Medicine
Introduction
This chapter will introduce a diverse group of noninvasive or minimally invasive services, including:
- Immunizations
- Vaccines, Toxoids
- Psychiatry
- Biofeedback
- Dialysis
- Gastroenterology
- Ophthalmology
- Otorhinolaryngology
- Cardiovascular
- Non-invasive Diagnostic Vascular Studies
- Pulmonary
- Allergy & Clinical Immunology
- Endocrinology
- Neurology/Neuromuscular Procedures
- Medical Genetics & Genetic Counseling Services
- Central Nervous System Assessments/Tests
- Health & Behavior Assessment/Intervention
- Hydration, Therapeutic, Prophylactic, Infusions & Injections
- Photodynamic Therapy
- Special Dermatological Procedures
- Physical Medicine & Rehabilitation
- Nutritional Therapy
- Acupuncture
- Osteopathic & Chiropractic Manipulative Treatment
- Education & Training for Patient Self-Management
- Non-Face-To-Face Nonphysician Services
- Qualifying Circumstances for Anesthesia
- Moderate Sedation
- Home Health Procedures/Services
- Medication Therapy Management Services
- CPT Coding
Anti-infective Immunizations
Codes 90281-90399 describe anti-infective immunizations derived from human blood or recombinant immune globulin products created in a laboratory.
Each code is specific to the type of anti-infective administered, with 90399 reserved for an immune globulin that is not described in a code.
Do not report modifier 51 if these services are performed with another procedure.
Report the administration of these products in addition to the product.
Codes 96365-96368, 96372, 96374, and 96375 are the codes reported for administration of immune globulin.
When the delivery is by infusion (96365-96371), adhere to times stated in the code descriptor. A minimum time of 31 minutes is required to report the add-on code for an additional hour.
Procedure coding tip: Refer to the nurse’s notes for the delivery technique and start and stop infusion times of each drug/substance administered to report the service correctly. These codes also may describe addition of sequential substances as an add-on to the base code.
Generally included in the service are local anesthesia, IV start, vascular access, flush at conclusion of an infusion, standard tubing, syringes, and supplies.
When fluids are used for delivery of the substance/drug, the fluid administration is incidental to the administration and is not separately reported.
Codes 96365-96371 are not reported for chemotherapy administration.
(The work for these services usually includes development of the treatment plan and direct supervision of staff. If a significant, separately identifiable E/M service is performed at the same encounter, the appropriate E/M code is reported with modifier 25)
Diagnosis coding tip: If the substance is ordered due to exposure to infection, report a Z code as the diagnosis. Example: Z20.820 Contact with and (suspected) exposure to varicella (90396).
Vaccines and Toxoids
Codes 90476-90749 describe vaccines and toxoids and are reported for the product only.
The administration codes are 90460-90474.
Report codes 90460-90461 only if the provider counsels the patient/family face-to-face during the administration of the vaccine/toxoid to a child younger than 18 years of age.
- These Administration codes are reported for vaccine(s) with multiple components (combination vaccine), in which you report 90460 for the first component and the additional component(s) in that vaccine you report 90461.
- An example of a combination vaccine is the MMR vaccine which is made up of three vaccine components: Mumps, Measles, and Rubella. Code 90460 is reported for the first component (Mumps) and 90461 x 2 is reported for the two additional components (Measles and Rubella). Add-on code +90461 is only reported for additional component(s) in combination vaccine(s).
Report codes 90471-90474 if no counseling is provided for a child less than 18 years of age and for the administration of vaccine(s)/toxoid(s) to patients over 18 years of age.
- These administration codes are not reported by each vaccine component in a combination vaccine but reported by how each vaccination is given (IM, orally, subcutaneously, etc.).
- For example, an MMR vaccine given intramuscularly without counseling is reported with one administration code, 90471.
Do not report modifier 51 with these services.
(If a significant, separately identifiable E/M service is provided at the same encounter, the appropriate E/M service may also be reported with modifier 25)
(Subcutaneous injections (Sub-Q) are delivered into the subcutaneous layer of skin. Intramuscular injections (IM) are administered directly into a muscle)
Diagnosis coding tip: Code Z23 is used in ICD-10-CM for all for prophylactic vaccination and inoculations.
Example: Z23 is reported when Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use (90691) is administered.
To select appropriate administration codes, we have to look into the following things,
1. How many vaccinations were administered and what are the vaccines
2. What was the route of administration
3. How many components were there in each vaccine
4. Whether counseling was provided by the physician or not.
When two or more vaccines were administered, to bill each additional vaccine administration with +add on codes. Only one initial administration code can be used at a given encounter.
Eg: For 3 Intramuscular injections we have to use one primary admin and 2 units with add on code.
CPT 90471 CPT 90472 x 2
Eg: One Intramuscular injection and one oral administration
CPT 90471 (Intramuscular)
CPT 90474 (Oral)
Eg: Two intramuscular injections and one oral administration
CPT 90471 (First intramuscular)
CPT 90472 (Second intramuscular)
CPT 90474 (Oral)
Eg: One nasal and one oral
CPT 90473
CPT 90474
Psychiatry
Codes 90785-90899 are reported for psychiatric services, which may include psychotherapy, behavior modification, and addictive disease therapy.
The remaining psychotherapy codes are used to report therapeutic services provided to the patient.
- Code selection is based on location of therapy (inpatient or in an office), type of psychotherapy, and time spent with the patient.
- Psychotherapy can be provided with or without medical E/M services.
