
5388   request for consult along with EKG tracings and other documentation to the specialist at
5389   the remote MTF. The family practitioner then telephones and discusses the patient with
5390   the specialist. The consulted provider (specialist at remote MTF) arrives at a diagnosis,
5391   develops a treatment plan, documents the encounter, and sends the requesting provider
5392   the consult report. This would be coded by the remote, consulted provider as a consult
5393   with the appropriate modifier.
5394
5395   8.5.1.4. Provider–Patient E-Mail
5396   A reportable service would encompass the sum of communication and be documented in
5397   the patient’s medical record. The entire e-mail thread must become part of the patient’s
5398   medical record, including the acknowledgment of informed consent for e-mails, all e-
5399   mails in the thread.
5400
5401   Documentation guidelines for e-mail consultations between patient and provider should
5402   include date and time of e-mail (this should be automatically imbedded in the body of the
5403   e-mail).
5404
5405
                                                  8-4
                                           MHS Coding Guidance
                                               March 2008
        OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
                                SCENARIOS



5406   8.5.1.5. Situations Applicable for Online Consultations (E-Mail)
5407        Patient describes new symptoms and requests intervention or advice from the
5408           privileged provider.
5409        Patient describes ongoing symptoms from a recent acute problem or chronic
5410           health problem and requests intervention or advice from the privileged provider to
5411           treat ongoing acute problem or chronic health problem.
5412        Physician is giving substantive medical advice, revising treatment plan,
5413           prescribing or revising medication, recommending additional testing, or providing
5414           self care or patient education information for a new or chronic health problem.
5415        Physician makes a new diagnosis and prescribes new treatment.
5416        Patient requests interpretation of lab or test results and privileged provider gives
5417           substantive explanation and possibly makes recommendations to modify
5418           treatment plan, revising medications, etc.
5419        Clinical psychologist gives extended personal patient counseling, changing the
5420           course of treatment and affecting the potential health outcome.
5421
5422   8.5.2. E&M Coding
5423
5424   8.5.2.1. Documentation Needed
5425   When telemedicine is applied to conduct a professional office visit or consultation between
5426   provider and patient, the appropriate E&M codes for those services should be used. In
5427   general, the initial visit will be a consult and follow-up visits will be established office visits.
5428   Documentation must be filed in the patient’s permanent medical record and should include:
5429        Patient’s chief complaint
5430        Additional information from the patient to clarify his or her condition
5431        Any medications (over the counter, herbal, or prescription) being taken
5432        Date and time a prescription was ordered (may be available in CHCS)
5433        Date and time the patient is to return for care
5434        Electronic signature of the individual who performed the service when the online
5435           consultation is placed into AHLTA
5436
5437   8.5.3. Diagnosis Coding
5438   Official outpatient coding guidelines will be followed for reporting diagnoses for
5439   telehealth encounters.
5440
5441   8.5.4. Procedural Coding
5442
5443   8.5.4.1. Originating Site
5444   The originating site will report telehealth episodes with Q3014 Telehealth Originating
5445   Site Facility Fee.
5446
5447
                                                      8-5
                                               MHS Coding Guidance
                                                   March 2008
        OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
                                SCENARIOS



5448   8.5.4.2. Distant Site
5449   The distant site may report telehealth for many store-and-forward applications including
5450   but not limited to the interpretation of:
5451        Colposcopy
5452        Obstetric ultrasound
5453        Electrocardiography, fetal
5454        Echocardiography
5455        ESRD-related services
5456        Cardiography interpretation and report
5457        MRI
5458        Laboratory results
5459        Video clips
5460
5461   8.5.5. Modifiers
5462
5463   8.5.5.1. Asynchronous vs. Real-Time Encounters
5464   Professional telehealth services are coded with the appropriate modifier, for example,
5465   99245 GT. Telehealth encounters will be identified with
5466        GQ for asynchronous encounters, or
5467        GT for real-time interactive encounters.
5468
5469   8.5.5.2. GT Modifiers
5470   This signifies real-time communication between the distant-site physician or practitioner
5471   has taken place with the patient present and participating in the telehealth visit.
5472
5473   8.5.5.3. GQ Modifiers
5474   This signifies the distant site physician or practitioner certifies that the asynchronous
5475   medical file was collected and transmitted to him/her at his or her distant site from an
5476   eligible originating site when the telehealth service was furnished.
5477
5478   8.5.5.4. Modifier -26
5479   When a provider at a distant site provides an interpretation and report of a diagnostic
5480   study (e.g. laboratory or radiology test), the service is reported with the -26 modifier for
5481   the professional component of the procedure. The originating site would report the
5482   procedure with the –TC modifier if no interpretation and report are rendered.
5483
5484   8.5.6. E-mail Encounters
5485
5486   8.5.6.1. Telephone Module
5487   The telephone (T-con) module documents e-mail. Each facility or Service (i.e. Army, Navy,
5488   Air Force) needs to determine its security risk and the Service must endorse in writing the
5489   use of e-mail in its facility or Service.
                                                   8-6
                                            MHS Coding Guidance
                                                March 2008
        OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
                                SCENARIOS



