Professional Documents
Culture Documents
Reimbursement
paperwork involved. The following reimbursement guidelines • Experimental or investigational services
will help you understand the various requirements for getting
claims paid promptly and correctly. • Services that are furnished at a duration, intensity, or
frequency that is not medically appropriate
Coverage Issues • Services that are not furnished in accordance with
First, you need to know what services are covered. Covered accepted standards of medical practice
services are services payable by the insurer in accordance • Services that are not furnished in a setting appropriate to
with the terms of the benefit-plan contract. Such services the patient’s medical needs and condition
must be documented and medically necessary for payment
to be made. Typically, third-party payers define medically Payer Types
necessary services or supplies as: Most providers have to deal with a number of different
• Services that have been established as safe and effective payers and plans, each with its own specific policies and
methods of reimbursement. For that reason, it is important
• Services that are consistent with the symptoms or to become familiar with the guidelines for every payer and
diagnosis plan that your practice has contact with. Some insurance
• Services that are necessary and consistent with generally plans are administered by either federal or state
accepted medical standards government, including Medicare, Medicaid, and TRICARE.
• Services that are furnished at the most appropriate, safe, Private payers range from fee-for-services plans to health
and effective level maintenance organizations.
• Services that are not typically accepted as safe and • Establishing eligibility standards
effective in the setting where they are provided • Determining the type, amount, duration, and scope of
• Services that are not generally accepted as safe and services
effective for the condition being treated
Documentation
pertinent data for referrals and consultations.
Computer conversion of the review process in the 1980s
Still, until about 35 years ago, no clear standards existed for added a new twist: speed and a degree of accuracy. Claims
recording patient information. Medical documentation was adjudication, data analysis, and physician profiling revealed
seen, maintained, and used almost exclusively by incongruities. A significant number of physicians and
physicians and medical staff. Patient care information was hospitals were found to have billed for services that were
never submitted to insurance companies or to government not provided or found to be medically unnecessary.
payers; only rarely did medical documentation become the Projected total estimates in the millions of dollars were
focus of malpractice suits. publicized by CMS as findings of fraud and abuse. These
Developments in the mid-1970s, however, irrevocably findings led to the creation of the federal fraud and abuse
affected the role of documentation in medicine. A dramatic program coordinated by several federal organizations,
national increase in medical malpractice claims and awards including the Department of Health and Human Services
abruptly altered the strictly clinical nature of documentation. (HHS) and its agencies, CMS, and the Office of Inspector
The patient medical record was swept into the broad realm General (OIG). In 1997, CMS reported a possible $23
of civil law. Since most medical liability suits approach billion in questionable Medicare payments due to
resolution years after the contested care, the medical record documentation problems in the hospital and outpatient
provides a main source of information about what settings.
happened. The patient record became a legal document, a Commercial insurance companies were quick to follow suit.
basis to reconstruct the quality and quantity of health care Similar to CMS, private payers monitor claims to uncover
services. In many instances, it also serves as a provider’s coding mistakes and to verify that the documentation
only defense against charges of malpractice. supports the claims submitted. Although there are no
Marked changes to the Medicare program also served to national guidelines for proper documentation, the
broaden the influence for medical documentation during guidelines this chapter provides should ensure better
the 1970s. For example, the Centers of Medicare and quality of care and increase the chances of full and fair
Medicaid Services (CMS), Medicare’s federal administrator, reimbursement.
authorizes the program’s regional carriers to review paid
claims to determine whether the care was medically General Guidelines for Documentation
necessary, as mandated under the Social Security Act of 1996. Documentation is the recording of pertinent facts and
observations about a patient’s health history, including past
This type of review checks processed and paid claims and present illnesses, tests, treatments, and outcomes. The
against the documentation recorded at the time of service. medical record chronologically documents the care of the
The aim is to ensure that Medicare dollars are administered patient to:
correctly and, once again, medical documentation must
support the medical necessity of the service, to what extent • Enable a health care professional to plan and evaluate
the service was rendered, and why it was medically the patient’s treatment
justified. For example, a physical therapist re-evaluates a • Enhance communication and promote continuity of
patient after the prescribed treatment plan has been care among health care professionals involved in the
completed. The physical therapist determines that the patient’s care
patient would continue to benefit from further encounters • Facilitate claims review and payment
for manual traction and therapeutic exercise. Depending
upon the payer guidelines, this may require prior • Assist in utilization review and quality of care
authorization from the primary care physician, or the payer. evaluations
• Reduce hassles related to medical review
Medicare does not pay for services that are “medically
unnecessary,” according to Medicare standards. Patients are • Provide clinical data for research and education
not liable to pay for such services if the service is performed
• Serve as a legal document to verify the care provided • The patient’s progress, including response to treatment,
(e.g., as defense in the case of a professional liability change in treatment, change in diagnosis, and patient
claim) noncompliance, should be documented.
Payers want to know that their health care dollars are well • The written plan for care should include treatments and
spent. Because they have a contractual obligation to medications—specifying frequency and dosage, any
beneficiaries, they look for the documentation to validate referrals and consultations, patient and family
that services are: education, and specific instructions for follow-up.
• Appropriate for treating the patient’s condition • The documentation should support the intensity of the
patient evaluation and the treatment, including thought
• Medically necessary for the diagnosis
processes and the complexity of medical decision
• Coded correctly making.
• All entries to the medical record should be dated and
Coding Tip authenticated.
Documentation
Documentation guidelines developed specifically for • The codes reported on the health insurance claim form
the physical therapist by the American Physical or billing statement should reflect the documentation
Therapy Association will be discussed in detail in the medical record.
further in this chapter.
To ensure the appropriate reimbursement for Documentation to Code and Bill
services, the provider should use documentation to Many insurers rely on written evidence of the evaluation of
demonstrate compliance with any third-party payer the patient, care plan, and goals for improvement to
utilization guidelines. determine and approve the medical necessity of care. Initial
evaluation findings documenting the diagnosis form the
Principles of Documentation basis for judging the reasonableness and necessity of care
To provide a basis for maintaining adequate medical record that was subsequently provided. Consequently, the more
information, follow the principles of medical record accurately the patient’s evaluation and treatment are
documentation listed. The principles below have been described, the easier it is to code the diagnoses and
developed by representatives of the following procedures properly.
organizations:
ICD-9-CM Coding
• American Health Information Management Association ICD-9-CM codes relate to the medical diagnosis and are
(AHIMA) used to classify illnesses, injuries, and reasons for patient
• American Hospital Association (AHA) encounters with the health care system. Patients may have a
• American Managed Care and Review Association single primary, or one primary and several secondary
(AMCRA) diagnoses. Medical diagnoses are sequenced by order of
severity or importance.
• American Medical Association (AMA)
Describing the onset of the problem and objectively
• American Medical Peer Review Association (AMPRA)
documenting the patient’s impairment are essential to
• Blue Cross and Blue Shield Association ensuring accurate coding and description of the diagnosis.
• Health Insurance Association of America (HIAA) Confirming any diagnosis is based on objective
measurements performed and values obtained during an
Medical Record Documentation assessment. The diagnostic description of the current
• The medical record should be complete and legible. problem for which the patient is being treated should be
• The documentation of each patient encounter should defined by:
include the date, the reason for the encounter, • Patient’s subjective complaint
appropriate history and physical exam (when • Problem’s date of onset
applicable), review of lab and x-ray data, as well as
other ancillary services (where appropriate), an • Objective test values confirming the diagnosis
assessment, and plan for care (including discharge plan, • Outcomes expected after treatment
if appropriate).
For more information tailored to your specialty, see the
• Past and present diagnoses should be accessible to the chapter on diagnostic coding.
treating or consulting health care professional.