- There are add-on codes for psychotherapy used when a significant and separately identifiable E/M service is performed on the same date.
- The add-on codes that include medical E/M services note in the description “when performed with an evaluation and management service” and provides a parenthetical instruction note as to which E/M codes are reported with it.
- The time performing the E/M service cannot be counted in the time used to determine the psychotherapy code.
- The documentation should clearly support how much time was spent in psychotherapy outside of the time spent for the E/M to use the add on codes.
EXAMPLE
99203New Patient office or other outpatient service
+90833when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
(In this example, add-on code +90833 is reported as an additional code if a medical E/M service was performed in addition to psychotherapy services indicated in the CPT subsection guidelines for Psychotherapy.)
Codes for psychotherapy for patients in crisis are reported when patients have a life-threatening condition or a very complex medical condition.
- The codes are selected based on time.
- The services performed include psychotherapy, mobilization of resources to defuse the crisis and restore safety, and implementation of psychotherapeutic interventions to minimize the potential for psychological trauma.
Pharmacologic management is reported with an add-on code (+90863). This service is reported in addition to psychotherapy (90832, 90834, 90837).
(The time spent performing pharmacologic management cannot be used to determine the time reported for the psychotherapy code, according to CPT.)
Diagnosis coding tip: If a definitive condition has been documented, it is reported as the diagnosis. If the patient is being observed for behavior patterns pending diagnosis, it may be appropriate to report a Z code for observation of certain conditions.
Biofeedback
Codes 90901, 90912-90913 are reported for biofeedback, during which patients learn to improve their health by using their own body signals, such as re-education of muscle groups to improve spasticity or weakness. Note, that codes 90912 and add-on code +90913 are time-based codes.
Diagnosis coding tip: Conditions may include stages of paralysis, muscle spasms, and urinary incontinence.
Dialysis and End Stage Renal Disease Services
Codes 90935-90940 are reported for hemodialysis, or direct removal of toxins from blood:
- Report 90935 for one physician or other qualified healthcare professional evaluation and 90937 for repeat evaluations.
- Report 90940 for evaluation of blood flow through the graft or AV fistula during hemodialysis.
- 90935 and 90937 include all E/M services related to the patient’s renal disease on the day of the hemodialysis procedure.
(When an E/M service is provided that is unrelated to the dialysis or renal failure, which cannot be rendered during the dialysis session, a separate E/M code is reported with modifier 25)
Codes 90945-90947 are reported for dialysis other than hemodialysis, such as peritoneal or hemofiltration.
- These codes include all E/M services related to the patient’s renal disease on the day of the procedure.
(A separately identifiable E/M service unrelated to the patient’s renal disease can be reported with modifier 25)
Codes 90951-90962 are reported once per month for end-stage renal disease services.
- Codes are selected based on the age of the patient and on the number of face-to-face physician or other qualified healthcare professional visits.
- If a complete assessment has been provided, but the patient had less than one month of treatment, report codes 90967-90970 per day.
Codes 90967-90970 are reported based on the age of patient and per day, for end-stage renal disease services, when less than a full month of service is provided.
- These codes are reported for certain circumstances, some examples include transient patients, patients admitted to the hospital, treatments terminated due to recovery or death of the patient, or in patients who have received a renal transplant.
- For example, home dialysis patients admitted as inpatients will have a break in their home dialysis. In this case, report codes 90967-90970 for each day outside of inpatient hospitalization.
Report as appropriate, codes 90935-90937, 90945, or 90947 for dialysis during an inpatient stay.
Codes 90989-90993 are reported for patient and helper dialysis training.
- If a complete training course has been accomplished, report 90989.
- If the training course has not been completed, report 90993 per training session.
(Significant, separately identifiable E/M services provided at the encounter, unrelated to dialysis and cannot be performed during the dialysis session may be reported separately using modifier 25)
Procedure coding tip: For declotting of an A/V fistula, report: 36831, 36833, 36860, or 36861 (percutaneous thrombectomy and intra-graft thrombolysis).
Report 36861 when an external cannula is declotted and the thrombus is removed with a balloon catheter.
Report 36833 if a revision is made to the graft after removing the clot.
Report +36908 when a stent is placed through a dialysis circuit after the revision of the graft.
Diagnosis coding tip: Patients requiring dialysis often have other chronic disease processes relating to dialysis.
Specifically, when the patient has hypertension, renal failure, and heart failure, the coder should report a combination code in lieu of reporting each condition separately.
- Report a code from category I12.- for hypertensive renal failure and report a code from category I13.- for hypertensive heart and chronic kidney disease.
HCPCS Level II code tip: Dialysis patients often experience fatigue and anemia.
- Aranesp (darbepoetin alfa) is a drug often administered to dialysis patients to encourage production of red blood cells. Report this drug with J0882 for dialysis patients.
Gastroenterology (Medicine codes for gastroenterology are covered in Chapter 9: Digestive System.)
Ophthalmological Services & Special Otorhinolaryngologic Services(Medicine codes for the eye and ocular adnexa are covered in Chapter 13: Eye and Ocular Adnexa, Auditory Systems.)
Cardiovascular Services(Medicine codes for the cardiovascular system are covered in Chapter 8: Cardiovascular System.)
Noninvasive Vascular Diagnostic Studies
Noninvasive vascular diagnostic studies are reported for investigation of blood flow in the head, extremities, viscera, and penis.Duplex scans are ultrasonic scanning procedures confirming patterns and direction of blood flow.
The scan produces real-time, two-dimensional images of arteries and veins.