5490   99444          Online evaluation and management service provided by a physician to an
5491                  established patient, guardian, or health care provider not originating from a
5492                  related E/M service provided within the previous 7 days, using the internet
5493                  or similar electronic communications network
5494
5495   8.5.6.2. Multiple E-Mails
5496   Beginning with an acknowledgment of informed consent, an episode of care can
5497   accommodate multiple e-mails for the same problem. If additional correspondence is
5498   expected on the same medical issue, the encounter should be left open until the e-mail
5499   thread is complete. Additionally, if acknowledgment is requested from the patient, the
5500   encounter should remain open until the acknowledgment is received. This is for an
5501   established patient only and not provider-to-provider e-mail. The appointment belongs to
5502   the B MEPRS clinic of the provider and would not be used for inpatient care or ancillary
5503   services. The E&M code is limited to 99371 at this time owing to DoD system
5504   limitations. There is no modifier.
5505
5506   8.5.6.3. Situations Applicable for Online Consultations (E-mail)
5507   Examples include the following:
5508        A patient describes new symptoms and requests intervention or advice from the
5509           privileged provider.
5510        A patient describes ongoing symptoms from a recent acute problem or chronic
5511           health problem and requests intervention or advice from the privileged provider to
5512           treat ongoing acute problem or chronic health problem.
5513        A privileged provider gives substantive medical advice, revises a treatment plan,
5514           prescribes or revises medication, recommending additional testing, or provides self
5515           care or patient education information for new or chronic health problem.
5516        A privileged provider makes a new diagnosis and prescribes new treatment.
5517        A patient requests interpretation of lab or test results with evidence that the
5518           privileged provider is giving substantive explanation and possibly making
5519           recommendations to modify treatment plan, revise medications, etc.
5520        A privileged provider gives extended personal patient counseling that changes the
5521           course of treatment and affects the potential health outcome.
5522
5523   8.5.6.4. E-Mail Consultation
5524   Following are documentation guidelines for e-mail consultations between patient and
5525   provider. Documentation must be filed in the patient’s permanent medical record.
5526
5527              Date and time of e-mail (should be automatically imbedded in the body of the e-
5528               mail)
5529              Patient’s chief complaint
5530              Additional information received from the patient to clarify his/her condition
5531              Medications (over-the-counter, herbal, or prescription) being taken
                                                  8-7
                                           MHS Coding Guidance
                                               March 2008
        OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
                                SCENARIOS



5532             Date and time a prescription was ordered (may be available in CHCS)
5533             Date and time the patient is to return for care
5534             Electronic signature of the individual who performed the service when the online
5535              consultation is placed into AHLTA
5536
5537   8.6. Resident/GME Services
5538
5539   8.6.1. Definitions for Staff and Providers
5540   For DoD purposes, the following definitions are applicable for staff or providers in a
5541   GME program.
5542
5543   Chief Resident. An individual who has completed an accredited residency program, then
5544   engaged in an additional year of training and responsibility. Chief residents are board-
5545   eligible or board-certified and are able to be privileged in the discipline of their
5546   completed specialty training program. Chief residents are frequently licensed independent
5547   practitioners. This model is common in internal medicine programs.
5548
5549   Fellow. A physician or dentist, who has enrolled in a special fellowship program for
5550   additional training, primarily in research.
5551
5552   Resident. An individual engaged in a graduate training program in medicine (including
5553   all specialties, e.g., internal medicine, surgery, psychiatry, radiology, nuclear medicine,
5554   dentistry, podiatry or optometry), who participates in patient care under the direction of
5555   supervising practitioners. Such programs must be accredited or certified as appropriate.
5556
5557   NOTE: The term resident includes individuals in a recognized ACGME
5558   (Accreditation Council for Graduate Medical Education) program and individuals
5559   in approved subspecialty graduate medical education programs who historically
5560   have also been referred to as fellows by some sponsoring institutions.
5561
5562   Intern. A physician typically in the first year of training after medical school, often
5563   described as PGY1. Interns typically do not have a license.
5564
5565   8.6.2. GME Documentation Requirements
5566