• The reasons for and results of x-rays, lab tests, and other Coding Tip
ancillary services should be documented and included At each visit, the therapist should record the medical
in the medical record. condition being treated.
• Relevant health risk factors should be identified.
Processing
office submit all Medicare claims directly to the carrier,
Claims
covered by the same policy that was in effect during the last
whether participating or not in the Medicare program. visit. The law requires Medicaid patients to provide current
For paper claims, use standard claim forms (CMS-1500 and proof of eligibility with each visit.
the UB-92 described in this chapter) when submitting
Preauthorization
charges, and be sure to complete the forms completely and
Determining in advance the benefits and allowables
accurately.
provides the physician’s office with reimbursement figures
before the patient’s visit. Under most circumstances, the
What to Include on Claims
office should be able to discuss the deductible, copayment,
Patient Information and balance over and above the allowable with the patient
Before filing any claim, obtain clear, accurate information prior to providing costly services. Asking a few pointed
from the patient, and update the information regularly. questions of the patient and insurer will provide additional
Most offices verify the information at each visit. A uniform information regarding deductibles, for example:
policy for multiple provider offices or clinics makes
• How much is the deductible and has it been met for the
everyone accountable for current and correct patient data.
current year?
Primary vs. Secondary Coverage • What are the allowables for the quoted procedures?
Households with dual incomes often have more than one • What percentage of the allowables will be paid?
insurer. Determine which is the primary and which is the
secondary insurance company. For commercial plans, the Clean Claims
subscriber’s or insured’s insurance company is always Claims submitted with all of the information necessary for
primary for the subscriber. In other words, the husband’s processing are referred to as “clean” and are usually paid in
insurance company is primary for him and the wife’s a timely manner. Paying careful attention to what should
insurance company is primary for her. However, the appear on the claim form helps produce these clean claims.
primary insurance company for any dependents is Common errors include the following:
determined by the insureds’ birthdays, the primary insured
being the individual whose birthday is first during the year. • Failure to pay attention to communications from
This is often referred to as the “birthday rule.” For example, carriers (including Medicare and Medicaid transmittals)
if the husband’s birthday is October 14, 1960 and the wife’s • An incorrect patient identification number
birthday is March 1, 1962, the wife is primary for their
• Patients’ names and addresses that differ from the
dependents because her birthday is first during the year
insurers’ records
(year of birth is ignored).
• Physician tax identification numbers, provider numbers,
Assignment of Benefits and Release of or Social Security numbers that are incorrect or missing
Information • No or insufficient information regarding primary or
Consider adding an assignment of benefits statement to the secondary coverage
patient information form. It should state that the patient
• Missing authorized signatures — patient and/or individuals and groups. While insurance reform (Title 1) is
physician an important aspect of the law, it is the anti-fraud and
• Dates of service that are incorrect or don’t coincide to abuse provisions that have the greatest impact on provider
the claims information sent by other providers (such as practices and daily operational activities. Other provisions
hospitals or nursing homes) promote the use of medical savings accounts, improving
access to long-term care services and coverage, and
• Dates that lack the correct number of digits simplification of health insurance administration.
• A fee column that is blank or not itemized and totaled
Possibly the best approach is to be certain that your
• Incomplete patient information practice keeps abreast of the rapid changes taking place as
• Invalid CPT and ICD-9 codes, or diagnostic codes that the different provisions of HIPAA are implemented. One of
are not linked to the correct services or procedures the best sources of information is the CMS web site, which
provides not only background information, but also keeps
• An illegible claim
you up to date with current rules and CMS requirements.
That address is http://www.cms.hhs.gov/hipaa
Medicare Billing for Independent
Physical Therapists Administrative Simplification Provisions
Independent PTs billing Medicare for physical therapy The Administrative Simplification provisions of HIPAA
services need to meet the following criteria: (Title II) require HHS to establish national standards for
electronic health care transactions and national identifiers
• The physical therapist is in an unincorporated solo
for providers, health plans, and employers. They also
practice or unincorporated partnership that meets all
address the security and privacy of protected health
state and local licensure laws; or is an individual
information. Implementing these standards and
practicing physical therapy as an employee of an
encouraging the use of electronic data interchange (EDI) in
Processing
CPT Definitions
The physical therapist in general practice will find the most American Medical Association (AMA) to be a minor
relevant codes in the physical medicine subsection of the surgical procedure that did not include pre- or
medicine section (codes in the 97001–97799 range). Other postoperative services. This designation, which was not
services physical therapists provide, particularly those in recognized for Medicare purposes, was eliminated in CPT
specialty areas, are described under their appropriate body 2004. Check with individual payers to determine their
system within the medicine or surgery section. specific billing guidelines.
CPT only ©2003 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association
©2003 Ingenix, Inc. + Add-On Code * Modifier 51 Exempt ● New Codes ▲ Changed Codes 69
Coding and Payment Guide for the Physical Therapist
For one example, modifier 22 could be used to indicate session by the same provider, the primary procedure
that the patient required the participation of more than one or service may be reported as listed. The additional
PT during an intervention. For another example, modifier procedure(s) or service(s) may be identified by
59 could be used when billing for both 97022, Whirlpool, appending the modifier 51 to the additional
and 97601, Wound debridement, to indicate that the two procedure or service code(s).
services were distinct from one another, or performed on 52 Reduced Services: Under certain circumstances a
different areas of the body. service or procedure is partially reduced or
Note that the CPT book uses the term "physician" when eliminated at the physician’s discretion. Under these
describing how a modifier is to be used. This does not limit circumstances the service provided can be identified
the use of the modifiers to physicians; any practitioner may by its usual procedure number and the addition of
use a modifier as long as the service or procedure to be the modifier 52, signifying that the service is
modified can be performed within that practitioner’s scope reduced. This provides a means of reporting reduced
of work. services without disturbing the identification of the
basic service.
The list of modifiers used most often by physical therapists:
59 Distinct Procedural Service: Under certain
22 Unusual Procedural Services: When the services(s) circumstances, the physician may need to indicate
provided is greater than that usually required for the that a procedure or service was distinct or
listed procedure, it may be identified by adding independent from other services performed on the
modifier 22 to the usual procedure number. A report same day. Modifier 59 is used to identify
may also be appropriate. procedures/services that are not normally reported
25 Significant, Separately Identifiable Evaluation and together, but are appropriate under the circumstances.
Management Service by the Same Physician on the This may represent a different session or patient
Same Day of the Procedure or Other Service: The encounter, different procedure or surgery, different site
physician may need to indicate that on the day a or organ system, separate incision/excision, separate
procedure or service identified by a CPT code was lesion or separate injury (or area of injury in extensive
performed, the patient’s condition required a injuries) not ordinarily encountered or performed on
significant, separately identifiable E/M service above the same day by the same physician. However, when
and beyond the usual preoperative and postoperative another already established modifier is appropriate it
care associated with the procedure that was should be used rather than modifier 59. Only if no
CPT Definitions
performed. The E/M service may be prompted by the more descriptive modifier is available, and the use of
symptom or condition for which the procedure modifier 59 best explains the circumstances, should
and/or service was provided. As such, different modifier 59 be used.
diagnoses are not required for reporting of the E/M 76 Repeat Procedure by Same Physician: The physician
services on the same date. This circumstance may be may need to indicate that a procedure or service was
reported by adding the modifier 25 to the repeated subsequent to the original procedure or
appropriate level of E/M service. Note: This modifier service. This circumstance may be reported by adding
is not used to report an E/M service that resulted in a the modifier 76 to the repeated procedure/service.
decision to perform surgery.