Cerebrovascular arterial studies evaluate right and left anterior and posterior circulation territories (including both the vertebral and basilar arteries) using ultrasound technology. If two or fewer territories are evaluated, report the code for a limited study.
Diagnosis coding tip: Indications for these studies include occlusion and stenosis of an artery, with or without infarction, arterial syndromes, transient ischemic attack (TIA), atherosclerosis, aneurysm, embolism, thrombosis, and arterial injury.
Pulmonary Studies (These services are covered in Chapter 7: Respiratory, Hemic, Lymphatic, Mediastinum, and Diaphragm)
Allergy and Immunology
Codes 95004-95079 are reported for the testing of persons who exhibit hypersensitivity to certain materials and include test interpretation and report by the provider.
If the provider does not issue a report, append modifier 52 for reduced services.
Codes 95115-95199 describe professional services of allergen immunotherapy.
Code 95180 is reported for rapid desensitization, which involves injecting an extract of allergen in gradually increasing doses.
Endocrinology & Neurology and Neuromuscular Procedures (These services are covered in Chapter 12: Endocrine and Nervous System)
Medical Genetics and Genetic Counseling Services
Code 96040 describes services provided by a qualified genetic counselor to determine genetic risk of hereditary diseases.
It is a time-based code to be reported for each 30 minutes of face-to-face time with the patient and/or family.
Central Nervous System Assessments/Tests
Psychological and neurological services (96105-96146) include evaluating the patient for aphasia, a standardized form to analyze the presence of any developmental disorder, typically during infancy or adolescence, and psychological testing for neurocognitive and mental status.
Neuropsychological finds out how a problem with your brain is affecting your ability to reason, concentrate, solve problems, or remember.
Health and behavior assessment interventions focus on cognitive, social, and behavior factors, with a goal of prevention or improvement of the patient’s physical health problems.
Coding for these services is determined by time documented by the provider and whether the session is individual, group, or in the presence of family.
Coding tip: Payers may require modifier AH be appended to the claim to indicate a clinical psychologist, or modifier AJ to indicate a clinical social worker as the service provider.
Hydration, Therapeutic, Prophylactic, Diagnostic Injections/Infusions and Chemotherapy, Highly Complex Drugs, or Highly Complex Biologic Agent Administration
Hydration
Codes 96360-96361 are reported for hydration administration.
- These are time-based codes.
- The infusion consists of pre-packaged fluid and electrolytes.
- These codes are not used for infusion of other substances.
Hydration CPT codes 96360-96361 and HCPCS Level II code J7040 are not reported separately if the fluid is used solely to facilitate administration of other drugs, such as chemotherapy.
The coder should review the record to determine if the fluids were delivered to a dehydrated patient needing hydration therapy.
Start and stop times for the infusion, as well as the agent, will be recorded. If the administration occurs in the facility, these codes are not reported by the physician or other qualified healthcare professional. The solution should be reported in addition to the administration charge using a HCPCS Level II code.
Non-Chemotherapy Complex Drugs and Substances
Codes 96365-96379 are reported for injection and infusion of complex nonchemotherapy drugs and substances.
These codes are specific to time, technique, substances added during the infusion time, and additional setup and establishment of a new infusion.
They are not reported by a physician or other qualified healthcare professional when performed in a facility setting.
If a different type of administration is used, report it as subsequent, even if it is the first service from the infusion group.
EXAMPLE
Initial infusion of 1 hour, different drug administered by IV push; report the IV push as a subsequent service.
When several techniques or drugs are given, always determine the primary service. Chemotherapy is primary to nonchemotherapy infusion, which is primary to hydration.
Do not report the add-on code for additional hour of time unless at least 31 additional minutes are utilized.
If multiple drugs are infusing at the same time through the same IV line, they are “concurrent.” Concurrent infusions may be reported only once per patient encounter unless protocol dictates two separate IV lines must be used. If infusion of a different drug through the same access site begins after the completion of the initial infusion, a sequential infusion is reported. Clinical justification for subsequent rather than concurrent should be clearly stated in the documentation.
Chemotherapy
Codes 96401-96425 are reported for chemotherapy administration by infusion, IV push, or injection.
- Codes are specific to time, technique, and additional substances added during administration.
- The substance is reported in addition to administration using the appropriate HCPCS Level II code(s).
- Injectable chemotherapy drugs are located in the J9XXX range.
Codes 96440-96549 are reported for services other than standard infusion/injection techniques.
When thoracentesis is performed it is bundled when the chemotherapy is delivered into the pleural cavity, code 96440 is reported.
Report 96446 when chemotherapy medication is delivered in the peritoneal cavity, which is space within the abdomen via an indwelling catheter or port.
When chemotherapy is delivered into the central nervous system (for example, by intrathecal technique), the spinal puncture is not separately reported.
Report 96542 If a ventricular reservoir has been implanted for chemotherapy administration into the subarachnoid or intraventricular areas.
Report 96549 for an unlisted chemotherapy procedure.
For refilling or maintenance of the implanted reservoir, report 96522.
For irrigation of an access device implanted for drug delivery, report 96523 if no other services are performed on the same day.
Coding tips: If infusion time is 15 minutes or less, IV push is reported. These infusion services include local anesthesia, start of the IV, access to indwelling IV, access to port or catheter, end of procedure flush, and standard tubing, supplies, and syringes.
When multiple substances are delivered, only one initial administration code is reported unless a separate IV site is required. For example, an ICU patient requires two lines. A central line is placed for a Dopamine drip for hypotension and another line is required for antibiotics. Do not report the add-on code for an additional hour of time unless at least 31 additional minutes are utilized. If multiple drugs are mixed in the same bag, report one administration code unless the time extends to at least 1 hour, 31 minutes. Drugs are reported separately.
