ICU and CCU Care

These fees apply to the services of being in constant or periodic attendance during a one day period, to provide all aspects of care to patients in Intensive or Coronary Care Units designated by the DHCS. There are four levels of care depending upon the procedures performed: 

(a) Comprehensive Care - This is the service rendered by a physician who provides complete care (both Critical Care and Ventilatory Support) to Critical Care Area patients. Comprehensive Care fees are not payable for services rendered to stabilized patients in ICUs or patients admitted for ECG monitoring or observation alone. 

(b) Critical Care - This is the service rendered by a physician who provides all aspects of care to a Critical Care Area patient except Ventilatory Support. Critical Care fees are not payable for services rendered to stabilized patients in ICUs or patients admitted for ECG monitoring or observation alone. 

(c) Observatory Care - This is the service rendered to stable ICU or CCU patients without invasive monitoring and without assisted ventilation. 

(d) Ventilatory Support - This is the service provided by a physician other than the one claiming Critical Care. It includes management of the intubated airway, tracheal toilet by suction catheter with or without instillation, and supervision of mechanical ventilation of the critically ill patient. 

These are team fees which apply to physicians providing complete daily care and should be claimed by the physician in charge of the patient. The daily fee includes payment for the initial consultation, subsequent assessments, and the ongoing monitoring of the patient’s condition, including the following procedures as required:

(a) insertion of IVs, intraosseous, arterial and CVP lines,

(b) use of pressure infusion sets, 

(c) endotracheal intubation and tracheobronchial toilet, 

(d) insertion and maintenance of urinary catheters and nasogastric tubes, 

Adjustment/Cancel Condition Codes

Use this reference guide to determine which condition code would be most appropriate in coding your adjustment/cancel claim.

D0 (zero) This code should be used when the From and Thru date of a claim is changed. 

*When you are only changing the admit date use condition code D9. 

D1 If another condition code does not apply and there is a change to the COVERED charges, this code should be used. 

*Use this code when adding a modifier to a line that would make the charges covered on the adjustment claim that were non-covered on the previous claim.

*Use this code when the previous claim rejected for home health, hospice, HMO and other overlap reasons that have been updated.

D2 This code is used when there is a change to the revenue codes, HCPC codes or HIPPS code. *This code is not used for a change in the RUG code. 

D3 This code is used for a second or subsequent interim PPS bill by inpatient PPS hospitals only.

D4 Change in grouper input (ICD Diagnosis codes, ICD Procedure codes, and RUG codes) 

*This code is only used if a provider is changing or adding an ICD or RUG code. 

* If the provider is only deleting these codes, then the D9 with remarks would be more appropriate.  

D5 This code is used when canceling a claim to correct the HIC number or provider number. 

*Condition code only applicable on an xx8 type of bill. 

D6 This code is used when canceling a claim for reasons other than the HIC number or provider number. Used when canceling a claim to repay a payment. 

*Condition code only applicable to an xx8 type of bill. 

D7 This code should be used when the original claim shows Medicare on the primary payer line and now the adjustment claim shows Medicare on the secondary payer line. 

D8 This code should be used when the original claim shows Medicare on the secondary payer line and now the adjustment claim shows Medicare on the primary payer line. 

D9 This code is used for adjustments not described in any other condition codes. Remarks are required when using the D9 condition code to make a change. 

*This code is used in place of the D7 when adjusting the claim for “conditional payment”. 

*This code is used if adding a modifier to change liability and there is no change to the covered charge amount. 

*This code is used when adding or changing occurrence, occurrence span and/or value codes that do not affect the covered charges. 

E0 (zero) This code is used when the ONLY change on the claim is a correction to the patient status. 

Adjustment Reason

Adjustment reason codes are required on DDE adjustments (TOB XX7) and are entered on page 3. Adjustment Reason Codes are not used on paper or electronic claims.

