Download Documentation and Coding Resource Packet

National Center
for Health Care
Capacity Building
Documentation
and Coding
Resource Packet
Prepared by JMS Billing Solutions
TABLE OF CONTENTS
Acronyms Used……………………………………………………………………………………….…..
3
Current Procedural Terminology Coding……………………………………………………………… 4
Evaluation and Management Services……………………………………………………….… 4
E&M Components……………………………………………………………………………..… 4
E&M Documentation Requirements…………………………………………………………… 9
Preventive Medicine Documentation Requirements………………………………………….. 10
Modifiers…………………………………………………………………………………………. 11
International Classification of Diseases, 10th Revision Clinical Modification Coding………………. 11
HIV/AIDS Diagnosis Coding…………………………………………………………………… 12
Inconclusive HIV Coding……………………………………………………………………….. 12
ICD-10-CM Code Sequencing…………………………………………………………………… 13
ICD-10-CM Code Tips………………………………………………………………………........ 13
Summary of Modifiers…………………………………………………………………………………… 14
Summary of Codes……………………………………………………………………………………….. 14
Evaluation and Management Codes……………………………………………………………
14
HIV/AIDS ICD-10-CM Codes…………………………………………………………………… 15
AIDS Related Condition Codes………………………………………………………………… 16
HIV/AIDS Screening Codes…………………………………………………………………….. 17
Well Visit ICD-10-CM Codes……………………………………………………………………. 18
Miscellaneous Visit Codes………………………………………………………………………. 18
Supplemental Resources…………………………………………………………………………………. 19
Coding Resources………………………………………………………………………………… 19
Web Resources…………………………………………………………………………………… 20
State Medicaid Agencies………………………………………………………………………… 21
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Acronyms Used
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AMA – American Medical Association
ARC – AIDS Related Complex
CDC – Centers for Disease Control
CLIA – Clinical Laboratory Improvement Amendments
CMS – Centers for Medicare and Medicaid Services
Dx - Diagnosis
EIA – Enzyme Immunoassay
ELISA – Enzyme Linked Immunosorbent Assay
HHS – Health and Human Services
HIV 1 – Human Immunodeficiency Virus 1
HIV 2 - Human Immunodeficiency Virus 2
OI – Opportunistic Infection
WHO – World Health Organization
Coding Acronyms Used
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cc – Chief Complaint
CPT - Current Procedural Terminology
E&M – Evaluation and Management
HCPCS – Healthcare Common Procedure Coding System
HPI – History of Present Illness
ICD-9-CM – International Classification of Diseases, 9th Revision, Clinical Modification
ICD-10-CM – International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS – International Classification of Diseases, 10th Revision, Procedure Coding System
MDM – Medical Decision Making
PDx – Principal Diagnosis
PE – Physical Examination
PMFSH – Past Medical, Family and Social History
ROS – Review of Systems
SDx – Secondary Diagnosis
*Current Procedural Terminology (CPT) 2016 American Medical Association: Chicago, IL.
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Current Procedural Terminology (CPT) Coding
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Developed by AMA in 1966
Updated annually (available January)
CPT codes describe the procedures and services that are performed to treat medical conditions
Reported on professional (physician) claims for services rendered on an outpatient basis
CPT comprise of 6 sections: Evaluation & Management, Anesthesia, Surgery, Radiology,
Pathology and Laboratory, Medicine
Evaluation and Management Services
E & M Codes (99201–99499)
Evaluation and Management E&M)
• Used to report medical (non-surgical) services provided by physicians
• Used by all specialties as appropriate
• Each E&M code is incremental in nature and reflects the resources necessary to provide health care
to patients
• E&M codes reflect medical care, preventive care and preventive counseling care
New vs. Established Patient Definition
• The E&M documentation guidelines provide a clear and concise definition of new vs. established
patient:
– New patient – has not received any face -to-face professional services from a physician within the
same health care entity within the last three years
• Established patient – has received face-to-face professional services from a physician within the
same health care entity within the last three years
– Commonly referred to as “follow up care”
E & M Documentation - Key Components
• History
• Physical Examination
• Medical Decision Making
Component#1
History – a chronological description of the patient’s present illness related to the chief complaint
History includes:
• CC, HPI, ROS, PMFSH
• CC - a clear concise statement that describes the reason for the medical encounter typically in the
patient’s own words
• Usually the first sentence in the health record
• The medical record should clearly reflect the chief complaint
• The statement patient “here for follow up care” is insufficient as this does not clearly state the reason
for the patient seeking medical care
• Satisfactory statements include:
― Patient here for HIV test results follow up
― Patient here for antiretroviral therapy follow up
Each type of history includes documentation of some or all of the following History of Present Illness
Elements (HPI)
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HPI elements
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Location – symptomatic areas
Quality – the quality of the symptom
Severity – intensity of the symptom
Duration – how long the symptoms occurred
Timing – onset of the symptoms
Context – what the patient was doing when symptoms began
Modifying factors – factors that improve or worsen the patient’s symptoms