5567                  DoD Rule
5568
5569                  Physicians at Teaching Hospitals (PATH)/Primary Care Exception. PATH,
5570                  which includes the Primary Care exception, does not apply to the MHS,
5571                  because the MHS funds its own GME programs. GME participants, except
5572                  for PGY1, are permitted to use any code based on the documentation.

                                                  8-8
                                           MHS Coding Guidance
                                               March 2008
        OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
                                SCENARIOS



5573
5574
5575

5576                  DoD Rule
5577                  Providers who participate in a residency program for GME usually do so
5578                  with the oversight of an attending or teaching provider. Licensed physicians
5579                  have the full range of E&M and procedure codes available. For unlicensed
5580                  physicians (typically interns or PGY1), coding is limited to lower or mid-
5581                  range E&M codes and office visit procedure codes.
5582
5583                  When an attending and resident are both involved in a procedure, the
5584                  primary provider must be identified in the documentation. The record is
5585                  coded under the primary and the other individual is assigned the role of
5586                  either supervising (staff) or GME (resident). The primary provider is the
5587                  individual who performs critical and key portions of the procedure.

5588
5589   8.6.2.1. Documentation
5590   All students, including medical students, may document in the medical record; however,
5591   coding cannot occur for these encounters.
5592
5593   8.6.2.2. Supervision Documentation
5594   Documentation of supervision must be entered into the medical record by the supervising
5595   practitioner or reflected in the resident progress notes or other appropriate entries in the
5596   medical record (e.g., procedure reports, consultations, discharge summaries). Pathology
5597   and radiology reports must be verified by a supervising practitioner.
5598
5599   NOTE: Co-signatures for coding purposes are required unless the notes meets the
5600   documentation standards outlined in 1 (d).
5601
5602          (1) Allowable documentation:
5603                  (a) SF 600/Progress note or other entry into the medical record by the
5604                      supervising practitioner, or
5605                  (b) Addendum to the resident SF 600 or progress note by the supervising
5606                      practitioner, or
5607                  (c) Co-signature of the SF 600 or progress note or other medical record
5608                      entry by the supervising practitioner, or
5609
5610                  (d) Resident SF 600 or progress note or other medical record entry
5611                      documenting the name of the supervising practitioner with whom the
5612                      case was discussed, a summary of the discussion, and a statement of
5613                      the supervising practitioner’s oversight responsibility for the
5614                      assessment, diagnosis, plan for evaluation, or treatment.
                                                   8-9
                                            MHS Coding Guidance
                                                March 2008
        OTHER FUNCTIONAL ISSUES RELATED TO CHCS/AHLTA OR CLINICAL
                                SCENARIOS



5615
5616   NOTE: Statements such as the following are acceptable to demonstrate the
5617   supervising practitioner’s oversight responsibility. ―I have seen and discussed the
5618   patient with my supervising practitioner, Dr. X, and Dr. X agrees with my
5619   assessment and plan.‖ ―I have discussed the patient with my supervising
5620   practitioner, Dr. X, and Dr. X agrees with my assessment and plan.‖ The
5621   supervising practitioner of record for this patient care encounter is Dr. X.
5622
5623          (2) Allowable documentation varies by clinical setting and kind of patient
5624              encounter. In all cases, the responsible supervising practitioner must be
5625              clearly identifiable in the documentation of the patient encounter or report of
5626              reviews of patient material.