Code Description 

AA   Automated Adjustment 

AD   Admission Denial - Technical Denial (PRO Review Code - A) 

AM Admission Denial - No Payment (Medical Denial) (PRO Review Code - A) 

AR Admission Reversal - Hard Copy Adjustment 

AW Admission Denial-Payable Per Waiver 

CA Cost Outlier Approved 

CB This Reason Code will be to Identify Credit Balance Accounts 

CC Covered Charges Changes 

CD Covered Days Changes (PRO Review Code - B) 

CO Cost Outlier - No Payment (PRO Review Code - E) 

CP Cost Outlier Partial Approved 

CR Claim Reconsideration 

CW Cost Outlier Denial-Payable Per Waiver 

DA Day Outlier Approved  

DC Diagnosis Changes (PRO Review Code - C) 

DD Discharge Destination Code Changes (PRO Review Code - C) 

DG DRG Change and Day Outlier Denial (PRO Review Code - G) 

DH DRG Change and Cost Outlier Denial (PRO Review Code - H) 

DI DRG and Beneficiary Liability Change (PRO Review Code - I) 

DO Day Outlier Denial - No Payment (PRO Review Code - D) 

DP Diagnosis and Procedure Changes (PRO Review Code - C) 

DS Discharge Status Change DV DRG Validation (PRO Review Code - C) 

DW Day Outlier Denial-Payable Per Waiver 

EF ESRD Adjustment Fix to Correct Original Claims

 FB Beneficiary Liability Change (PRO Review Code - F) 

FC HHPPS Final claim 

FD Full Denial (PRO Review Code - A) 

FR Full Reversal (PRO Review Code - N) 

FT Full Denial - Technical Denial (PRO Review Code - A) 

HA Home Health 485/486 Post-payment Audits 

HC Home Health Covered Compliance Reviews 

HD HMO Disenrollment 

HP HMO Pay

 IB PPS Interim Bill IC Non-Billable Revenue Codes Invalid Revenue Codes 

ID Inpatient or Blood Deductible 

JP Deemed Admission Change in Days (PRO Review Code - J) 

KB Deemed Admission Change in Days (PRO Review Code - J) 

KD Deemed Admission/Diagnosis Code Change (PRO Review Code - K) 

KP Deemed Admission/Procedure Code Change (PRO Review Code - K) 

LD Deemed Admission/Day Outlier Denial (PRO Review Code - L) 

LI Liability 

LS Length of Stay Denial-No Payment 

LW Length of Stay Denial-Payable Per Waiver 

MC Deemed Admission/Cost Outlier Denial (PRO Review Code - M) 

NF HHPPS No Final Claim 

OC Procedure Codes Changed, Denied, or Added (PRO Review Code - R) 

OP Day Outlier Approved 

OT Other Change 

PC Procedure Changes (PRO Review Code - C) 

PD Procedural Denial - No Payment 

PI Program Integrity 

PN Provider Number Change 

PP Discharge Status Change (PRO Review Code - P) 

PR Previous Adjustment Modifi ed (Modifies the PROs Last Action) (PRO Review Code - O) 

PT Admission Denial and D

RG Change (PRO Review Code - T) 

PW Procedural Denial - Payable Per Waiver 

QC Procedure Codes (HCPCS) Changed/Deleted/Added (PRO Review Code - R) 

QD Ancillary Services Denied or Approved (PRO Review Code - Q) 

QR HCPC Added/Deleted/Changed with Ancillary Change (PRO Review Code-S) 

RI Recovery Audit Contractor (RAC) Identifi ed Overpayment 

RC Complete Reversal of Previous Adjustment (PRO Review Code - N) 

RP Partial Reversal of Previous Adjustment (PRO Review Code - O) 

SB Same Benefi t Period 

SD Seven Day Readmission Denial 

SW Seven Day Re-admission Denial - Payable Per Waiver 

TD Transfer Denial - No Payment 

TW Transfer Denial - Payable Per Waiver 

YA Pacemaker Denial - No Data 

YB Pacemaker Denial - With Errors 

YC Pacemaker Reversal to Denial 

YD Pacemaker Reversal to Denial and not going to pay 

ZW Debit Adjustment being processed for Provider and Intermediary and an initial bill is being processed to CWF 

PC/TC - Professional Component/Technical Component Indicators

0 Physician Service Codes--Identifies codes that describe physician services. Examples include visits, consultations, and surgical procedures. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Modifi ers 26 and TC cannot be used with these codes. The RVUS include values for physician work, practice expense and malpractice expense. There are some codes with no work RVUs. 