Associated signs and symptoms – additional complaints that add to the symptoms
Review of Systems (ROS)
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The status of each body system
Defines the problem
Clarifies differential diagnoses
Identifies the need for diagnostic tests
Serves as baseline data for other affected body systems that may impact management and treatment
options
ROS – Body Systems
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Constitutional systems
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Past Medical, Family and Social History (PMFSH) Elements
PMFSH consists of a review of 3 areas:
• Past medical history – personal illnesses, injuries, major operations and medication
• Past family history – review of family medical illnesses
• Past social history – age appropriate review of past and current activities
• Documentation of all 3 areas is required for new patient encounters
Component#2
Physical Examination (PE):
• An objective assessment of organ systems or body areas pertinent to the medical complaint, illness
or injury
• The extent of the exam performed depends on the physician’s clinical judgment and the patient’s
reason for seeking medical attention
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PE Body Areas
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Head, including face
Neck
Chest, including breast and axillae
Abdomen
Genitalia, groin, buttocks
Back
Each extremity
PE Organ Systems
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Constitutional systems
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Physical Exam Documentation Tips
• Examine the body systems/body areas related to the presenting problem
• Abnormal and relevant negative exam findings of the affected or symptomatic body areas or organ
systems must be documented in detail
o A statement of “normal” is sufficient
o A statement of “abnormal” or “asymptomatic” without any explanation is not
acceptable
o Examples include:
 Abnormal skin/positive for skin rashes or lesions should be documented as
“discolored skin lesions on the left arm and face”
The AMA and CMS developed a set of physical examination documentation guidelines in 1995 and
again in 1997
• The 1995 guidelines are ambiguous and somewhat subjective
• The 1997 guidelines reflect clearly defined examination elements for physicians to understand
• Physicians may choose to use either set of guidelines; but not both
Component#3
Medical Decision Making (MDM)
Complexity of establishing final diagnoses, selection of management options, and/or preparation of the
patient’s treatment plan.
MDM is determined by:
• Number of possible diagnoses and/or management options considered
• Documentation of data reviewed, amount of data and/or complexity data for review
• Risks of significant complications, morbidity and/or mortality relevant to the reason for seeking
healthcare
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Number of possible diagnoses and/or management options considered:
• Clinical impression
• Management plans and/or further evaluation
• If treatment is for an established condition, documentation should clearly reflect whether the
problem is improving, well controlled, resolving, resolved, controlled, inadequately controlled,
worsening or failing to change as expected
• The initiation of, or change in treatment or medication must be clearly documented
• Referrals to specialists must clearly reflect the type of specialist and reason for the referral
Documentation of data reviewed and/or complexity of data for review:
• Diagnostic tests such as labs, radiology or procedures which are ordered
• Review of diagnostic test results such as labs, radiology or other procedure results
• Discussions with health care professionals who performed labs, radiology or procedures
• Direct visualization and independent interpretation of image tracings or lab specimens that were
previously interpreted by other physicians
• Relevant findings from old medical records, history obtained from family members, caretakers or
other sources
Risks of significant complications, morbidity and/or mortality relevant to the reason for seeking
healthcare based on:
• The risks associated with the presenting problems, diagnostic tests, procedures and specialty referrals
• The risks related to the disease process anticipated between the present encounter and the next
encounter
• Diagnostic tests, procedures and specialty referrals based on the risks during and immediately after
diagnostic tests, procedures and specialty referrals
The E&M Table of Risk is used to help determine whether the risk of significant complications,
morbidity, and/or mortality is minimal, low, moderate, or high. Because the determination of risk is
complex and not readily quantifiable, the table includes common clinical examples rather than absolute
measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the
disease process anticipated between the present encounter and the next one. The assessment of risk of
selecting diagnostic procedures and management options is based on the risk during and immediately
following any procedures or treatment. The highest level of risk in any one category (presenting
problem(s), diagnostic procedure(s), or management options) determines the overall risk.
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E&M Table of Risk
Level of Risk
Presenting
Problem
Diag.
Procedures
Ordered
Minimal
*One self-limited or
minor problem (e.g.,
cold, insect bite,
tinea corporis)
*Rest
*Gargle
*Elastic bandages
*Superficial dressings
Low
*Two/more selflimited minor prob.