                                                  8-10
                                           MHS Coding Guidance
                                               March 2008
                               INPATIENT PROFESSIONAL SERVICES


5627   INPATIENT PROFESSIONAL SERVICES
5628
5629   9.1. Background
5630   The MHS captures inpatient workload with professional and institutional data. All
5631   SADRs generated have a flag that indicates if the patient is inpatient or outpatient. The
5632   flag can be used to identify all inpatient professional services.
5633
5634   9.2. Definitions
5635
5636   9.2.1. Attending Service
5637   Is the medical or surgical service to which the patient is officially admitted via admission
5638   or transfer orders.
5639
5640   9.2.2. House Staff
5641   Medical students, interns (PGY1), and residents working under approved GME program
5642   guidelines.
5643
5644   9.2.3. Diagnosis
5645   The documentation records the progression of the workup and treatments leading to the
5646   final (principal) diagnosis. The coding will reflect what is addressed each day; except for
5647   the discharge day when non-surgical admissions coding reflects the discharge diagnoses.
5648   Post-operative inpatient professional services will be coded with the appropriate aftercare
5649   code with the 99024 CPT.
5650
5651   9.2.4. Inpatient Consult
5652   A consult resulting from a request by the attending physician or provider to a physician
5653   or provider from another service to evaluate or give advice and initiate diagnostic or
5654   therapeutic services to an inpatient remaining under the care of the attending physician or
5655   provider. There is only one inpatient consult code per service per admission. Follow-up
5656   inpatient consults from that service are coded with subsequent E&M hospital day codes.
5657
5658   9.2.5. Institutional Services
5659   Healthcare services provided by interns, residents, fellows, technicians, and some physician
5660   extenders and non-privileged providers. It includes resources used or consumed during a
5661   patient’s encounter with the healthcare system (e.g., equipment, facilities, utilities, and
5662   supplies) including cardiac care units and intensive care units.
5663
5664   9.2.6. Interservice Transfers
5665   If an inpatient is transferred from one clinical service to another for care and the transfer is
5666   noted in CHCS, an inpatient SADR may be generated for both the losing and gaining
5667   clinical services for that day.
5668
5669   9.2.7. Professional Services
5670   Healthcare services provided directly to the patient by a privileged provider or GME
5671   personnel with appropriate documentation. This excludes ancillary services.
                                                    9-1
                                             MHS Coding Guidance
                                                 March 2008
                               INPATIENT PROFESSIONAL SERVICES


5672
5673   9.2.8. Rounds (RNDS)
5674   An appointment type in DoD information systems (CHCS/AHLTA) is designed to capture
5675   professional services delivered in the inpatient environment by the service of the attending
5676   provider of record.
5677
5678   9.2.9. Business Rules
5679
5680   9.2.9.1. Institutional Service or Cost
5681   Inpatient services provided by technicians, allied health providers, some physician
5682   extenders, and non-privileged providers are counted as a part of institutional service/cost
5683   and will not produce an inpatient professional service round in CHCS.
5684
5685   Professional Services Scenarios for Inpatient Encounters
5686
        GYN Example:
        Patient with menorrhagia is admitted to GYN for planned hysterectomy. Hysterectomy was
        performed the day of admission. It was determined that uterine fibroids were the cause of
        menorrhagia.
5687
                                      ICD-9          E/M         CPT     Responsible
         Planned                                                           Clinic
        admission       Day 1    Uterine fibroids     N/A   Hysterectomy    GYN
          w/out         Day 2       Aftercare         N/A      99024        GYN
       complication     Day 3       Aftercare         N/A      99024        GYN
                       Discharge    Aftercare         N/A      99024        GYN
5688
        Family Practice Transfer of Care to General Surgery
        Example:
        Patient was admitted to family practice with abdominal pain. General surgery consulted on
        day 3 of admission and determined a diagnosis of appendicitis. Care was transferred to
        general surgery. On day 3, an appendectomy was performed. General surgery consulted
        prior to transfer of care so the consult with -57 modifier is entered in the B MEPRS for
        general surgery since it was not the attending practice at the time.
5689
        Medical                   ICD-9               E&M                CPT         Responsible
       condition                                                                       Clinic
       w/global       Day 1     Abdominal          99221–99223           ~~         Family Practice
         event                     Pain
                      Day 2     Abdominal          99231–99233           ~~         Family Practice
                                   Pain
                      Day 3     Appendicitis      99251–99255-       Appendectomy   General Surgery
                                                       57
                   Discharge     Aftercare            N/A               99024       General Surgery
5690
5691
                                                      9-2
                                               MHS Coding Guidance
                                                   March 2008
                                INPATIENT PROFESSIONAL SERVICES