1 Diagnostic Tests for Radiology Services--Identifies codes that describe diagnostic tests. Examples are pulmonary function tests or therapeutic radiology procedures, e.g., radiation therapy. These codes have both a professional and technical component. Modifiers 26 and TC can be used with these codes. The total RVUs for codes reported with a 26 modifier include values for physician work, practice expense, and malpractice expense. The total RVUs for codes reported with a TC modifier include values for practice expense and malpractice expense only. The total RVUs for codes reported without a modifier include values for physician work, practice expense, and malpractice expense. 

2 Professional Component Only Codes--This indicator identifies stand-alone codes that describe the physician work portion of selected diagnostic tests for which there is an associated code that describes the technical component of the diagnostic test only and another associated code that describes the global test. An example of a professional component only code is 93010--Electrocardiogram; Interpretation and Report. Modifiers 26 and TC cannot be used with these codes. The total RVUs for professional component only codes include values for physician work, practice expense, and malpractice expense. 

3 Technical Component Only Codes--This indicator identifies stand- alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic test only. An example of a technical component only code is 93005--Electrocardiogram; Tracing Only, without interpretation and report. It also identifies codes that are covered only as diagnostic tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be used with these codes. The total RVUs for technical component only codes include values for practice expense and malpractice expense only. 

4 Global Test Only Codes. This indicator identifies stand-alone codes that describe selected diagnostic tests for which there are associated codes that describe: (a) the professional component of the test only, and (b) the technical component of the test only. Modifiers 26 and TC cannot be used with these codes. The total RVUs for global procedure only codes include values for physician work, practice expense, and malpractice expense. The total RVUs for global procedure only codes equals the sum of the total RVUs for the professional and technical components only codes combined. 

5 Incident To Codes--This indicator identifies codes that describe services covered incident to a physician’s service when they are provided by auxiliary personnel employed by the physician and working under his or her direct personal supervision. Payment may not be made by carriers for these services when they are provided to hospital inpatients or patients in a hospital outpatient department. Modifiers 26 and TC cannot be used with these codes. 

6 Laboratory Physician Interpretation Codes--This indicator identifies clinical laboratory codes for which separate payment for interpretations by laboratory physicians may be made. Actual performance of the tests is paid for under the lab fee schedule. Modifier TC cannot be used with these codes. The total RVUs for laboratory physician interpretation codes include values for physician work, practice expense, and malpractice expense. 

7 Physical therapy service, for which payment may not be made--Payment may not be made if the service is provided to either a patient in a hospital outpatient department or to an inpatient of the hospital by an independently practicing physical or occupational therapist. 

8 Physician interpretation codes: This indicator identifies the processional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. This applies to codes 88141, 85060 and P3001-26. No TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, generally through the PPS rate. No payment is recognized for codes 88141, 85060 or P3001-26 furnished to hospital outpatients or non-hospital patients. The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test. 

9 Not Applicable--Concept of a professional/technical component does not apply. 

Additional CPT Modifiers

CPT Modifier : 22

Description :

Increased Procedural Services: When the work required to provide a service is substantially is greater than typically required, it may be identified by adding CPT modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required). 

Note: This modifier should not be appended to an E/M service. It should only be reported with procedure codes that have a global period of 0, 10, or 90 days. 

CPT Modifier : 26

Description :Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the CPT modifier 26 to the usual procedure number. This modifier must be reported in the fi rst modifier field.

 

CPT Modifier : 32

Description :Mandated Services: Services related to mandated consultation and/or related services (e.g., third-party payer governmental, legislative or regulatory requirement) may be identifi ed by adding CPT modifier 32 to the basic procedure.

 

CPT Modifier : 52

Description :Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the CPT modifi er 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. 