26 Professional Component: Certain procedures are a Coding Tip
combination of a physician component and a technical Physical therapists in skilled nursing facilities might use
component. When the physician component is modifier 76 for patients paid under Medicare Part B.
reported separately, the service may be identified by These patients may receive services in both the
adding the modifier 26 to the usual procedure number. morning and the afternoon of the same day, and
modifier 76 would indicate that the services were not
Coding Tip duplicative.
Identifies that the professional component is being
HCPCS Level II modifiers may also be appended to CPT
reported separately from the technical component for
codes for services. Refer to the HCPCS Level II Definitions
the diagnostic procedure performed. Payment is
and Guidelines for a listing of the HCPCS Level II modifiers.
based solely on the professional component relative
value of the procedure.
Unlisted Procedure Codes
32 Mandated Services: Services related to mandated Not all medical services or procedures are assigned CPT
consultation and/or related services (eg, PRO, third codes. The book does not contain codes for infrequently
party payer, governmental, legislative or regulatory used, new, or experimental procedures. Each code section
requirement) may be identified by adding the contains codes set aside specifically for reporting unlisted
modifier 32 to the basic procedure. procedures. Before choosing an unlisted procedure code,
51 Multiple Procedures: When multiple procedures, carefully review the CPT code list to ensure that a more
other than E/M services, are performed at the same specific code is not available. Also, check for HCPCS Level
CPT Index
EMG (with Anorectal), 90911 Unattended, 97014
Eyelids, 90901
Nerve Conduction, 90901 Electromyography
Other (unlisted) Biofeedback, 90901 Anus
Perineal Muscles, 90911 Biofeedback, 90911
Urethral Sphincter, 90911 Needle
Extremities, 95861–95864
Blood Gases Face and Neck Muscles, 95867
by Pulse Oximetry, 94760 Limited Study, 95869
Bohler Splinting, 29515 Other than Paraspinal, 95870
Single Fiber Electrode, 95872
Bronchospasm Evaluation, 94060 Thoracic Paraspinal Muscles, 95869
Pulmonology, Diagnostic, Spirometry, 94010, 94060 Rectum
Burns Biofeedback, 90911
Debridement, 16020–16030 Surface
Dressing, 16020–16030 Dynamic, 96002–96003
Cardiac Rehabilitation, 93797 EMG (Electromyography, Needle), 95861–95872
Cardiology EPIS, 95925–95930
Diagnostic Evaluation and Management
Stress Tests Athletic Training
Cardiovascular, 93015–93018 Evaluation, 97005
Therapeutic Re-evaluation, 97006
Cardiopulmonary Resuscitation, 92950 Case Management Services, 99361–99373
Cardiopulmonary Resuscitation, 92950 Occupational Therapy Evaluation, 97003
Case Management Services Re-evaluation, 97004
Team Conferences, 99361–99362 Physical Therapy Evaluation, 97001
Telephone Calls, 99371–99373 Re-evaluation, 97002
Chest Wall
Manipulation, 94667
Joint
Mobilization, 97140 Neuropsychological Testing, 96117
Kinetic Therapy, 97530 Neurostimulation
Knee Application, 64550
Strapping, 29530 Occupational Therapy
Leg Evaluation, 97003
Lower Orthotics
Splint, 29515 Check-Out, 97703
Strapping, 29580 Training and Fitting, 97504
Unna Boot, 29580
Upper Oximetry (Noninvasive)
Splint, 29505 Blood O2 Saturation
Strapping, 29580 Ear or Pulse, 94760–94761
Unna Boot, 29580 Oxygen Saturation
Manipulation Ear Oximetry, 94760–94761
Chest Wall, 94667 Pulse Oximetry, 94760–94761
Dislocation and/or Fracture Paraffin Bath Therapy, 97018
Chest Wall, 94667
Physical Therapy, 97140 Peak Flow Rate, 94150
Manometry Pentamidine
Rectum Inhalation Treatment, 94640
Anus, 90911 Performance Test,
Manual Therapy, 97140 Physical Therapy, 97750
Massage Physical Medicine/Therapy/Occupational Therapy
Therapy, 97124 Activities of Daily Living, 97535
Aquatic Therapy
Microwave Therapy, 97020 with Exercises, 97113
Definitions
ICD-9-CM
coders limit audit liability and decrease the number of to identify the drug as a poisoning agent, resulting from
denied claims and requests for additional information. incorrect substances given, incorrect dosages taken,
overdose, or intoxication. The five columns titled, External
This chapter provides information on the structure of
Cause, list E codes for external causes depending upon if
ICD-9-CM. We have also identified coding tips and
the circumstances involving the use of the drug were
guidelines for the ICD-9-CM chapters that are pertinent to
accidental, for therapeutic use, a suicide attempt, an assault,
the physical therapy provider.
or undetermined.
Coding Tip
Alphabetic Index to External Causes of Injury
Be sure that your ICD-9-CM coding system contains
the most up-to-date information available. Changes
and Poisoning (E Codes)
This section is an alphabetic list of environmental events,
take place October 1 of every year, and your code
circumstances, and other conditions that can cause injury
book must be current to ensure accurate coding.
and adverse effects.
The Structure of the Tabular List decimal point followed by another digit. The fourth digit
The Tabular List contains codes and their narrative provides specificity or more information regarding such
descriptions. There are three sections: the Classification of things as etiology, site, and manifestation. Four-digit codes
Disease and Injuries, Supplementary Classifications, and are referred to as “subcategory codes” and take precedence
the Appendices. over three-digit category codes.
Subclassification—Five-digit codes. Greater specificity has
Section 1: Classification of Diseases and been added to the ICD-9-CM system with the expansion of
Injuries four-digit subcategories to the fifth-digit subclassification
The first section of the Tabular List contains 17 chapters. level. Five-digit codes are the most precise subdivisions in
Ten chapters are devoted to major body systems. The other the ICD-9-CM system.
seven chapters describe specific types of conditions that
affect the entire body. This classification contains only
Section 2: Supplementary Classifications (V
numeric codes, from 001.0 to 999.9. Codes and E Codes)
Classification of Factors Influencing Health Status and
Category Contact with Health Services (V Codes). The codes in this
Chapter Chapter Title Code Range classification, otherwise known as V codes, are
1. Infectious and Parasitic Diseases 001–139 alphanumeric and begin with the letter “V.” These codes are
used to describe circumstances, other than a disease or
2. Neoplasms 140–239
injury, that are the reason for an encounter with the health
3. Endocrine, Nutritional and Metabolic care delivery system or that have an influence on the
Diseases, and Immunity Disorders 240–279 patient’s current condition.