5692   OB Care Example:
5693   Patient admitted for planned c-section. There were no complications during delivery or
5694   admission.
5695
                                       ICD-9              E&M         CPT           Responsible Clinic
       OB with       DAY 1         Delivery codes          N/A      5XXXX                 OB
       planned       DAY 2      Post partum aftercare      N/A       99024                OB
         C-          DAY 3      Post partum aftercare      N/A       99024                OB
       section                                             N/A
                    Discharge   Post partum aftercare               99024                  OB
5696
5697   OB Care Example:
5698   Patient admitted in labor. Baby was delivered the following day. There were no
5699   complications during delivery or during admission.
5700
                                                                                          Responsible
                                           ICD-9             E&M              CPT           Clinic
         OB with           DAY 1         Pregnancy            N/A            0502F            OB
         normal                           Delivery            N/A
         delivery          DAY 2            codes                           59XXX               OB
                                        Post partum          N/A
                           DAY 3          aftercare                          99024              OB
                                        Post partum          N/A
                         Discharge        aftercare                          99024              OB
5701
5702   Surgery Example:
5703   Orthopedist consulted in emergency room on patient and decided there that surgery
5704   should be performed. Patient was then admitted to Ortho for reduction of fracture.
5705
                                                                                         Responsible
                                      ICD-9               E&M            CPT               Clinic
                                 Fracture code w/        99241-      Reduction of
       Traumatic      Day 1           E code            99245–57       Fracture             Ortho
        Fracture      Day 2         Aftercare              N/A          99024               Ortho
                      Day 3         Aftercare              N/A          99024               Ortho
                    Discharge       Aftercare              N/A          99024               Ortho
5706
5707   Illness With No Complication Example:
5708   Patient admitted from clinic with a diagnosis of gastritis. No surgical procedure was
5709   performed during this stay.
5710
                            ICD-9           E&M      CPT Responsible Clinic
                 Admission Gastritis     99221–99223 ~~       Gastro
       Gastritis  DAY 2    Gastritis     99231–99233 ~~       Gastro
                  DAY 3    Gastritis     99231–99233 ~~       Gastro
                 Discharge Gastritis     99238–99239 ~~       Gastro
5711
                                                    9-3
                                             MHS Coding Guidance
                                                 March 2008
                              INPATIENT PROFESSIONAL SERVICES


5712   9.2.9.2. Ambulatory Data Module (ADM/AHLTA/P-GUI).
5713   Inpatient professional services rely on accurately capturing inpatient professional services
5714   (diagnosis, procedures, etc.).
5715
5716   9.2.9.3. ADT Module
5717   Inpatient professional services rely on appropriate use of the ADT Module. The correct
5718   specialty service is designated by the MEPRS code. The attending physician’s name and
5719   MEPRS code must be associated with the patient to accurately identify and allocate both
5720   professional and institutional services and costs. This is especially important when
5721   patients are transferred from one service to another.
5722
5723   9.2.9.4. MTFs with GME Program
5724   MTFs that operate a GME program are particularly affected by this effort. For example,
5725   MTF medical staff bylaws typically permit the attending (teaching) physician to place
5726   documentation in the inpatient record once every three days. If the house staff or
5727   attending work is to be captured using the rounds (RNDS) process, the attending provider
5728   is required to provide more frequent and detailed documentation. Residents will
5729   document the involvement of the staff attending provider’s management of the patient.
5730   The documentation requirements will mirror those outlined in section 8.6. Residents may
5731   be included as secondary provider on the rounds encounter.
5732
5733   9.2.9.5. Inpatient Professional Services
5734   These will capture surgical services (see surgical services guidelines 9.4).
5735
5736   9.2.9.6 Ancillary Services
5737   For the purposes of the MHS and these guidelines, ancillary services include radiology,
5738   laboratory, pharmacy, and anesthesiology. These are not coded in rounds.
5739
5740   9.3 Inpatient Professional Services Data Capture
5741   There are two methods for capturing this workload in ADM/AHLTA/P-GUI.
5742
5743   9.3.1 Auto Generation
5744   The RNDS appointment type will automatically be generated upon admission and each
5745   night at the census hour in the A MEPRS code of the inpatient service to which the
5746   patient is admitted. (Example: A nephrologist admits a patient to internal medicine. The
5747   MEPRS code will be AAA based on the service to which the patient is admitted; ADT
5748   determines both the attending provider and the service.
5749
5750      Example: When a surgical consult is performed on an internal medicine patient
5751      who is subsequently transferred to the surgical service on the same day, the
5752      surgeon cannot get credit for the consultation and the RNDS on the same patient
5753      on the same day.
5754
5755
5756
                                                   9-4
                                            MHS Coding Guidance
                                                March 2008
                              INPATIENT PROFESSIONAL SERVICES