CPT modifier 52 is used for “unusual (reduced) circumstances.” It designates that the service performed was significantly less than usually required. In many instances, attachments, medical records, etc. are not required to be sent in if an explanation for the reduction is in the narrative field of the claim. For example, submit “one view only” in the narrative when only one view of a two view study is performed. Similarly “right side only” may be submitted when a procedure code that is bilateral by definition is not performed bilaterally. When additional information to support the use of the 52 CPT modifier cannot be contained in the narrative of the claim, additional documentation may be submitted.

 

CPT Modifier : 76

Description :Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the CPT modifier 76 to the repeated procedure or service.

 

CPT Modifier : 77

Description :Repeat Procedure by Another Physician: The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding CPT modifier 77 to the repeated procedure or service.

 

CPT Modifier : 90

Description :Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the CPT modifier 90 to the usual procedure number. 

For the Medicare program, this modifier is used by independent clinical laboratories when referring tests to a reference laboratory for analysis.

 

CPT Modifier : 91

Description :Repeat Clinical Diagnostic Laboratory Test: In the same course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the CPT modifi er 91. 

Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other codes describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory tests performed more than once on the same day for the same patient.

 

CPT Modifier :92

Description :Alternative Laboratory Platform Testing: When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding CPT modifi er 92 to the usual laboratory procedure code (HIV testing CPT codes 86701-86703). The test does not require permanent dedicated space; hence by its design it may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of the testing is not in itself determinative of the use of this modifier.

CPT Modifiers

 CPT Modifier  :  62

Description : 

Two surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding CPT modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with CPT modifier 62 added. 

Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with CPT modifier 80 or modifier 82 added, as appropriate. 

 CPT Modifier  :  66

Description : Surgical Team: Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances may be identified by each participating physician with the addition of the CPT modifier 66 to the basic procedure number used for reporting services.

 Documentation establishing that a surgical team was medically necessary is required for certain services identified by Centers for Medicare & Medicaid Services (CMS). All claims for team surgeons must contain sufficient information i.e., operative reports, to allow pricing “by report”.

 CPT Modifier  :  73

Description : Discontinued Out-patient Hospital/Ambulatory Surgical Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the CPT modifi er 73. 

Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see CPT modifi er 53.

 CPT Modifier  :  74

Description : Discontinued Out-patient Hospital/Ambulatory Surgical Center (ASC) Procedure after Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of the CPT modifi er 74. 

Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see CPT modifi er 53.

 CPT Modifier  :  80

Description : Assistant Surgeon: Surgical assistant services may be identified by adding the CPT modifier 80 to the usual procedure number(s). 

This modifi er should be reported to identify surgical assistant services performed in a nonteaching setting or in a teaching setting when a resident was available but the surgeon opted not to use the resident. In the latter case, the service is generally not covered by Medicare. When the surgical services are performed in a non-teaching setting, report “Non-teaching” in the narrative section of an electronic claim submission.

 CPT Modifier  :  81

Description : Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding CPT modifier 81 to the usual procedure number. 

 CPT Modifier  :  82

Description : Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of CPT modifier 82 appended to the usual procedure code number(s). 

This modifier is used in teaching hospitals if there is no approved training program related to the medical specialty required for the surgical procedure or no qualified resident was available.

Surgical Modifiers

 CPT Modifier  :  50

Description :Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the CPT modifi er 50 to the appropriate five digit code. 

Report such procedures as a single line item with a unit of 1. For example, when CPT code 19303 (Mastectomy, simple, complete) is performed bilaterally, report the service as 1930350 (CPT code/modifier). 

If a procedure is identified by the terminology as bilateral (or unilateral or bilateral), do NOT report the procedure code with CPT modifier 50. For example, CPT code 68810 to 68815, (probing of nasolacrimal duct, with or without irrigation, unilateral or bilateral) includes terminology which indicates the procedure is performed either unilaterally or bilaterally. Therefore it’s not appropriate to report this modifier with this code. 