4. Diseases of the Blood and Blood
forming Organs 280–289 Example
5. Mental Disorders 290–319 V70.0 Routine general medical examination at a
health care facility
6. Diseases of the Nervous System
and Sense Organs 320–389 V codes are sequenced depending on the circumstance or
7. Diseases of the Circulatory System 390–459 problem being coded. Some V codes are sequenced first to
describe the reason for the encounter, while others are
8. Diseases of the Respiratory System 460–519
sequenced second because they identify a circumstance that
9. Diseases of the Digestive System 520–579 affects the patient’s health status but is not in itself a
10. Diseases of the Genitourinary System 580–629 current illness. Assignment of V codes will be discussed in
11. Complications of Pregnancy, depth in a separate section.
Childbirth and the Puerperium 630–677 Classification of External Causes of Injury and Poisoning
12. Diseases of the Skin and (E Codes). These codes are also alphanumeric and begin
Subcutaneous Tissue 680–709 with the letter “E.” They are used to describe circumstances
and conditions that cause injury, poisoning, or other
13. Diseases of the Musculoskeletal
adverse side effects. They may be used in addition to codes
System and Connective Tissue 710–739
in the main classification (001–999) to identify the external
14. Congenital Anomalies 740–759 cause of an injury or condition. They may never be used
15. Certain Conditions Originating in alone and may never be listed as the first diagnosis.
the Perinatal Period 760–779
Example
16. Symptoms, Signs and 821.01 Right femur shaft fracture
Conditions 780–799
Definitions
term that they modify. Nonessential modifiers may be producing cells from the initial site of malignancy. Primary
either present or absent in the diagnostic or procedure defines the body site or tissue where the malignancy first
statement without affecting the code selection. These began to grow and spread from there to other areas.
modifiers do not affect the code selection. Secondary malignancies are those sites that have been
invaded by the cancer cells coming from another part of the
Essential modifiers are indented under the main term. body and are now exhibiting cancerous growth. Carcinoma
When there is only one essential modifier, it is listed next in situ is confined to the epithelium of the vessels, glands,
to the main term after a comma. Essential modifiers affect organs, or tissues in the body area where it originated and
code assignment; therefore, they should be used in the has not crossed the basement membrane to spread to the
neighboring tissues.
©2003 Ingenix, Inc. 2 Unspecified E Signs & symptoms K Codes that require a fifth-digit 131
Coding and Payment Guide for the Physical Therapist
Benign neoplasms are those found not to be cancerous in and, therefore, appear together in these guidelines without
nature. The dividing cells adhere to each other in the tumor distinguishing one from the other.
and remain a circumscribed lesion. Neoplasms of uncertain
Though the conventions and general guidelines apply to all
behavior are those whose subsequent behaviour cannot
settings, coding guidelines for outpatient and physician
currently be predicted from the present appearance of the
reporting of diagnoses will vary in a number of instances
tumor and will require further study. Unspecified indicates
from those for inpatient diagnoses, recognizing that: 1) the
simply a lack of documentation to support the selection of
Uniform Hospital Discharge Data Set (UHDDS) definition
any more specific code.
of principal diagnosis applies only to inpatients in acute,
short-term, general hospitals, and 2) coding guidelines for
Manifestation Codes inconclusive diagnoses (probable, suspected, rule out, etc.)
As in the following example, when two codes are required
were developed for inpatient reporting and do not apply to
to indicate etiology and manifestation, the manifestation
outpatients.
code appears in italics and brackets. The manifestation code
is never a principal/primary diagnosis. Etiology is always A. Selection of first-listed condition
sequenced first.
In the outpatient setting, the term “first-listed
Arthritis, arthritic (acute) (chronic) diagnosis” is used in lieu of principal diagnosis.
due to or associated
with enteritis NEC 009.1 [711.3] In determining the first-listed diagnosis, the coding
conventions of ICD-9-CM, as well as the general and
Official ICD-9-CM Guidelines for disease-specific guidelines, take precedence over the
Coding and Reporting outpatient guidelines. Diagnoses often are not
The Public Health Service and CMS of the U.S. Department established at the time of the initial encounter/visit. It
of Health and Human Services (DHHS) present the may take two or more visits before the diagnosis is
following guidelines for coding and reporting using confirmed.
ICD-9-CM. These guidelines should be used as a companion
The most critical rule involves beginning the search for
document to the official versions of the ICD-9-CM.
the correct code assignment through the Alphabetic
These guidelines for coding and reporting have been Index. Never begin searching initially in the Tabular
developed and approved by the cooperating parties for List as this will lead to coding errors.
ICD-9-CM: American Hospital Association, American
B. The appropriate code or codes from 001.0 through
Health Information Management Association, and the
V83.89 must be used to identify diagnoses, symptoms,
National Center for Health Statistics. These guidelines
conditions, problems, complaints, or other reason(s)
appear in the second quarter 2002 Coding Clinic for
for the encounter/visit.
ICD-9-CM, published by the American Hospital
Association, where they are updated regularly. C. For accurate reporting of ICD-9-CM diagnosis codes,
These guidelines have been developed to assist the user in the documentation should describe the patient's
coding and reporting in situations where the ICD-9-CM condition, using terminology which includes specific
book does not provide direction. Coding and sequencing diagnoses as well as symptoms, problems, or reasons
instruction in the three ICD-9-CM volumes take precedence for the encounter. There are ICD-9-CM codes to
over any guidelines. describe all of these.
These guidelines are not exhaustive. The cooperating parties D. The selection of codes 001.0 through 999.9 will
are continuing to conduct review of these guidelines and to frequently be used to describe the reason for the
develop new guidelines as needed. Users of ICD-9-CM encounter. These codes are from the section of
should be aware that only guidelines approved by the ICD-9-CM for the classification of diseases and injuries
cooperating parties are official. Revisions of these (e.g., infectious and parasitic diseases; neoplasms;
guidelines and new guidelines will be published by the symptoms, signs, and ill-defined conditions, etc.).
DHHS when they are approved by the cooperating parties. E. Codes that describe symptoms and signs, as opposed
to diagnoses, are acceptable for reporting purposes
Diagnostic Coding and Reporting Guidelines
when a diagnosis has not been established (confirmed)
for Outpatient Services (Hospital-Based and by the physician. Chapter 16 of ICD-9-CM, Symptoms,
ICD-9-CM Index
132 2 Unspecified E Signs & symptoms K Codes that require a fifth-digit ©2003 Ingenix, Inc.
HCPCS Level II Definitions and Guidelines
One of the keys to gaining accurate reimbursement lies in a temporary national code for that service/supply, with an
understanding the multiple coding systems that are used to explanation as to why the code should be kept. These
identify services and supplies. To be well versed in requests were due to their regional office by April 1, 2002.
reimbursement practices, coders should be familiar not
The next phase was the elimination of the official HCPCS
only with the CPT coding system (HCPCS Level I) but also
Level III local codes and modifiers by December 31, 2003.
with HCPCS Level II codes which are becoming
Again, carriers were required to review all local codes in
increasingly important to reimbursement as they are
their systems, crosswalk them to appropriate national codes
extended to a wider array of medical services.
and submit requests for replacement temporary national
HCPCS Level II codes commonly are referred to as national codes by April 1, 2003. Temporary national codes that are
codes or by the acronym HCPCS (pronounced “hik-piks”), requested and approved will be implemented January 1,
which stands for the Healthcare Common Procedure 2004.
Coding System. HCPCS codes are used for billing Medicare
Local codes had been used to denote new procedures or
and Medicaid patients and have been adopted by some
specific supplies for which there was no national code. For
third-party payers.
Medicare, these five-digit alphanumeric codes use the letters
These codes, updated and published annually by the W through Z. Each carrier may create local codes as the
Centers for Medicare and Medicaid Services (CMS), are need dictates. However, carriers were required to obtain
intended to supplement the CPT coding system by approval from CMS's central office before implementing
including codes for nonphysician services, administration them. The Medicare carrier was responsible for providing
of injectable drugs, durable medical equipment and office you with these codes.
supplies.