5757   9.3.1.1 Default to Admitting Provider
5758   If the attending provider field is not filled in, the default will be the admitting provider.
5759   In a GME program, this is extremely important since the ambulatory data record-
5760   generated IBWA round will default to the house staff, if the house staff is listed as
5761   admitting provider. Per MHS policy, house staff do not have admitting privileges. If a
5762   house staff officer receives an inpatient RNDS, the record needs to be redirected to the
5763   attending provider and the ADT module must be updated appropriately.
5764   9.3.1.2. Appointment Status Default to Kept
5765   CHCS automatically sets the appointment status to kept. This will generate an encounter
5766   to be completed by the physician/provider.
5767
5768   9.3.2. Manual Creation
5769   Use the RNDS Appointment Processing option to create new RNDS appointments. There
5770   are two common reasons for creating a RNDS manually.
5771
5772      1. Interservice transfers at the same facility: When a transfer is not precipitated by a
5773         consult, or the consult was done on a day preceding the transfer, a RNDS
5774         encounter will be initiated using the manual creation feature in DoD systems.
5775      2. Transfer precipitated by the consult module on the same day. Instead of collecting
5776         the inpatient consult in the B MEPRS, use the Data Entry Menu/Rounds
5777         Appointment Processing to generate a RNDS visit in the A MEPRS.
5778
5779   NOTE: The inpatient admission E&M is collected by the admitting clinical
5780   service; an E&M is not collected in the clinic (or B MEPRS). The workload
5781   for an inpatient consult that results in the transfer to a new service is
5782   collected in the RNDS E&M for the new service for that day.
5783
5784   9.3.2.1. Inter-service Transfer at Same Facility Without Referral Initiated in the
5785   Consult Module.
5786   When an inpatient is transferred from one clinical service to another for care and the
5787   transfer is noted in CHCS, an inpatient E&M may be generated for both the losing and
5788   the gaining clinical service for that day.
5789
5790   NOTE: The gaining clinical service will have to manually generate a new
5791   encounter. The E&M will be based on the rounds documentation for that service
5792   for that day.
5793
5794        Example: A patient changes services (e.g., a surgical patient with a post-
5795        surgical embolism is transferred to internal medicine). One E&M may be
5796        coded in the initial service (surgery) and one E&M may be coded in the new
5797        service for that day (internal medicine).
5798
5799        Example: When a patient is transferred from service A to service B and the
5800        attending on service B sees the patient and had completed an inpatient consult

                                                   9-5
                                            MHS Coding Guidance
                                                March 2008
                              INPATIENT PROFESSIONAL SERVICES


5801        earlier that day, an RNDS record for the attending on service B will need to be
5802        manually generated and completed.
5803
5804   9.3.2.2. Recording a Procedure by Another Provider at the Same Clinical Service
5805
5806      Example: Dr. A makes rounds on patient X in the morning. Dr. A documents
5807      sufficiently for E&M code 99232 for the rounds with appropriate diagnoses..
5808      Dr. B (same clinic service, covering for Dr. A) is called to see patient X that
5809      same calendar day. Dr. B documents patient’s fever, headache, and stiff neck
5810      and wants to rule out meningitis. Dr. B performs a lumbar puncture. Additional
5811      diagnosis codes would be added to Dr A’s ADM RNDS encounter. Enter Dr. B
5812      as an additional provider on Dr. A’s ADM record for the total E&M services.
5813
5814   9.3.2.3. A separate RNDS encounter would be created for Dr B with diagnosis codes for
5815   fever, headache and stiff neck. These diagnosis codes support the medical necessity for
5816   the procedure (lumbar puncture). The lumbar puncture code (62270) would be coded on
5817   Dr B’s ambulatory data record. Dr B’s E&M was included in Dr A’s SADR.
5818   9.3.3. RNDS Record Completion
5819   Complete the RNDS encounter based on the patient interaction and the documentation in
5820   the inpatient record. The physician or provider is responsible for documenting all patient
5821   encounters in the medical record in accordance with hospital and Service policies. Codes
5822   will be assigned based on documentation.
5823
5824   9.3.3.1. Dates for RNDS Documentation
5825   RNDS encounters will be completed for the dates the attending physician sees and
5826   documents the encounter with the patient. If house staff sees the patient and the attending
5827   provider is not physically present during the portion of the service that determines the
5828   level of service and the attending does not document the key components of those
5829   services, no RNDS encounter will be completed. The RNDS appointment for that date
5830   should be cancelled by the physician or provider (or by the coder upon completion of the
5831   inpatient stay), although it will automatically disappear after 30 days. Once cancelled or
5832   after 30 days, the RNDS appointment cannot be re-created.
5833
5834   NOTE: Even though the rounds appointment is canceled, patients may appear on
5835   other reports as ―kept‖ appointments.
5836
5837   9.3.4. E&M Coding
5838
5839   9.3.4.1. Services Recorded Once Daily
5840   E&M services may only be recorded once per patient per clinical specialty day. The
5841   correct codes are based on the sum of the documentation of all E&M services.
5842
5843   NOTE: If the admission E&M is not documented within 24 hours by the
5844   attending, then only the E&M code for a subsequent day of care can be used.
5845   Once the initial hospital care visit is completed and fully documented, only
                                                  9-6
                                           MHS Coding Guidance
                                               March 2008
                                INPATIENT PROFESSIONAL SERVICES