When multiple types of infusions are reported, an established hierarchy is utilized. For physician or other qualified healthcare professional reporting, report the initial service as the primary reason for the encounter. For facility reporting, chemotherapy is reported primary to therapeutic, prophylactic, and diagnostic delivery, which is primary to hydration. Infusions are primary to IV push, which is primary to injections.
Patients receiving chemotherapy have a malignancy. After checking the ICD-10-CM Alphabetic Index, utilize the Table of Neoplasm in ICD-10-CM for the correct site to report a neoplasm. The primary site is the origin of the cancer. Any metastasized cancer to secondary sites is reported with the secondary category. The first listed code for the encounter is the site that is being treated. If the provider clinically is unable to determine the origin of the cancer, report C80.1 as the primary site. Blood cancers, such as leukemia and lymphoma, are in the ICD-10-CM Alphabetic Index instead of the Table of Neoplasms.
Photodynamic Therapy & Special Dermatological Procedures
These CPT codes describe special dermatology procedures frequently rendered on a consultative basis.
Actinotherapy involves exposing the patient’s skin to ultraviolet light to treat skin disease, such as acne.
Photochemotherapy combines light (photo) and chemicals to deliver an effective treatment.
Goeckerman treatment involves topical application of tar (which makes lesions more sensitive to ultraviolet B light) or petrolatum and increasingly strong doses of ultraviolet B light. This form of therapy is used to treat psoriasis, eczema, or mycosis. Psoralens and ultraviolet A light help prevent the accelerated growth of immature skin cells characterizing psoriasis.
Code 96913 describes an aggressive form of photochemotherapy used to treat severe psoriasis and is usually an inpatient procedure.
Laser treatment for inflammatory skin disease (psoriasis) involves use of a beam of laser light concentrated on active psoriatic skin plaques. Codes are selected based on size in square centimeters of the area treated.
Physical Medicine and Rehabilitation
Codes 97010-97799 are reported for this service.
The provider develops an initial treatment plan outlining the problem(s), goals, modalities to be used, and projected time to reach the goal.
Procedures are performed by qualified physical, occupational, and speech therapists. The referring provider should review progress each 30 days. Medicare rules for billing and payment of therapy services may be different from CPT® information. Refer to the CMS website under therapy services for CMS guidelines.
Evaluation
Evaluations are based on the complexity of the condition being treated for physical therapy, occupational therapy, and athletic training services.
Physical therapy is a method of treating a disease, injury, or deformity by physical methods such as massage, heat, ultrasound, or exercise rather than by drugs or surgery.
Occupational medicine deals with prevention of injuries in the workplace and the treatment of Injuries to prepare a patient to return to the workplace.
Athletic training evaluations are performed for prevention, clinical evaluation, and rehabilitation of injuries and other medical conditions.
Codes 97161-97164 are reported for physical therapy evaluation of a patient.
Codes 97165-97168 are reported for Occupational medicine services.
Athletic training services are reported with 97169-97172.
Modalities
Codes 97010-97028 are modalities not requiring one-on-one contact by the therapist.
- These modalities include hot or cold packs, traction, vasopneumatic devices, paraffin bath, whirlpool, diathermy, infrared, ultraviolet, and some types of electric stimulation.
- More than one modality may be utilized during the therapy session.
Codes 97032-97039 are modalities requiring one-on-one (constant attendance) patient contact by the therapist.
- These modalities include contrast baths, Hubbard tank, ultrasound, manual electric stimulation, and iontophoresis (introduction of ions into the tissue by electricity).
- These codes are reported for each 15-minute increment and require provider documentation of time for correct reporting of units.
Codes 97110-97546 are reported for therapeutic procedures performed to improve function and require one-on-one interaction by the provider.
- Code 97542 is reported for fitting and training of wheelchair use.
- Codes 97545 and 97546 are reported for work conditioning.
- Code 97150 is reported for group therapy of two or more patients and is reported for each member of the group.
Codes 97597-97610 are reported for wound care management.
- The provider must document the technique used to remove the tissue and the surface area of the wound.
- Services are reported for each session and require one-on-one interaction by the provider.
- Removal by debridement is reported with codes 97597-97602.
- Tissue removal by vacuum (negative pressure therapy) is reported with 97605-97608.
- Wound care utilizing low frequency ultrasound is reported with 97610. Nonphysicians usually perform these procedures.
- Surgical debridement services are reported with 11042-11047 and should not be reported with 97597-97602.
Code 97750 is for reporting of performance measurement. When assistive technology is used to improve patient functionality, report 97755.
Codes 97760-97763 are reported for management of prosthetics and orthotics.
- Report 97761 for patient initial training in use of an extremity prosthesis and 97760 for initial Orthotic training encounters, and 97763 for subsequent orthotic/prosthetic encounters.
Coding tip: Orthotic and prosthetic products are custom-made for the patient and reported separately using HCPCS Level II codes L0112-L9900.
- Modifiers used in therapy are: GN Services delivered under an outpatient speech-language pathology plan of care, GO Services delivered under an outpatient occupational therapy plan of care, and GP Services delivered under an outpatient physical therapy plan of care.
Medical Nutritional Therapy
Codes 97802-97804 are reported for special dietary assessments for patients requiring special dietary management.
- Codes 97802 and 97803 are reported for face-to-face interaction with the patient and are reported in 15-minute increments.