Due to the Consolidated Appropriations Act of 2001, and
When using HCPCS Level II codes, keep the following in as part of the National Code Data Sets implemented under
mind: the Health Insurance Portability Accountability Act, the
Secretary of Health and Human Services was instructed to
• CMS does not use consistent terminology for unlisted
maintain and continue the use of HCPCS level III codes
services or procedures. The code descriptions may
through December 31, 2003.
include any one of the following terms: unlisted, not
otherwise classified (NOC), unspecified, unclassified, Program Memorandum (PM) AB-01-45 instructed Carriers
other and miscellaneous. to take the following steps to implement the law on April
• If billing for specific supplies and materials, avoid CPT 29th, 2001:
code 99070 (general supplies) and be as specific as • Maintain and accept current level III HCPCS codes and
possible unless the local carrier directs otherwise. or modifiers until December 31, 2003. However,
• Coding and billing should be based on the service Carriers were not allowed to create any new HCPCS
provided. Documentation should describe the patient’s Level III codes and or modifiers.
problems and the service provided to enable the payer • Carriers were to reinstate any HCPCS level III codes
to determine reasonableness and necessity of care. and/or modifiers they may have eliminated after August
• Refer to Medicare coverage references to determine 16, 2000.
whether the care provided is a covered service. • Carriers were to publish on their websites any HCPCS
• When both a CPT and HCPCS Level II code share nearly level III and modifiers with their descriptors that were
identical narratives, apply the CPT code. If the narratives in effect August 16, 2000.
are not identical, select the code with the narrative that Medicare carriers who wished to establish a temporary
better describes the service. Generally, for Medicare national code had to submit the request to their regional
claims, the HCPCS Level II code is more specific and office. The regional office then submitted that
takes precedence over the CPT code. recommendation to the central office for approval.
©2003 Ingenix, Inc. ● New Codes ▲ Changed Codes MED: Medicare Reference 217
Coding and Payment Guide for the Physical Therapist
218 ● New Codes ▲ Changed Codes MED: Medicare Reference ©2003 Ingenix, Inc.
HCPCS Index
HCPCS Level II Index
Abdomen/abdominal Carex
dressing holder/binder, A4462 aluminum crutches, E0114
Abdominal binder cane, E0100
elastic, A4462 folding walker, E0135
Abduction Cervical
pillow, E1399 collar, L0120, L0150
halo, L0810
Absorption dressing, A6251-A6256 orthosis, L0120, L0140-L0174
Accessories traction equipment, not requiring frame, E0855
ambulation devices, E0153-E0159 Chair
beds, E0277-E0280 shower or bath, E0240
Adhesive Chin
pads, A6203-A6205, A6212-A6214, A6237-A6239 cup, cervical, L0150
remover, A4455
tape, A4452 Cida
exostatic cervical collar, L0140
Algiderm, alginate dressing, A6196-A6199 form fit collar, L0120
Alginate dressing, A6196-A6199 Cleaning solvent, Nu-Hope
Algosteril, alginate dressing, A6196-A6199 16 oz bottle, A4455
4 oz bottle, A4455
Ambulation device, E0100-E0159
Collagen
Ambulation stimulator wound dressing, A6021-A6024
spinal cord injured, K0600
Collar, cervical
Anterior-posterior orthosis, L0530 contour (low, standard), L0120
lateral orthosis, L0520 nonadjust (foam), L0120
Apnea monitor, Philly One-piece Extrication collar, L0150
electrodes, A4556 tracheotomy, L0172
Philadelphia tracheotomy cervical collar, L0172
Arm
sling Composite dressing, A6203-A6205
deluxe, A4565 Compression bandage
mesh cradle, A4565 high, A6452
universal light, A6448
arm, A4565 medium, A6451
elevator, A4565
Compression
Auto-Glide folding walker, E0143 burn garment, A6501-A6506, A6509-A6512
Back supports, L0500-L0540, L0600-L0620, L0810, L0861 stockings, L8100-L8190, L8200-L8230
Baseball finger splint, A4570 Conductive
garment (for TENS), E0731
Bath chair, E0240 paste or gel, A4558
Battery, Conforming bandage, A6442-A6447
TENS, A4630
Contact layer, A6206-A6208
Bed
cradle, any type, E0280 Corset, spinal orthosis, L0970-L0976
Bell-Horn Cover, wound
sacrocinch, L0510 alginate dressing, A6196-A6198
collagen dressing,
Belt foam dressing, A6209-A6214
extremity, E0945 hydrocolloid dressing, A6234-A6239
pelvic, E0944 hydrogel dressing, A6242-A6248
Binder specialty absorptive dressing, A6251-A6256
extremity, nonelastic, A4465 Cradle, bed, E0280
lumbar-sacral-orthosis (LSO), A4462
Crutch
Biofeedback device, E0746 substitute, E0118
Body jacket Crutches, E0110-E0116
lumbar-sacral orthosis (spinal), L0500-L0540, L0610 accessories, A4635-A4637
Body Wrap aluminum, E0114
foam positioners, E0191 articulating, spring assisted, E0117
therapeutic overlay, E0199 forearm, E0111
Ortho-Ease, E0111
Boot underarm, other than wood, pair, E0114
pelvic, E0944 Quikfit Custom Pack, E0114
Brake attachment, wheeled walker, E0159 Red Dot, E0114
Burn garment, A6501 underarm, wood, single, E0113
Ready-for-use, E0113
Cane, E0100 wooden, E0112
accessory, A4636-A4637
Easy-Care quad, E0105 Curasorb, alginate dressing, A6196-A6199
quad canes, E0105 Cushion
Quadri-Poise, E0105 decubitus care, E0190
wooden canes, E0100
References
MCM/CIM
initiated its long awaited transition from a paper-based manual is under development.
manual system to a Web-based system on October 1, 2003, Please continue to use the paper-
which updates and restructures all manual instructions. The based manual.)
new system, called the online CMS Manual system, Pub. 100-8 Medicare Program Integrity
combines all of the various program instructions into an Pub. 100-9 Medicare Contractor Beneficiary
electronic manual, which can be found at and Provider Communications
http://www.cms.hhs.gov/manuals. Pub. 100-10 Medicare Quality Improvement
Organization
Effective September 30, 2003, the former method of Pub. 100-11 Reserved
publishing program memoranda (PMs) to communicate Pub. 100-12 State Medicaid (The new manual is
program instructions was replaced by the following four under development. Please
templates: continue to use the paper-based
• One-time notification manual.)
Pub. 100-13 Medicaid State Children's Health
• Manual revisions
Insurance Program
• Business requirement (Under development)
• Confidential requirements Pub. 100-14 Medicare End Stage Renal Disease
Network
The Office of Strategic Operations and Regulatory Affairs
Pub. 100-15 Medicare State Buy-In
(OSORA), Division of Issuances, will continue to
Pub. 100-16 Medicare Managed Care
communicate advanced program instructions to the regions
Pub. 100-17 Medicare Business Partners Systems
and contractor community every Friday as it currently does.
Security
These instructions will also contain a transmittal sheet to
Pub. 100-18 Medicare Business Partners
identify changes pertaining to a specific manual,
Security Oversight
requirement, or notification.