*One stable chronic
illness
*Acute
uncomplicated
illness or injury
Moderate
*One/more chronic
illnesses w/mild
progression-side
effect treatment
*Two/more stable
chronic illnesses
*Undiagnosed new
problem w/uncertain
prognosis
*Acute illness with
systemic symptoms
(e.g. pneumonia,
colitis)
*Acute
uncomplicated injury
*One/more chronic
illness w/severe
progression – side
effect of treatment
*Acute/chronic
illnesses/injuries
threat to life
*Abrupt neurologic
change
*Lab tests –
venipuncture
*Chest X-ray
*EKG/EEG
*Urinalysis
*Ultrasound
*KOH Preparation
*Physiologic tests
not under stress
(e.g., pulmonary
function)
*Non-cardio imaging
with contrast (e.g.,
barium enema)
*Superficial
needle/skin biopsy
*Clinical lab tests (i.e.
arterial puncture)
*Physiologic tests
under stress
*DX endoscopies w/o
risk factor
*Deep needle biopsy
*Refer patient for
consult
*Cardio imaging
studies w/contrast,
w/o risk factors
*Obtain body cavity
fluid
*Cardio imaging
studies w/contrast,
w/risk factor
*Cardiac
electrophysiologic
tests
*Diag. endoscopies
w/risk factor
*Discography
*Elective major surgery w/risk
factor
*Emergency major surgery
*Parenteral controlled
substances
*Drug treatment with intense
monitoring for toxicity
*Decision not to resuscitate or to
de-escalate care due to poor
prognosis
High
Management Options
*Over-the-counter drugs
*Minor surgery/no risk factors
*PT
*OT
*IV fluids w/o additive
*Minor surgery w/risk factor
*Elective major surgery w/o risk
factor
*Prescription management
*Treatment nuclear medicine
*Closed fracture
treatment/dislocation w/o
reduction
*IV fluids w/additives
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Evaluation and Management Services
Documentation Requirements
There are general principles of medical record documentation that are applicable to health care services in all
settings. The following general principles help ensure that medical record documentation for all E&M
services is appropriate:
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The medical record should be complete and legible
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The documentation of each patient encounter should include:
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Reason for the encounter and relevant history, physical examination findings, and prior diagnostic
test results
Assessment, clinical impression, or diagnosis
Medical plan of care
Date and legible identity of the observer
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Past and present diagnoses should be accessible to the treating and/or consulting physician
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Appropriate health risk factors should be identified
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The patient’s progress, response to and changes in treatment, and revision of diagnosis should be clearly
documented
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The diagnosis and treatment codes reported on the health insurance claim form should be supported by
the documentation in the medical record
The code sets used to bill for E&M services are organized into various categories and levels. In general, the
more complex the visit, the higher the level of code reported. In order to report any code, the services
furnished must meet the definition of the code. The code definition comprises of Three (3) Key
Components:
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History – chief complaint, history of present illness, review of systems and past medical, family and
social history
Physical Examination – a general multi-system or single system examination of the body areas/organ
systems pertinent to the chief complaint
Medical decision making – establishing final diagnoses and management of treatment options
All new patient/initial visits require documentation of all 3 components. Established patient/subsequent
visits require clear and concise documentation of 2 of the 3 components. Medical decision making should
always be 1 of the components of an established patient visit. In order to maintain an accurate medical
record, services should be documented during the encounter or as soon as practical after the encounter.
Documentation is the key to ensuring that the level of service provided justifies the E&M visit code.
When ordering diagnostic ancillary services on your patients (i.e. lab work, radiology, physical therapy,
etc), be sure to properly document the medical condition that establishes the reason for ordering
these services in the medical record, on any requisition forms and on medical claims.
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Preventive Medicine Visits
Documentation Requirements
Preventive/well visit services are comprehensive in nature and include:
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A comprehensive health and developmental history, review of systems, past family and social history
and assessment and history of pertinent risk factors
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An age and gender appropriate multi-system physical examination which should include a Body
Mass Index (BMI) assessment
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Anticipatory guidance, health education, risk factor reduction and/or interventions and age
appropriate counseling. Counseling should include: HIV, nutrition, exercise, depression/mental
health, tobacco, alcohol and substance abuse.
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The ordering of appropriate immunizations and/or the need for laboratory/diagnostic screening
exams
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Management of insignificant problems or the status of previously diagnosed stable conditions (SEE
NOTE)
The comprehensive history and examination performed during a preventive medicine visit are not the same as
the comprehensive history and exam that are required for a problem-oriented Evaluation and Management
(E&M) sick visit.
If a significant amount of additional work or effort is necessary to treat an abnormality or illness which results
in a problem oriented sick visit during the preventive medicine visit encounter, both services should be
reported with the applicable CPT code. The sick visit service should be reported with a problem oriented
E&M sick visit CPT code and all of the sick visit ICD-10-CM codes should be reported. The well visit service
should be reported with the preventive medicine visit E&M CPT code and the well visit ICD-10-CM code.