- Code 97804 is reported for a group session with two or more participants and is reported in 30-minute increments.
- These codes also have a designation to allow reporting for telemedicine.
- These codes are typically reserved for dietitians only and payer policies should be verified before billing.
HCPCS Level II coding tip: Enteral and parenteral therapy products are reported separately with HCPCS Level II codes B4034-B9999.
Acupuncture
Codes 97810-97814 are reported for acupuncture services, with or without electric stimulation.
Time is counted only for the provider’s face-to-face work with the patient, not the time the needles are in. Services are reported in 15-minute increments.
Coding tip: If a separate E/M service is provided at the same encounter and is significantly outside the normal pre and post procedure work, it may be additionally reported using modifier 25. Do not include the time of the acupuncture service in the E/M service.
Osteopathic Manipulative Treatment
This service involves the osteopathic physician (DO) using hands to move muscles and joints and includes stretching, gentle pressure, and resistance.
Codes 98925-98929 are reported for application of manual manipulation to improve somatic and related disorders.
Code selection is based on the number of body regions manipulated. Body regions are specified in the CPT guidelines.
Coding tip: If a separate E/M service is provided at the same encounter and is significantly outside the normal pre- and post-procedure work, it may be additionally reported using modifier 25. Services may be related to symptoms for which osteopathic manipulative treatment (OMT) was provided.
Chiropractic Manipulative Treatment
Codes 98940-98943 are reported for chiropractic services (CMT).
Codes are reported per number of regions manipulated, with 98940-98942 reported specifically for spinal manipulation.
Code 98943 is reported for extraspinal manipulation.
The spinal and extraspinal regions are listed in the CPT guidelines.
Coding tip: Diagnosis codes will be related to neuropathy, spinal lesions, osteoarthrosis, spondylosis, inflammation, intervertebral disc disorders, spinal stenosis, scoliosis, injuries, and muscle spasms. If the diagnosis describes an acute condition, include modifier AT Acute treatment on the service line. Medicare rules governing chiropractic services may be found at www.cms.hhs.gov.
Education and Training for Patient Self-Management
Codes 98960-98962 are reported for patient self-management training and education when prescribed by a physician or other qualified healthcare professional.
A nonphysician practitioner (NPP) provides the service.
Training and education are applicable to the condition(s) identified by the appropriate diagnosis code(s).
Codes are selected based on the number of patients. Codes will be selected based on the number of patients.
Caregivers may be included in the sessions.
The codes are reportable in 30-minute increments and require the provider to document the time of the encounter.
These codes carry a designation that allows reporting for telemedicine services.
Non-Face-to-Face Nonphysician Services
Telephone Services
Codes 98966-98968 are reported by qualified NPPs for telephone services provided to an established patient, parent, or guardian.
If the telephone discussion results in a determination to see the patient within 24 hours or at the next available urgent appointment, the telephone service is considered part of the pre-work for the upcoming encounter and should not be reported as a telephone service.
These codes may be billed only if the call does not result in an urgent appointment and does not relate to an assessment and/or management service within the past seven days.
Codes are selected by time, which must be documented by the provider.
Coding tip: Coverage and reimbursement for codes 98966-98968 is payer-specific. Discuss with your payer the circumstances of coverage.
Report codes 99441-99443 if a physician or other qualified healthcare professional provides the telephone service.
Online Medical Evaluation
Codes 98970-98981 are reported for online medical evaluation using the internet or other electronic communication modes to answer an established patient’s online inquiry.
Service may include parent or guardian inquiry.
The codes are reported for online medical evaluation and management services by nonphysician healthcare professionals.
Services are provided to established patients to answer their online inquiries.
Services may also include inquiries by a parent or guardian. Services are reported by cumulative service time provided over a seven-day period.
Code 98970 reports cumulative 5-10 minutes over a period of seven days.
Code 98971 reports total time of 11-20 minutes, and
code 98972 reports a period of 21 minutes or more.
It is expected that the communication will include a total of telephone calls, laboratory orders, and prescription management that relate to the online patient encounter.
Codes 98975-98981 are reported for remote therapeutic monitoring.
Code 98975 is reported for the initial setup of the equipment and patient education.
Codes 98976-98977 are reported for 30 days of monitoring the respiratory and musculoskeletal system.
Codes 98980-98981 are reported for the treatment management services and communications with the patient and/or caregiver.
These codes are reported for each 20 minutes of communications.
Coding tip: Coverage and reimbursement for codes 98970-98981 are payer-specific. Discuss with your payer the circumstances of coverage. Report codes 99421-99423 (found in E/M section at the beginning of CPT) if a physician or other qualified healthcare professional provides the online service.
Special Services, Procedures, and Reports
Codes 99000-99091 are miscellaneous codes involving special services, procedures, and reports.
- Providers often contract with an independent laboratory to test specimens and provide reports.
- Code 99000 is reported for transfer of a laboratory specimen from a provider’s office to a laboratory.
- Code 99001 is reported for transfer of a specimen from the patient in a site other than a provider’s office.
When an order involves a service related to custom-made devices, report 99002.
- These items need to be fitted and adjusted by the provider and require delivery to the provider’s office.
Report code 99024 for a related post-operative visit during the global period of a procedure to indicate the E/M service provided.
- This code is not separately payable but is considered a component of the procedure.
Report codes 99026 and 99027 for mandated hospital on-call personnel.
- These codes typically are not reimbursed, but are required by certain hospital personnel.
- Do not report codes 99026 and 99027 for standby services.