Pub. 100-19 Demonstrations
The Web-based system has been organized by functional Pub. 100-20 One-Time Notification
area (e.g., eligibility, entitlement, claims processing, benefit
Table of Contents
policy, program integrity) in an effort to eliminate
redundancy within the manuals, simplify the updating The table below shows the paper-based manuals used to
process, and make CMS program instructions available in a construct the Web-based system. Although this is just an
more timely manner. The initial release will include Pub. overview, CMS is in the process of developing detailed
100, Pub. 100-02, Pub. 100-03, Pub. 100-04, Pub. 100-05, crosswalks to guide you from a specific section of the old
Pub. 100-09, Pub. 100-15, and Pub. 100-20. manuals to the appropriate area of the new manual, as well
as to show how the information in each section was
The Web-based system contains the functional areas
derived.
included in the table below:
Paper-Based Manuals Internet-Only Manuals
Publication # Title
Pub. 06–Medicare Coverage Pub. 100-01–Medicare General
Pub. 100 Introduction
Issues Information, Eligibility, and
Pub. 100-1 Medicare General Information,
Entitlement
Eligibility, and Entitlement
Pub. 09–Medicare Outpatient
Pub. 100-2 Medicare Benefit Policy (basic
Physical Therapy
coverage rules)
Pub. 10–Medicare Hospital Pub. 100-02–Medicare Benefit Policy
Pub. 100-3 Medicare National Coverage
Pub. 11–Medicare Home Pub. 100-03–Medicare National
Determinations (national
Health Agency Coverage Determinations
coverage decisions)
Pub. 12–Medicare Skilled
Pub. 100-4 Medicare Claims Processing
Nursing Facility
(includes appeals, contractor
Pub. 13–Medicare Intermediary Pub. 100-04–Medicare Claims
interface with CWF, and MSN)
Manual, Parts 1, 2, 3, and 4 Processing
Pub. 100-5 Medicare Secondary Payer
Pub. 14–Medicare Carriers Pub. 100-05–Medicare Secondary
Pub. 100-6 Medicare Financial Management
Manual, Parts 1, 2, 3, and 4 Payer
(includes Intermediary Desk
Review and Audit)
*Medicare Carriers Manual (MCM) and Coverage Issues Manual (CIM) sections are printed verbatim from these manuals and are current at the
time of printing of this publication. These references may be changed by CMS at any time thoughout the year.
Paper-Based Manuals Internet-Only Manuals category. A revision transmittal sheet will identify any new
Pub. 21–Medicare Hospice Pub. 100-06–Medicare Financial material and recap the changes as well as provide an
Management effective date for the change and any background
Pub. 27–Medicare Rural Pub. 100-08–Medicare Program information. At any time, one can refer to a transmittal
Health Clinic and Federally Integrity indicated on the page of the manual to view this
Qualified Health Center information.
Pub. 29–Medicare Renal Pub. 100-09–Medicare Contractor
References
MCM/CIM
0008F No CCI edits apply to this code. 0030T No CCI edits apply to this code.
0008T 00740, 00810, 36000, 36410, 43200, 43202- 0031T No CCI edits apply to this code.
43235, 43255, 69990, 89130, 90780-90784, 0032T 0031T
91105, 94760-94761
CCI
0033T 01926, 36000, 36410, 37202, 62318-62319,
0009F No CCI edits apply to this code. 64415, 64417, 64450-64470, 64475, 69990,
0009T 36000, 36410, 57100, 57180, 57400-57410, 90780
57452, 57500, 57530, 57800, 58100-58120, 0034T 01926, 36000, 36410, 37202, 62318-62319,
58353v, 58558, 58563v, 64435, 69990, 64415, 64417, 64450-64470, 64475, 69990,
76362, 76394, 76490, 76942, 76986, 90780 90780
0010F No CCI edits apply to this code. 0035T 01926, 36000, 36410, 37202, 62318-62319,
0010T No CCI edits apply to this code. 64415, 64417, 64450-64470, 64475, 69990,
90780
0011F No CCI edits apply to this code.
0036T No CCI edits apply to this code.
0012T 29870-29871, 29874-29875, 29877-29879,
29884, 29886-29887, 36000, 36410, 37202, 0037T 36000, 36410, 37202, 62318-62319, 64415,
62318-62319, 64415-64417, 64450-64470, 64417, 64450-64470, 64475, 69990, 90780
64475, 90780 0038T 01916
0013T 0012Tv, 29870-29871, 29874-29875, 29877- 0039T 01916
29879, 29884, 29886-29887, 36000, 36410,
0040T 01916
37202, 62318-62319, 64415-64417, 64450-
64470, 64475, 90780 0041T No CCI edits apply to this code.
0014T 29870-29871, 29874-29875, 29877, 29880- 0042T 01922, 36000, 36410, 90780
29884, 36000, 36410, 37202, 62318-62319,
0043T No CCI edits apply to this code.
64415-64417, 64450-64470, 64475, 90780
0044T No CCI edits apply to this code.
0016T 36000, 36410, 90780
0045T No CCI edits apply to this code.
0017T 36000, 36410, 90780
0046T No CCI edits apply to this code.
0047T No CCI edits apply to this code. 29505 29445v, 29515, 29540, 36000, 36410, 37202,
0048T No CCI edits apply to this code. 62318-62319, 64415-64417, 64450-64470,
64475, 69990, 90780
0049T No CCI edits apply to this code.
29515 11055-11056, 29445v, 29540-29580, 36000,
0050T No CCI edits apply to this code. 36410, 37202, 62318-62319, 64415-64417,
0051T No CCI edits apply to this code. 64450-64470, 64475, 69990, 90780
0052T No CCI edits apply to this code. 29520 29445v, 36000, 36410, 37202, 62318-62319,
64415-64417, 64450-64470, 64475, 69990,
0053T No CCI edits apply to this code. 90780
0054T No CCI edits apply to this code. 29530 12002, 29445v, 36000, 36410, 37202, 62318-
0055T No CCI edits apply to this code. 62319, 64415-64417, 64450-64470, 64475,
69990, 90780
0056T No CCI edits apply to this code.
29540 11900, 12004, 29445v, 29550, 36000, 36410,
0057T No CCI edits apply to this code. 37202, 62318-62319, 64415-64417, 64450-
0058T No CCI edits apply to this code. 64470, 64475, 69990, 90780
0059T No CCI edits apply to this code. 29550 11719, 11900, 36000, 36410, 37202, 62318-
62319, 64415-64417, 64450-64470, 64475,
0060T No CCI edits apply to this code.
69990, 90780, G0127
0061T No CCI edits apply to this code.
29580 12002-12004, 15852, 29540-29550, 29700,
16020 01995, 11100, 11719, 16000v-16015v, 36000, 36410, 37202, 62318-62319, 64415-
16025v-16030v, 36000, 36410, 37202, 64417, 64450-64470, 64475, 69990, 87070,
62318-62319, 64415-64417, 64450-64470, 87076-87077, 90780
64475, 69990, 90780, 97022, 97601v
29590 29540, 36000, 36410, 37202, 62318-62319,
16025 01995, 11100, 16015v, 16030v, 36000, 36410, 64415-64417, 64450-64470, 64475, 69990,
37202, 62318-62319, 64415-64417, 64450- 90780
64470, 64475, 69990, 90780, 97022
64550 36000, 36410, 61850v-61880v, 62318-62319,
v
16030 01995, 11100, 16015 , 36000, 36410, 37202, 64415-64417, 64450-64470, 64475, 69990,
62318-62319, 64415-64417, 64450-64470, 90780
64475, 69990, 90780, 97022
CCI
Glossary
bacteria; frequently associated with swelling and other signs
of medical necessity, the provider may ask the patient to
of inflammation.
waive protection from liability by asking the patient to sign
Absorbable sutures. Strands prepared from collagen or a an advanced beneficiary notice. The ABN must specify each
synthetic polymer and capable of being absorbed by tissue service and each date of service, and the specific reason why
over time. Examples include surgical gut; collagen sutures; it is believed the service will be denied.
or synthetics like polydioxanone (PDS), polyglactin 910
Algoneurodystrophy. A neuropathy of the peripheral
(Vicryl), poliglecaprone 25 (Monocryl), polyglyconate
nervous system of the body.
(Maxon), and polyglycolic acid (Dexon).
Alignment. The establishment of a straight line or
Abuse. As defined by Medicare, an incident that is
harmonious relationship between structures.
inconsistent with accepted sound medical, business, or
fiscal practices and directly or indirectly results in Alloplastic. Inert material (foreign body), such as plastic or
unnecessary costs to the Medicare program, improper metal, implanted into tissues for the purpose of
reimbursement, or reimbursement for services that do not construction, augmentation, or reconstruction.
meet professionally recognized standards of care or which
Amputation. The removal of all or part of a limb or digit
are medically unnecessary. Examples of abuse include
through the shaft or body of a bone either by surgery or
excessive charges, improper billing practices, billing
accidental injury.