Additionally some procedure codes, i.e., CPT code 52000 (Cystourethroscopy, separate procedure) should NOT be reported with the 50 CPT modifier since anatomy does not permit this procedure to be performed bilaterally.

 CPT Modifier  :  51

Description : 

Multiple Procedures: When multiple procedures, other than E/M services, physical medicine and rehabilitation services or provision of supplies (e.g., vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the CPT modifier 51 to the additional procedure or service code(s). 

Note: This modifier should not be appended to designated “add-on” codes. 

 CPT Modifier  :  53

Description : 

Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the CPT modifier 53 to the code reported by the physician for the discontinued procedure. 

CPT modifier 53 is used for “unusual (discontinued) circumstances”. Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure due to extenuating circumstances that may threaten the well-being of the patient. In many instances, attachments, medical records, etc. are not required to be sent in if an explanation for the discontinuation is in the narrative field of the claim. For example, submit “discontinued due to elevated blood pressure”. When additional information to support the use of the 53 CPT modifier cannot be contained in the narrative of the claim, additional documentation may be submitted. 

Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see CPT modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use) 

 CPT Modifier  :  54

Description : Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the CPT modifier 54 to the usual procedure code. Services billed with a 54 CPT modifier will be reimbursed at the intraoperative allowance for the surgical procedure. The intraoperative allowance includes the one day preoperative care, the intraoperative service, as well as any in-hospital visits that are performed.

 CPT Modifier  :  55

Description : Postoperative Management Only: When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding the CPT modifier 55 to the usual procedure number. 

This modifier is used to identify postoperative, out of hospital medical care associated with a given surgical procedure. When billing for postoperative care only, report the original date of surgery as your date of service and the procedure code for the surgical procedure followed by the 55 CPT modifier. In rare situations where the out of hospital postoperative care is split between physicians, each physician must also indicate the period of his/her responsibility for the patient’s postoperative care by reporting the appropriate range of dates. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service.

Global Surgery Modifiers

CPT Modifier  :  25

Description : Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or be beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding CPT modifier 25 to the appropriate level of E/M service. 

Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See CPT modifier 57. For significant, separately identifiable non-E/M services, see CPT modifi er 59.

 

CPT Modifier  :  57

Description :

Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding CPT modifier 57 to the appropriate level of E/M service. 

E/M services on the day before or on the day of major surgery (90 day global period) which result in the initial decision to perform the surgery are not included in the global surgery payment.

 These E/M services may be billed separately and identified with the 57 CPT modifi er. This modifier should not be used for visits furnished during the global period of minor procedures (0 or 10 day global period) unless the purpose of the visit is a decision for major surgery. 

This modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.

CPT Modifier  :  58

Description :

Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding the CPT modifier 58 to the staged or related procedure. 

Note: For treatment of a problem that required a return to the operating or procedure room (e.g., unanticipated clinical condition), see CPT modifier 78. 

CPT Modifier  :  59

Description :Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. CPT modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than CPT modifier 59. CPT modifier 59 should only be used if there is no other more descriptive modifier available and the use of CPT modifier 59 best explains the circumstances. 

Note: CPT modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see CPT modifi er 25.

 

CPT Modifier  :  78

Description :Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure).

 When this procedure is related to the first and requires the use of an operating room, it may be reported by adding CPT modifier 78 to the related procedure. (For repeat procedures, see CPT modifi er 76).

 CPT Modifier  :  79

Description :Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. 

This circumstance may be reported by using the CPT modifier 79. (For repeat procedures on the same day, see CPT modifi er 76).

 

HEALTH STATUS

FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES (Z00- Z99) 

Z codes are supplemental codes and represent reasons for an encounter and must be reported with a procedure, if performed. 