Codes 99050-99060 are reported for patient encounters outside normal posted business hours or for special circumstances at the request of the patient.
- These codes are reported in addition to the basic service.
Coding tip: Coverage and reimbursement for codes 99050-99060 are payer specific. Discuss the circumstances of coverage with your payer.
Code 99070 is reported for supplies provided by the physician or other qualified healthcare professional not usually included in an office visit.
- Items may include sterile trays, drugs, vaccines, and immune globulins; and may be reported separately if not considered integral to a procedure. Reimbursement may be on an acquisition cost basis.
Coding tip: Eyeglasses are not included in 99070. Refer to HCPCS Level II codes for specific eyeglass codes. Some payers (Medicare and possibly others) require individual listing of the items/drugs using HCPCS Level II codes instead of 99070.
Code 99071 is reported for physician or other qualified healthcare professional cost of educational materials dispensed to the patient for specific educational information.
Code 99072 is reported for additional supplies, material, and clinical staff time over and above that of a normal office visit or other non-facility service when performed during a public health emergency.
Code 99075 is reported for time the provider spends providing medical testimony.
Code 99078 is reported for group educational sessions when conducted by a physician or other qualified healthcare professional.
Code 99080 is reported for completion of forms and reports exceeding usual and standard information.
Code 99082 is reported for unusual travel by a provider (for example, accompanying a patient).
Code 99091 is reported for interpretation of data that has been stored digitally and transmitted to the physician or qualified healthcare professional trained by education, licensure/regulation when relevant.
- Transmission may be by the patient or caregiver.
- The provider must spend at least 30 minutes each 30 days to report this code.
Coding tip: Coverage and reimbursement for codes 99071-99091 is payer-specific. Discuss with your payer the circumstances of coverage.
Qualifying Circumstances for Anesthesia & Moderate (Conscious) Sedation (These services are covered in Chapter 14: Anesthesia.)
Codes for moderate sedation are chosen and assigned based on three primary factors:
- Whether the same provider is both administering the sedation and performing the procedure for which the sedation is required. Coding changes when a different provider administers the sedation. E.g. A patient undergoes a procedure that requires moderate sedation. The treating physician will perform both the supported procedure and the moderate sedation service. The physician will supervise and direct an independent, trained observer who will assist in monitoring the patient’s level of consciousness and physiologic status throughout the procedure. If a different provider, other than the provider performing the primary procedure, administers the moderate sedation, an independent observer is not required.
- Whether the patient is younger than five years of age; or five years old, or older.
| Total Intra-service Time | Patient age | CPT Code(s)=Same physician performing procedure | CPT Code(s)=Different physician who is performing a procedure |
| Less than 10 minutes | Any Age | Not reported separately | Not reported separately |
| 10-22 minutes | < 5 years | 99151 | 99155 |
| 10-22 minutes | 5 years or older | 99152 | 99156 |
| 23-37 minutes | < 5 years | 99151 + 99153 x1 | 99155 + 99157 x1 |
| 23-37 minutes | 5 years or older | 99152 + 99153 x1 | 99156 + 99157 x1 |
| 38-52 minutes | < 5 years | 99151 + 99153 x2 | 99155 + 99157 x2 |
| 38-52 minutes | 5 years or older | 99152 + 99153 x2 | 99156 + 99157 x2 |
| 53-67 minutes | < 5 years | 99151 + 99153 x3 | 99155 + 99157 x3 |
| 53-67 minutes | 5 years or older | 99152 + 99153 x3 | 99156 + 99157 x3 |
| 68-82 minutes | < 5 years | 99151 + 99153 x4 | 99155 + 99157 x4 |
| 68-82 minutes | 5 years or older | 99152 + 99153 x4 | 99156 + 99157 x4 |
- The ‘intra-service time’ of the procedure. Intra-service time begins with the administration of the sedation agent and ends when the procedure is completed, the patient is stable for recovery status, and the provider performing the sedation ends personal continuous face-to-face time with the patient.
MODERATE SEDATION PERFORMED BY THE SAME PROVIDER:
| 99151 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient younger than 5 years of age |
| 99152 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older |
| 99153 | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; each additional 15 minutes of intra-service time |
MODERATE SEDATION PERFORMED BY ANOTHER PROVIDER
| 99155 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intra-service time, patient younger than 5 years of age |
| 99156 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intra-service time, patient age 5 years or older |
| 99157 | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intra-service time |
Other Services and ProceduresS
Code 99170 is reported for an anogenital magnified examination of a child that includes image recording when performed and is performed when there is suspicion of trauma.
Coding tip: Diagnosis codes may be related to injuries in the rectal and/or genital area and suspected child abuse. If an examination is performed with no confirmation of diagnosis, report codes Z71.1 Person with feared health complaint in whom no diagnosis is made or a code from category Z04 Encounter for examination and observation for other reasons.
Code 99172 is reported for determination of visual acuity, ocular alignment, color vision, and visual field. The service must use graduated visual acuity stimuli allowing a quantitative estimate of visual acuity (sharpness of vision). Code 99173 is reported for a screening test of visual acuity.
Coding tip: Do not report codes 99172 and 99173 if a general ophthalmological service or an E/M of the eye is performed. If an additional E/M service is performed and is unrelated to these tests, it may be reported separately using modifier 25.
Code 99174 is reported for bilateral instrument based ocular screening.
Coding tip: Do not report 99174 with 92002-92014, 99172, and 99173. Diagnosis codes supporting this service are in categories H52-H53
Code 99175 is reported for administration of Ipecac or similar material for initiation of emesis. The provider observes the patient until the stomach has emptied.