Medicare as the primary insurance instead of other third-
party payers that are primary, and increasing charges for Anticoagulant. A substance that reduces or eradicates the
Medicare beneficiaries, but not to other patients. blood’s ability to clot.
Acetabuloplasty. Plastic repair/reconstruction of the Alternative delivery system (ADS). A phrase indicating any
acetabulum. The acetabulum is the rounded cavity on the health care delivery system other than traditional fee-for-
external surface of the innominate bone that receives the service.
head of the femur. Aneurysmal bone cyst. Solitary bone lesion that bulges
Achilles tendon. The tendon attached to the posterior of the into the periosteum; marked by calcified rim.
calcaneus that plantar flexes the foot. Angiodysplasia. Vascular abnormalities, with or without
Acromioplasty. Repair of the part of the shoulder blade that bleeding.
connects to the deltoid muscles and clavicle. Angioplasty. Reconstruction or repair of a diseased or
Activities of daily living.* The self-care,communication, damaged blood vessel.
and mobility skills (eg, bathing, bed mobility, dressing, Ankylosis. Abnormal immobility and consolidation of a
eating, grooming, toileting, and transfers)required for bone or joint.
independence in everyday living.
Anterior. The front area or toward the front area of the
Acquired. A condition, which is not genetic, that is body; an anatomical reference point used to show the
produced by outside influences. position and relationship of one body structure to another
Acute. Sudden, severe. body structure.
Acute lymphadenitis. Sudden, severe inflammation, Anterolateral. Situated in the front part and off to one side.
infection, and swelling in lymphatic tissue. Anteromedial. Situated in the front part and off to the
Add-on codes. A procedure performed in addition to the medial side.
primary procedure and designated with a + in CPT. Add-on Anteroposterior. Front to back.
* Starred definitions printed with permission from the Guide to Physical Therapist Practice, 2nd ed. Phys Ther. 2001; 81: 9-744.
Appeal. A specific request (reconsideration) to reverse a Atony. Absence of normal muscle tone and strength.
denial or adverse coverage or payment decision and
Atrophy. Reduction in size or activity in an anatomic
potential restriction of benefit reimbursement. An appeal is
structure, due to disease or other factors.
a special kind of formal complaint to let the carrier know
that you disagree with any decision about health care Autograft. Tissue grafted from one anatomical site of a
services. This complaint is made directly to the health plan person to another anatomical site of the same person.
by following a specific process set up by the health plan. Other terms for autograft include autogenic graft,
The insured or the health care provider can initiate appeals autologous graft, and autotransplant.
when the insured and the plan disagree with a plan’s Avulsion. Forcible removal of a part, such as the partial or
decision to deny or limit care. total removal of a toenail.
Appliance. Device providing function to a body part. Axon. An extension from a neuron that carries impulses to
Appropriateness of care. Term often used to denote proper receiving terminal branches.
setting of medical care that best meets the patient’s Balance billing. An arrangement where a health care
diagnosis. provider may bill a covered person for charges above the
Glossary
Arthrocentesis. Aspiration of fluid from a joint with a amount reimbursed by the health plan (i.e., the difference
needle. between billed charges and the amount paid). This may or
may not be appropriate, depending upon the contractual
Arthrodesis (fusion). Surgical fixation of a joint.
arrangements between the health care provider and carrier
Arthrogram. An x-ray of a joint after the injection of and/or any government regulations (i.e., Medicare).
contrast material. Medicare risk plan members cannot be balance billed by
contracted providers; Medicare fee-for-service participants
Arthrography. Contrast study of a joint performed in
cannot be balance billed by participating providers.
radiology to diagnose joint disorders.
Bell’s palsy. A lesion of the facial nerve that results in
Arthroplasty. Restoration of a joint.
unilateral facial paralysis that onsets suddenly.
Arthrotomy. Surgical incision into a joint.
Beneficiary. A person entitled to receive Medicare or other
Aseptic necrosis. A condition sometimes following a payer benefits and who maintains a health insurance policy
traumatic dislocation of the hip or shoulder in which the claim number.
head of the femur or humerus shows increasing signs of
Bicipital tenosynovitis. An inflammatory condition
sclerosis and cystic changes.
affecting the bicipital tendon.
Aspirate. To withdraw fluid or air from a body cavity by
Brachial plexus lesions. Acquired defect in tissues along
suction.
the network of nerves in the shoulder, causing
Assessment.* The measurement or quantification of a corresponding motor and sensory dysfunction.
variable or the placement of a value on something.
Bundled. 1) The gathering of several types of health
Assessment should not be confused with examination or
insurance policies under a single payer, 2) The inclusive
evaluation.
grouping of codes related to a procedure when submitting a
Assigned claim. A claim from a physician or supplier who claim.
has agreed to accept the Medicare allowable amount as
Bursa. A cavity or sac containing fluid.
payment in full for the services rendered. Payment for an
assigned claim is made directly to the provider or supplier Bursectomy. The surgical excision of a bursa.
of the item or service. Under the terms of assignment, the
Bursitis. Inflammation of a bursa.
physician or supplier may not collect from the beneficiary
or another insurer the difference between the Medicare Calcifying tendinitis. Inflammation and hardening of the
allowable and the physician’s actual charge for the item or tissue (due to calcium salt deposits), occurring in the
service (excluding the beneficiary’s 20 percent coinsurance tendons and tendon-muscle attachments.
and deductible). Cancellous bone. Spongy bone containing many large
Assignment. An arrangement in which the provider spaces filled with bone marrow or embryonal connective
submits the claim on behalf of the patient and is tissue. Cancellous bone makes up most of the bone tissue
reimbursed directly by the patient’s plan. By doing so, the of short, flat, and irregular shaped bones as well as most of
provider agrees to accept what the plan pays after the epiphysis (end portion) of the long bones. It makes the
deductibles and copayments are met. bones lighter.
Assistive devices.* A variety of implements or equipment Capsulectomy. Excision of a structure that has something
used to aid patients/clients in performing actions, activities, enclosed. The capsule can be either hard or soft.
movements, or tasks. Assistive devices include canes, Capsulorrhaphy. Suturing of a joint capsule.
crutches, long-handled reacher, power devices, static and
dynamic splints, walkers, and wheelchairs. Capsulotomy. Incision of a joint capsule.