Z01.1 Encounter for examination of ears and hearing 

Z01.10 Encounter for examination of ears and hearing without abnormal findings 

Z01.11 Encounter for examination of ears and hearing with abnormal findings

Z01.110 Encounter for hearing examination following failed hearing screening 

Z01.118 Encounter for examination of ears and hearing with other abnormal findings (use additional code to identify abnormal findings) 

Z01.12 Encounter for hearing conservation and treatment 

Z02 Encounter for administrative examination 

Z02.1 Encounter for examination for admission to educational institution 

Z02.2 Encounter for pre-employment examination 

Z02.3 Encounter for examination for recruitment to armed services 

Z02.71 Encounter for disability determination 

Z03 Encounter for screening for other diseases and disorders 

Z13.5 Encounter for screening for eye and ear disorders 

Z13.850 Encounter for screening for traumatic brain injury 

Z45 Encounter for adjustment and management of implanted device

Z45.320 Encounter for adjustment and management of bone conduction device 

Z45.321 Encounter for adjustment and management of cochlear device 

Z45.328 Encounter for adjustment and management of other implanted hearing device 

Z46.1 Encounter for fitting and adjustment of hearing aid 

Z57.0 Occupational exposure to noise 

Z71.2 Person consulting for explanation of examination or test findings 

Z76.5 Malingerer (personal feigning illness with obvious motivation) 

Z77.122 Contact with and (suspected) exposure to noise

Persons with potential health hazards related to family and personal history and certain conditions influencing health status 

Z79.1 Long term (current) use of non-steroidal anti-inflammatories (NSAID) 

Z79.82 Long term (current) use of aspirin 

Z83.52 Family history of ear disorders 

Z86.69 Personal history of other diseases of the nervous system and sense organs 

Z96.20 Presence of ontological and audiological implant, unspecified 

Z96.21 Cochlear implant status 

Z96.22 Myringotomy tube(s) status 

Z96.29 Presence of other ontological and audiological implants 

Z97.4 Presence of external hearing aid

Scenario: CHF and Pulmonary Embolism Example

Scenario Details 

Chief Complaint 

• “I was in the hospital last week with a blood clot in my lung, and was told at discharge that I need to have my blood checked to see if it is thin enough. My right chest still hurts, though it is better, and I am still more short of breath than usual.” 

History 

• 72-year-old female seen 1 week earlier in ED with history of sudden onset right sided chest pain and shortness of breath which had started 3 hours prior to arrival. Pain was made worse with deep inspiration. Exam at that time showed vital signs of P 110 and regular, BP 140/102, T. 98.6, RR 26, SAO2 83% on oximetry, breathing room air. Physical exam showed swollen R lower extremity which was painful and warm to the touch. A pleural friction rub was heard over the right lower chest, posteriorly. Doppler ultrasound of right lower extremity shows deep vein thrombosis. Pulmonary CT Angiography showed total occlusion of RLL artery, as well as signs of chronic pulmonary artery hypertension. 

• Patient diagnosed with hypertensive heart disease with mild chronic left ventricular diastolic failure and mild pulmonary artery hypertension 2 years previously. Has been well managed on ARB therapy without complications. 

Review of Systems, Physical Exam, Laboratory Tests 

• P 84, regular, BP 132/96,T 98.4, RR 22, SAO2 89% by oximetry on room air 

• Chest: dullness to percussion over RLL posteriorly with decreased breath sounds in same area • Right lower calf mildly swollen but not warm or tender 

• CXR: moderate sized pleural effusion on R 

• Lab: INR 3.2 on Coumadin 10 mg/day (preferred range 2.0-3.0) 

Assessment and Plan 

• Acute RLL Pulmonary Embolism: continue Coumadin but reduce dose to 5 mg/day

• Acute Right Side Pleural Effusion, presumed secondary to P.E.: follow in 2 weeks with repeat chest x-ray 

• Acute Deep Vein Thrombophlebitis of right leg: continue Coumadin at 5 mg/day 

• Acute Respiratory Failure with Mild Hypoxemia: arrange home oxygen at 2L/min by nasal cannula • Hypertensive heart disease with Chronic mild left ventricular diastolic failure: continue ARB therapy 

• Chronic mild pulmonary artery hypertension 

• Over anti-coagulation: reduce Coumadin to 5 mg/day, check INR in 4 days

Scenario 4: Subsequent AMI

Chief Complaint 

• Follow up after my second heart attack.