Coding tip: Refer to the Table of Drugs and Chemicals in the ICD-10-CM book for diagnosis code information.
Code 99183 is reported for hyperbaric oxygen therapy when supervised and attended by a physician or other qualified healthcare professional. Procedures such as wound debridement and/or E/M services may be reported separately when provided during a hyperbaric oxygen therapy session in a dedicated treatment facility.
Code 99190-99192 is reported for operation of a pump with oxygenator or heat exchanger and includes assembly and operation of the unit. Codes are selected based on time.
Coding tip: Appropriate diagnosis codes are related to cardiac failure in category I50. They also may be reported for cardiogenic shock.
Home Health Procedures and Services
Codes 99500-99602 are reported by nonphysician practitioners providing services in a home setting (the environment in which the patient resides, including assisted living facilities, group homes, and custodial care facilities).
Code 99500 is reported for a home visit for prenatal services including monitoring of gestational diabetes, fetal assessment, and uterine monitoring.
Coding tip: Diagnosis codes are in categories O44, O10, O60, O24 if a condition has been confirmed. If the encounter is for supervision or examination, report the diagnosis from category Z34 or category Z39
Code 99501 is reported for a home visit for postnatal follow-up care.
Coding tip: Diagnosis codes are reported from category Z39.
Code 99502 is reported for home care assessment of a newborn.
Coding tip: Diagnosis code from range Z00.110-Z00.111 is reported for this service.
Code 99503 is reported for home care management of respiratory conditions, including evaluation of apnea, oxygen management, and changes in medication such as bronchodilators.
Coding tip: Review diagnosis codes related to respiratory neoplasms, cystic fibrosis, obstructive bronchitis, asthma, pneumonia, and other pulmonary conditions.
Code 99504 is reported for home care management of a ventilator.
Coding tip: Diagnosis codes are reported from category J80, J95-J98 or categories P22, P91.6-, P84, P94 for newborns.
Code 99505 is reported for home care of ostomies and stomas.
Coding tip: The diagnosis code should be reported from category Z43 range, along with the condition requiring the ostomy/stoma.
Code 99506 is reported for a home visit for intramuscular injections. Diagnosis codes are determined by the condition as stated by the plan of care. Medications may be reported with appropriate HCPCS Level II codes, in addition to the injection administration code.
Code 99507 is reported for a home care visit for catheter maintenance. The service varies depending on the type, location, and reason for the catheter.
Coding tip: The diagnosis code is Z46.82, plus the condition that required the catheter.
Code 99509 is reported for a home visit for assistance with activities of daily living. The patient must be unable to perform two or more activities of daily living, such as: eating, toileting, transferring, bathing, dressing, and continence.
Coding tip: Diagnosis codes are reported to describe the impairment preventing independent daily activities. Do not report this code for speech therapy (92507-92508), nutrition assessment (97802-97804), or self-management training (97535).
Code 99510 is reported for a home visit for counseling sessions including marriage counseling. Participants may be an individual or family.
Coding tip: Diagnosis codes to report are in category Z55-Z65 and category Z69-Z76, including any specific problems addressed in the order for services.
Code 99511 is reported for a home visit for management of fecal impaction and/or administration of enema.
Coding tip: Refer to diagnosis codes K56.41, K56.49, and K59.00-K59.09.
Code 99512 is reported for home visits for hemodialysis.
Coding tip: The diagnosis code is Z99.2 Dependence on renal dialysis. Other diagnosis codes may include categories I12 and I13 and N18.1-N18.9. Do not report this code for peritoneal dialysis (90945-90947).
Home Infusion Procedures
Peritoneal Dialysis
Codes 99601 and 99602 are reported for home visits for infusion of specialty drug administration and are reported per visit.
Coding tip: These codes may be reported for peritoneal dialysis and other therapeutic and prophylactic agents. Medications given are reported separately.
Medication Therapy Management Services
A pharmacist may report codes 99605-99607 for patient assessment, intervention, or management of medication interaction/complications. Code selection is determined on whether the patient is new or established, and time reported for the management service.
Coding tip: Report a diagnosis code from category Z71 and Z76
Glossary
Allergy—Hypersensitivity caused by exposure to an antigen (or allergen).
Artery—Vessel carrying blood from the heart to the tissues.
Autonomic—Involuntary, relating to the autonomic nervous system.
Biofeedback—Training technique for development of a person’s ability to control his or her autonomic nervous system.
Bipolar Disorder—Affective disorder with alternating mood swings from euphoria to depression.
Catheterization—Insertion of a catheter into a body structure.
Chemotherapy—Treatment of disease by means of chemical substances or drugs; usually cancers.
Chiropractic—Treatment predominately using manipulation of spinal and musculoskeletal structures and recuperative powers of the body.
Cognitive—Thoughts or thinking, learning, or memory processes.
Comorbidity—Presence of two or more illnesses at the same time. There may be an association between the illnesses.
Compulsion—Repetitive behavior with ritualistic characteristics; uncontrolled impulse.
Debridement—Removal of dead or damaged tissue to promote healing.
Decompensation—Deterioration; exacerbation of an illness or condition.
Desensitize—Lessening of sensitivity by administration of a specific antigen in low doses.
Dialysis—Removal of toxins from the blood by diffusion over a membrane or filter in patients with renal impairment or failure.
Disorientation—Inability to estimate direction or location.
Doppler Study—Use of an ultrasound probe to determine blood flow.