Index
Assignment of benefits, 37 Collection policies, 42-43 Durable medical equipment, 1, 6, 9-
Asthma, 113-115, 143, 149, 162, 168, Complications, 32, 86, 100-101, 104- 10, 17, 46, 53, 62, 217-218, 220,
182, 202-205, 208-209, 214, 244- 107, 120, 123, 126, 130, 133, 149, 225, 228, 234, 248-249, 251, 256-
245 210, 212, 214, 246, 258 259, 261, 268
Concussion, 124, 145, 149-150, 163,
Bell's palsy, 79, 144, 246, 266 169, 176, 209 E code, 107, 112, 115, 120, 125-126,
Belt, extremity, 233 Congenital anomalies, 100, 121-122 130
Beneficiary late filing, 45 Congestive heart failure, 111, 114, 162 Ear oximetry, 96
Benign neoplasm, 184-193 Constant attendance, 71, 86, 88, 252 ECG, 76, 95, 156, 175, 245-247, 264
Biofeedback, device, 228, 233 Convulsions, 122, 140 EEG, 10, 79, 95
Biofeedback, training, 74, 96, 98 COPD, 113-114, 146, 157 EKG, 10, 54, 95, 111, 248, 254
Blue Cross and Blue Shield, 6, 26, 37 Correct Coding Initiative, 11-12, 90, Electrical stimulation, 74, 79, 81, 85-
Bronchitis, acute, 113 268, 277, 279, 281 86, 90, 95, 97, 229, 245-248
Bronchitis, chronic, 157-158, 163, Coverage issues, 3, 5, 71, 74-75, 85, Electrodes, 73, 79, 81-83, 85, 149,
194-195, 212 232, 237-238, 244, 257, 272 221, 228, 233-234, 245-248
Burns, local treatment, 72 Coverage Issues Manual, 3, 74-75, Electromyography, 69, 74, 78-83, 95-
237-238, 244, 257, 272 96, 228, 245
Calculating costs, 8 CPAP, 77, 95, 97, 250, 260 Electrotherapy, 79, 246
Cane, 221, 226, 233-236, 249, 252, CPR, 7, 95, 97 Embolisms, 111-112
262 Encephalitis, 102, 108, 156, 176, 179-
Capitation, 8, 47, 62 182, 198
EOB, 21, 46, 52 ICD-9-CM, definitions and guidelines, Medicare, summary notice, 46
Epilepsy, 109, 163, 168, 183, 214 3, 99, 101, 103, 105, 107, 109, 111, Medigap, 18-19, 49, 51-53, 56-57, 271
Evaluation and Management, 69-70, 113, 115, 117, 119, 121, 123, 125, Meningitis, 101-102, 108-109, 176,
76, 90-91, 95, 253-254, 264, 270 127, 129 179, 181
Evaluation, occupational, 96 ICD-9-CM, Index, 3, 116, 124, 131- Metabolic diseases, 100, 104
Evaluation, physical therapy, 84 215 Migraine, 109, 137, 144, 148, 157,
Evaluation, spirometry, 76 Ice cap or collar, 227 169-170, 180-182, 193, 195, 208-
Exercise therapy, 96, 136, 245-247 IDDM, 104-105, 138-139, 141-143, 210
External counterpulsation, 246, 264 148, 155, 168, 181-182, 193-194, Motion analysis, 82-83, 96
196, 201-202, 209, 213 Multiple sclerosis, 109, 156, 244
Flat foot, 121, 206, 263 Immunity disorders, 100, 104, 108 Muscle testing, 79-80, 96
Foam Dressing, 222, 233-234, 236 Incident to, 86, 229, 244-245, 248, Muscular dystrophy, 147, 156, 161,
Foot care, 12, 15, 54, 263 253-258, 262 168, 183, 202
Foreign body, 114, 123-124, 126, 166, Independent practice, 6, 253, 262, 264 Musculoskeletal System, 72, 92, 100,
168, 177, 194, 203, 208, 265, 267 Independent Practice Association, 6 116, 137, 157, 160, 175, 196, 202
Fracture, multiple, 179 Index, 3-4, 95-99, 104, 110, 113, 115- Myasthenia gravis, 109, 272
Fracture, skull, 123 116, 122, 124, 126, 130-215, 217-
Fraud and abuse, 25, 33-35, 46 218, 233-236 Neoplasm, 100, 102-104, 119, 129,
FTT, 122 Infectious & parasitic diseases, 100- 131, 136, 162, 170, 182-195, 197,
F-wave, 81 102, 108, 115, 132 201, 209, 213, 267
Insurance, 1-2, 5-7, 12, 19-23, 25-26, Neoplasm, benign, 100, 184
Gait, training, 9, 71, 87, 96-97, 137, 32, 37-38, 40, 42, 49-53, 63, 65, 78, Neoplasm, malignant, 184
270 103, 217, 232, 237-238, 257-258, Neoplasm, table, 103, 131
Gout, 108, 117, 168, 194 265-266, 268, 270-271, 273-274 Neoplasm, uncertain behavior, 184
Gradient compression stocking, 231 IPPB, 77, 250-251, 260 Nerve conduction, 78-81, 95-96, 111,
Group therapy, 61, 88, 252 229
Guidelines for physical therapy Kyphosis, 151, 153, 178, 201, 213, 270 Nervous system, 73, 79, 81-83, 100,
documentation, 27 102, 106, 108-109, 134-137, 139-
Leukemia, 103 140, 144, 149-152, 154, 156-157,
HCPCS, Level III Codes, 2, 39, 217 Limiting charge, 18-20, 44, 48, 270 160, 162, 165, 175-182, 184, 187,
Health Maintenance Organizations, 5- Lordosis, 153, 180, 213 190, 192, 202, 208, 265, 272
6, 238 LSO, 230, 233-236 Neurobehavioral status exam, 83
Heat, lamp, 227, 250, 260 Lupus, 115-116, 157, 163, 180, 183, Neurology, 69, 78, 96
Heat, pad, 227, 236 199, 201, 211 Neuromuscular electrical stimulation,
Heel pad, 231, 234 246, 248
Hemiplegia, 109, 141, 144, 169-170, Malignant neoplasm, 102, 129, 170, Neuromuscular, junction testing, 82
178, 204, 211 182-184, 195, 201, 267 Neuromuscular, reeducation, 75, 87,
Hemorrhage, subarachnoid, 138, 141, Malnutrition, 104, 107-108 96-97
165, 169-170 Manifestation codes, 117, 132-133 NIDDM, 104-105, 138-139, 141-143,
Index
Hemorrhage, subdural, 169-170 Manipulation, 54, 78, 87, 95-97, 244, 148, 155, 168, 181-182, 193-194,
Herpes zoster, 102, 115 264, 267, 271 196, 201-202, 209, 213
HIV, 92, 101-102, 110, 127, 129, 157, Manual therapy techniques, 87, 271 Non-Covered Services, 15, 17, 47
165, 176 MCM, 3, 52, 54-55, 77-91, 220-228, Non-participating providers, 6, 12, 18,
Home management training, 87, 89 231, 237-264, 271 20, 43
Hot water bottle, 227, 234 Medicaid, 1, 5, 9-10, 25, 32-34, 37, Non-speech-generating device, 74
Huntington's chorea, 109, 154, 170 45, 49, 52, 57, 62-64, 88, 99, 131,
Hydrocephalus, 121, 135, 137, 153, 217, 220, 237-238, 267-272 OIG, 25, 33-35
170, 180 Medical necessity, 3, 5, 12, 15, 17, 25- Open wounds, 123-124, 270, 273
Hydrocollator unit, 227 26, 37, 42, 44-45, 47, 49, 55, 84, Orthotic, 29-31, 61, 84, 88, 90, 137,
Hydrocolloid dressing, 223, 233-234, 87, 221, 245, 248, 253-255, 257, 212, 218-219, 229-231, 235, 246,
236 264-265, 268, 271 267
Hydrogel dressing, 223-224, 233-234, Medicare, benefit notices, 46 Orthotic, devices, 230-231, 235, 267
236 Medicare, Carriers Manual, 3, 71, 237- Orthotic, shoes, 231
Hypertension, 99, 101, 110, 141, 143, 238, 244, 247, 249, 252, 264, 271- Orthotic, training, 137, 246
145, 147-149, 151-154, 156-157, 272 Osteoarthrosis, 118, 141-143, 154,
161-164, 170, 172-175, 183, 202, Medicare, Official Regulatory 157, 175, 195-196, 272
204-205, 207-209, 212 Information, 3, 237, 239, 241, 243, Osteogenic stimulation, 245
Hypotension, 112, 175, 198, 211 245, 247, 249, 251, 253, 255, 257, Osteomyelitis, 107, 116, 155, 168,
259, 261, 263 183, 195-196, 272
Medicare, remittance advice, 22