History 

• 81 year old male retired professor presents for follow up visit after hospital admission for NSTEMI; he was discharged five days ago. Currently denies chest pain, shortness of breath. Able to walk without symptoms.

• Medical history remarkable for CAD requiring CABG times four, PVD, bilateral carotid stenosis, hypertension, dyslipidemia, COPD, emphysema, renal artery stenosis, CHF with diastolic dysfunction, and NSTEMI. 

• NSTEMI #1 while patient was on a cruise about three weeks ago. Limited data indicates ECG findings included ST depression, rise in troponin. 

• NSTEMI #2: myocardial infarction with rise in cardiac biomarkers with no ST changes on EKG, seven days ago. Partially reversible inferorposterior wall defect by perfusion study. Probably represents disease of vein graft to RCA. 

• Prior evaluation: Extensive vascular disease. Multiple revascularization procedures done in staged manner due to chronic renal failure. Catheterization: patent grafts. Peripheral angiogram: stenosis of renal arteries and lower extremity circulation. Duplex of renal arteries: bilateral renal artery stenosis. • Social History: cigarette smoker for 64 years, ½ pack per day. No alcohol or drug use.

 • Family History: cancer, diabetes, kidney disease. 

• Current medications: hydrochlorothiazide – telmisartan, simvastatin, clopidogrel, amlodipine, metoprolol succinate, aspirin. 

• Review of Systems: Denies fever, chills, cough, nausea, vomiting, TIA, syncope, rash, or melena. 

Exam

 • Pleasant elderly male in no acute distress. 

• Vital signs: BP 150/80. HR: 74. Respirations: 18/min. Afebrile. 

• HEENT: EOMI, PERRLA. 

• NECK: Supple. No JVD. Positive right carotid bruit. 

• CHEST: Clear to auscultation. Bilateral equal breath sounds. Has cough. 

• CV: RRR, S1 and S2 present. No S3. Positive S4. Crescendo-decrescendo systolic murmur 3/6 heard in aortic valve/apex area. 

• PERIPHERAL VASCULAR: Skin pink, warm and dry and well perfused. No clubbing or cyanosis. Plus 2 pitting ankle edema. 

• ABDOMEN: Soft, non-tender without masses, or organomegaly. Active bowel sounds. 

• NEURO: Patient A&Ox3, appropriate. No focal deficits noted.

Assessment and Plan 

• Hemodynamically and clinically stable today. 

• Continue medical therapy. 

• Schedule doppler echocardiogram to evaluate of new murmur.

 • Discussed with patient the need for optimal compliance including pharmacologic regimen and lifestyle modifications. 

• Patient continues to smoke, albeit less, and is not interested in quitting at this time. 

Summary of ICD-10-CM Impacts 

Clinical Documentation 

1.In ICD-10, there are numerous changes for cardiac related medical conditions. The changes include but are not limited to: 

• Inclusion terms of ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction are made to reflect the national standard guidelines of The American College of Cardiology and the American Heart Association for classifying patients with acute coronary syndrome For example, the non-ST elevation MI term replaces the older terminology of non-Q wave MI. 

• The time frame for acute myocardial infarction codes has changed from 8 weeks or less in ICD-9-CM to 4 weeks or less in ICD-10-CM. 

• When the patient has a new AMI within the 4 week time frame of the initial AMI, this information should be documented. 

• Delineate in your documentation whether an MI no longer requires further care. That information allows a clinical coder to determine whether the patient has an old or a healed MI. If after 4 weeks they still need care use “aftercare” in ICD-10-CM. 

2.If applicable, note items such as presence or absence of an increase in cardiac enzymes or troponin, or ECG findings (e.g., ST elevation, ST depression, T inversion, new pathological Q waves) in your documentation. 

3.In coding this scenario we assumed that the carotid stenosis is resolved as well as the renal artery stenosis, since this encounter is post revascularization procedure. While it may be controversial, we do not think that a code for the CABG is sufficiently supported in the documentation, although we recognize that the stress test findings may be interpreted as supporting atherosclerosis of the grafts as well as of the native arteries. 