5846   two of the three components for an E&M are required to be documented on
5847   subsequent visits. Multiple E&M codes can be reported in a cost center but
5848   they must all be recorded on one RNDS encounter. Generally, one E&M
5849   code is sufficient.
5850
5851   9.3.4.2. Coding for Multiple Providers
5852   When multiple providers from the same clinical specialty cover for the attending
5853   provider, and the attending provider does not see the patient at all that day, the E&M
5854   services will be coded under the name of the last provider who documents services on
5855   that calendar day. This will require the default provider on the ADM to be changed to the
5856   last provider of the day. All other providers may be listed as additional providers on the
5857   encounter record.
5858
5859   9.3.4.3. Providers Covering for Attendings
5860   Providers covering for the attending are considered to be in the same specialty as the
5861   attending, even if the provider is from a different specialty. For example, if it is an
5862   internal medicine patient, then it is internal medicine work, even if the provider covering
5863   is a family practice provider.
5864
5865   9.3.4.4. Inter-Service Transfer.
5866   When an inpatient is transferred from one clinical specialty to another for care, and the
5867   transfer is noted in CHCS, an inpatient ambulatory data record may be generated for both
5868   the losing and gaining clinical specialty for that day. NOTE: The gaining clinical
5869   specialty will have to manually generate a new RNDS encounter if the patient is not
5870   transferred through a consult.
5871
5872      Example: A patient who has taken an overdose as a suicide attempt is admitted
5873      to the internal medicine service. The internist requests a psychiatry consult.
5874      The psychiatrist sees the patient and recommends the patient be transferred to
5875      the psychiatry service when medically stable. The next day, the patient is
5876      deemed medically stable and the transfer occurs.
5877
5878   9.3.4.5. Transfer on Day of Consult
5879   If the patient is transferred to a new specialty on the day of the consult, no RNDS
5880   appointment is completed. Professional services are recorded through the inpatient
5881   consult process and in this example would be accrued to the Psychiatry B MEPRS code.
5882
5883   9.4. Surgical Services
5884
5885   9.4.1. Elective Surgery
5886   When elective/non-elective surgery is determined to be necessary, assign appropriate
5887   E&M code with modifier -57 in addition to any surgical procedure codes performed by
5888   the same provider.
5889
5890
                                                  9-7
                                           MHS Coding Guidance
                                               March 2008
                             INPATIENT PROFESSIONAL SERVICES