Enteral Nutrition—Nutrients for patients with impaired ability to chew/swallow or ingest food, typically delivered by gastric or nasogastric tube.
Extracranial—Outside the skull.
Extraspinal—Outside the spine.
Gait Training—Method of restoration of balance, extremity swings, stance.
Gastroenterology—Study of the stomach, intestine, esophagus, liver, gallbladder, and pancreas.
Genetics—Study of heredity.
Grandiosity—Unrealistic concept of self-importance.
Hallucination—False sense of perception or reality.
Home Care—Prescribed medical care provided in a patient’s home.
Hydration—Replenishment of fluids.
Immune Globulin—Antibodies derived from blood plasma providing short term protection against certain infections.
Infusion—Therapeutic agent (liquid) introduced into the body by a vein.
Injection—Fluid introduced into tissue, cavity, or vessel, usually by needle.
Loosening of Association—Frequent change of subject, often with minimal relationship.
Manipulation—Thrusting movement to achieve realignment of joints or spine.
Modality—A therapeutic agent or application.
Neuro Psychology—Study and treatment of psychiatric and neurological disorders.
On Call—Medical personnel with special training and skills available to provide services when summoned.
Orientation—Awareness; ability to comprehend and to adjust in an environment.
Orthotic—Custom made mechanical appliance used in orthopedics.
Panic Attack—Intense anxiety; feels like a loss of control.
Parenteral Nutrition—Nutrients delivered intravenously to patients who are postoperative, in shock, or otherwise unresponsive.
Prosthetic—Artificial body part.
Psychology—Study of behavior, thoughts, feelings.
Psychotherapy—Method of treating mental disorders. Treatment may involve education, pharmacology, suggestion, psychoanalysis.
Range of Motion—Natural movement; usually referring to movement of a joint.
Reflux—Backward flow.
Rehabilitation—Effort to restore to optimal function.
Short Term Memory—Ability to recall recent events.
Therapeutic—To promote healing; treatment.
Toxoid—Substance no longer toxic but is capable of stimulating antibody production.
Vaccine—Preparation of (bacteria or virus) nonpathogenic material, induces immunity to prevent disease.
Vein—Blood vessel carrying blood toward the heart.
Venom—Poisonous fluid secreted by bites or stings from snakes, spiders, etc.
Chapter Review Questions
1.Nerve conduction, amplitude, and latency study of the median sensory nerve to the first digit is coded with what CPT code?
A.95905 C.95908
B.95907 D.95909
2. 28-week pregnant 35-year-old established patient with thoracic and low back pain, requests osteopathic manipulative treatment to her back. Osteopathic manipulative therapy is done on one to two body regions for somatic dysfunction. Therapy is performed by high velocity, low amplitude. Muscle spasm is not present. What CPT® and diagnoses codes are reported for this encounter?
A.98925, O99.891, M54.6, M54.50, Z3A.28
B.98926, O99.891, M54.9, Z3A.35
C.98940, O99.891, M54.6, M54.50
D.98943, O99.891, M54.6, M54.9, Z3A.28
3. 10-year-old, established patient has a high fever and sore throat. The mother contacts the office at closing time and is told to bring the child to the office for treatment. The office remained open until they arrived. The physician performs a medically appropriate history and exam and the medical decision making is of low complexity. What CPT® codes are reported for this service?
A.99213, 99058
B.99212, 99056
C.99213, 99050
D.99212, 99051
4.Medical Record Documentation
Chief Complaints/Concerns: 1. New patient; 2-year-old WCE (well child exam). Mom does not have immunization record. States child’s last shot was given when he was 5 months old.
Past Medical History & Family History—Reviewed.
Pediatric Interval Social History
Sleep: There are no sleep concerns.
Activity Level: There are no activity or exercise concerns.
Developmental History—All areas of development are appropriate for age.
Review of Systems
Constitutional: No fever, irritability, or lethargy; good appetite.
HEENT: Sees and hears well; no eye, ear, or nasal discharge.
Respiratory: No cough, no audible wheeze, respirations normal.
Cardiovascular: No color changes.
Gastrointestinal: No vomiting, diarrhea, or constipation.
Bowel elimination history: There are no bowel concerns.
Nutrition history:
Patient drinks milk from a cup; on demand; of 2% milk daily.
Patient drinks juice from a cup on demand; of varied juice daily.
Patient drinks water from a cup; on demand; of well water daily.
Genitourinary: Normal urine output.
Bladder elimination history: There are no bladder concerns.
Dermatologic: No unusual rashes.
Musculoskeletal: Moving all extremities as usual; normal gait.
Vital Signs: Height 37.50 in, Weight 35.50 lb
Physical Exam
General/Constitutional: No apparent distress. Well-nourished and well developed.
Ears: TM’s gray. Landmarks normal. Positive light reflex.
Nose/Throat: Nose and throat clear; palate intact; no lesions.
Lymphatic: No palpable cervical, supraclavicular, or axillary adenopathy.
Respiratory: Normal to inspection. Lungs clear to auscultation.
Cardiovascular: RRR without murmurs.
Abdomen: Non-distended, non-tender. Soft, no organomegaly, no masses.
Integumentary: No unusual rashes or lesions.
Musculoskeletal: Good strength; no deformities. Full ROM all extremities.
Extremities: Extremities appear normal.
Assessment/Plan
Routine Infant/Child Health Visit Immunizations given: DTaP, IPV, MMR, Hib-HepB, Varicella
What are the CPT® and ICD-10-CM codes for this dictation?