4.In ICD-9, the clinician needs to document that the patient smokes tobacco or uses tobacco. In ICD-10-CM the amount of detail increases as there are 20 choices for nicotine dependence. In ICD-10, the required documentation includes the type of tobacco product used and whether or not there are nicotine-induced disorders such as remission or withdrawal present. Classifications for nicotine dependence include: uncomplicated, in remission, with withdrawal, or present with other nicotine induced disorders. In this note, even though the patient’s health condition is complicated and he has multiple comorbid conditions, his nicotine dependence is classified as uncomplicated as it does not meet the other classifications since as he is not attempting to quit.

Scenario 2: Syncope

Chief Complaint 

• Dizziness, weakness, and feeling tired last few days. He reports passing out at school.

History

 • 20 year old male college athlete with no prior medical history. On wrestling and cross country running team. Feeling dizzy, lightheaded, weak, and tired for the past two days. Had three several second witnessed syncopal episodes at school yesterday. Went to university clinic and was referred by nurse. Patient states no palpitations, no tachycardia, and no blurred vision noticed prior to each episode1 . 

• Upon questioning, patient admitted he had to lose 11 lbs. to meet wrestling weight requirement. He accomplished this by ingesting carbohydrates, minimal fluids, heavy exercise, and purging2 .

 • No medication or allergies. Denies alcohol, drugs, supplements, or diuretics use.

Exam

• Looks exhausted. No apparent distress. Afebrile. 

• Orthostatic VS: 

1.  Lying BP 116/78 with HR 56, 
2.  Sitting BP 107/60 with HR 74, 
3.  Standing BP 92/49 with HR 1123

• Mucus membranes pale, skin is dry, with turgor and tenting. Capillary refill is 2-3 seconds. 

• Chest is clear. Heart sounds normal. 

• Labs significant for creatinine (2.13), BUN (43), glucose (60). 

• EKG shows sinus tachycardia4 .

Assessment and Plan 

• Orthostatic intolerance. Dizziness, fatigue, and syncope likely secondary to hypotension, dehydration and hypovolemia. 

• Provided fluid challenge of 2L IV NS in office today with improved condition post infusion including resolution of orthostasis and tachycardia. 

• Ordered nutritional consult for dietary intake requirements, physical activity, and potential bulimia2 .• Recommended patient have a psychological consult for potential bulimia; stated he would think about it. 

• Scheduled a follow-up in 2 weeks to ensure no further symptoms. Return earlier if symptoms persist. No driving until follow up appointment.

Summary of ICD-10-CM Impacts

 Clinical Documentation

1.Since the etiologies for syncope and collapse scenarios are multifactorial, clear documentation is required to support your clinical thinking and judgment. Quantify the number of syncope or pre-syncope episodes. 

2.Note if the purging behavior is recurring or if it is a one-time occurrence (e.g., in this case due to the need for the significant weight loss of 11 pounds). 

3.Orthostatic hypotension should be supported in the record with specific vital signs or measurements, and clinical manifestations whenever possible. This note provided clear documentation to support the orthostatic hypotension and the link with the patient’s initial dehydration and hypovolemia. Given the patient’s presentation, and the resolution of the orthostatic intolerance with IV fluids, addressing the coding for autonomic dysfunction syndrome is not relevant. 4.Ideally, if the note is to stand alone, then more detail needs to be provided to document sinus tachycardia. 

Coding

ICD-9-CM Diagnosis Codes

780.2         Syncope and collapse 

785.0         Tachycardia, unspecified  

458.0         Orthostatic hypotension  

276.51       Dehydration

276.52       Hypovolemia

ICD-10-CM Diagnosis Codes

R55        Syncope and collapse 

R00.0     Tachycardia, unspecified 

I95.1      Orthostatic hypotension 

E86.0     Dehydration 

E86.1     Hypovolemia

Other Impacts 

Documenting the vital signs and lab results supports the medical necessity for administering intravenous normal saline and an EKG.