5891   9.4.2. Surgery More Than Two Days After Admission
5892   If surgery is not the day of or the day after admission, use inpatient hospital care E&M
5893   codes. Review rules for modifiers if care involves a separately identifiable E&M service
5894   on the day of procedure (-25) or an unrelated E&M service during the post-op period (-
5895   24).
5896
5897   9.4.3. Assigning CPT Codes
5898   Assign CPT codes for any operating room or bedside procedures.
5899
5900   9.4.4. Post-Surgical Codes
5901   Assign code 99024 for routine postoperative follow-up visits.
5902
5903   9.4.5. Surgical Specialty
5904   Following are scenarios that surgical specialists may encounter. The following codes are
5905   reported by surgical specialists:
5906
5907       SCENARIO                                        E&M                  PROCEDURE
       1. Elective surgical admission:                      N/A                   27447
       Scheduled total knee replacement
       2. Non-elective surgical admission:                9922_-57                 44950
       Patient presents to ER with abdominal
       pain; admitted for appendectomy
       3. Medical admission for pneumonia;      If applicable, E&M code            33910
       patient develops pulmonary embolism      with modifier -57 if decision
       and requires embolectomy with            for surgery is made that day
       cardiopulmonary bypass                   or within 24 hours of
                                                surgery
5908
5909   9.5. Inpatient Consults
5910
5911   9.5.1. Outpatient Appointment Type
5912   Follow current procedures for capturing consults to inpatients, using the outpatient
5913   appointment type walk-in. When prompted, ―Is this clinic visit related to the inpatient
5914   stay?‖ answer No. This will ensure credit is given to the appropriate B MEPRS code for
5915   services rendered.
5916
5917   Inpatient consults are collected using the appropriate E&M code along with the
5918   appropriate diagnoses and procedure codes. Example: Dr Orthopedics, an orthopedic
5919   surgeon, requests a pulmonary consult on a high-risk surgical patient. In this case, Dr.
5920   Pulmonary did not recommend the patient be transferred to his service. The inpatient
5921   consult performed by Dr. Pulmonary, the consulting physician, will be entered in CHCS
5922   under the B MEPRS code along with the appropriate diagnosis and procedures.
5923
5924   9.5.2. Non-Attending Inpatient Professional Service
5925   Use codes 99251–99255 when a physician provides an initial opinion or gives advice on
5926   the evaluation or management of a specific problem at the request of another physician.
                                                 9-8
                                          MHS Coding Guidance
                                              March 2008
                              INPATIENT PROFESSIONAL SERVICES


5927   The consultant may start diagnostic or therapeutic services. A written report must be sent
5928   to the requesting physician to be placed in the inpatient medical record. The
5929   documentation required for the consultation is the request for a consult, the need for the
5930   consultation, the consultant’s opinion, and any services ordered or performed. A code
5931   from the initial inpatient consult code series (99251–99255) may only be used once by a
5932   consultant during a hospitalization.
5933
5934   9.6. Subsequent Hospital Care
5935   Use the 99231–99233, 99294, 99296, 99298–99299 codes when an initial consult is
5936   completed and the consultant assumes some (both attending and consultant responsible
5937   for different aspects of care) or all (patient transferred to consultant) inpatient care.
5938
5939
5940   9.6.1. Same Specialty: Additional Provider
5941   A request for a consult from a physician or provider in the same specialty would be listed
5942   as an additional provider on the attending’s inpatient E&M encounter.
5943
5944      Example: An internist seeing another internist’s patient would be listed as the
5945      additional provider.
5946
5947      Example: A cardiologist seeing an internal medicine patient will generate a
5948      separate inpatient consultation (B MEPRS). The document will be maintained
5949      in the inpatient record and not the clinic.
5950
5951   9.7. Observation Status
5952   This is an outpatient status. Patients may not be discharged from inpatient status to
5953   observation status. Patients may be admitted directly from observation. Once admitted,
5954   all E&M services, both the observation and inpatient, for a specific condition provided
5955   that calendar day (for clinic or observation status) shall be collected in the E&M code for
5956   inpatient services.
5957
5958   9.7.1. Inpatient Record
5959   All professional services given to the patient are documented in the inpatient record.
5960   Ambulatory clinic services for the inpatient are also recorded in the inpatient record.
5961
5962   9.8. Newborn Early Hearing Detection and Intervention (EHDI)
5963
5964   9.8.1. EHDI while the newborn is in the hospital should be documented in the RNDS if
5965   done by the attending provider.
5966
5967
5968
5969
5970
5971
                                                  9-9
                                           MHS Coding Guidance
                                               March 2008
                               INPATIENT PROFESSIONAL SERVICES


5972         NEWBORN EARLY HEARING DETECTION AND INTERVENTION
                       Encounter Type                    ICD-9-CM               CPT            CPT
                                                          Diagnosis            E&M          Procedure
                                                           Codes               Codes          Codes
          Newborn hearing screening with no               V72.1**          If applicable,    92586 or
          abnormalities performed in newborn                                  992XX*          92587
          nursery or neonatal ICU (Inpatient rounds
          SADR)
5973
5974   If a newborn hearing test is performed by the pediatrician, then the service is reported as
5975   a "Rounds" encounters.
5976
5977   If a newborn hearing test is performed by the audiologist (a consult), then report to the
5978   appropriate "B" MEPRS.
5979




                                                    9-10
                                             MHS Coding Guidance
                                                 March 2008

								
To top