Append modifier 25 to the preventive medicine visit E&M service code.
Documentation is the key to whether or not the additional work performed during the preventive medicine
visit justifies the reason for assigning an additional E&M visit code.
NOTE: The Preventive Medicine Services CPT guidelines state, “An insignificant/trivial problem or
abnormality that is encountered during a preventive medicine evaluation and management service
which does not require additional work and does not require the performance of the key components of
a problem-oriented E/M service should not be reported”.
Please refer to the Evaluation & Management Services section of the CPT code book for specific
reporting instructions.
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HIV Testing Documentation
First visit consists of:
• The signed HIV consent form
• HIV test results
• Notation that the test results were communicated to the patient
Second visit consists of:
• Written justification for the rationale for the second or subsequent HIV test visit (i.e. risks identified
during the first visit requiring further counseling)
HIV Counseling without Testing
• Written justification that counseling was provided
• The reason why the patient declined testing
• The follow up care plan, including indications for further counseling and testing
HIV Counseling Documentation (Positive Results for Asymptomatic HIV or AIDS Infection)
Initial visit for confirmed results consists of:
• Preliminary or confirmatory positive test results
• Referrals for medical care and supportive services
• Follow up to confirm continuum of care
• Prevention/risk reduction counseling and follow up care plan
• Partner counseling and assistance including domestic violence screening
• Medical Provider HIV/AIDS Report and Partner Contact Form
Annual assessments consist of:
• Prevention/risk reduction counseling and follow up care plan
• Partner counseling and assistance including domestic violence screening
While various state Medicaid agencies suggest the use of the rapid HIV test, it is the health care provider’s
discretion to order a rapid HIV screen or the conventional HIV screening test. Contact your local Medicaid
agency for specific guidance
Rapid HIV tests – G0435, 86701, 86702 and 86703
• Orasure Technology
• Trinity Biotech Uni-Gold
• One test payable every 6 months
Venipuncture – blood sample or urine sample collection
• CPT 36415 – routine venipuncture
• If HIV blood screening performed, must also report code 36415
Modifiers
What are Modifiers?
Modifiers are two-digit (numeric or alpha numeric) codes that indicate that a procedure or service has been
altered by a specific circumstance, but has not changed the code’s definition
• There are CPT modifiers and HCPCS modifiers
• Some modifiers impact reimbursement
• Modifiers are never reported alone
• Each state Medicaid agency determines the approved modifiers
• Contact your local Medicaid agency for specific guidance
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Modifiers commonly reported with HIV Services
Modifier 25 - Significant, Separately, Identifiable E&M Service by Same MD on the Same Day of a
Procedure, Service or Other E&M Service
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Only report with E&M service codes (99201-99499)
Do NOT report with lab codes
Do NOT report with HCPCS codes
Contact your local Medicaid agency for specific guidance
Modifier 92 - Alternative Laboratory Platform Testing
With current CDC recommendations on routine testing and the move toward HIV testing as a routine part of
care, more providers may use rapid test kits. Several of these are CLIA-waived and suitable for use in
physician offices. The following is the CPT guidance for use of this modifier:
“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 modifier 92
to the usual laboratory procedure code (HIV testing 86701-86703).”
• Only report with Path/Lab test codes (86701-86703)
• Do NOT report on E&M codes
• Contact your local Medicaid agency for specific guidance
Modifier QW - CLIA waived test
In accordance with the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), a laboratory
provider must have: a Certificate of Compliance, a Certificate of Accreditation or a Certificate of
Registration in order to perform clinical diagnostic laboratory procedures of high or moderate complexity.
Waived tests include test systems cleared by the FDA designated as simple, have a low risk for error and are
approved for waiver under the CLIA criteria.
• Only report with Path/Lab test codes (86701-86703)
• Do NOT report on E&M codes
• If a combination of waived and non-waived tests are performed, modifier QW should not be used.
• Contact your local Medicaid agency for specific guidance
International Classification of Diseases
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ICD-9 codes developed by the World Health Organization in 1948
ICD-9-CM revised and published for use in 1979
CMS mandated the use of ICD-9-CM codes on all claims since October 1988
CMS revised these mandates to reflect “mandatory” correct reporting of ICD-9-CM codes on all claims
ICD-9-CM codes describe medical conditions, (diseases) and injuries and poisoning
Updated annually
Reported on all claim types (physician, institutional, pharmacy, DME, etc)
The ICD-9 Coding System was phased out October 1, 2015 and replaced with two new Coding Systems:
ICD-10-CM & ICD-10-PCS
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• The ICD-10 Coding System is consistent with changes in health care and provides more codes that reflect
emerging technology
• ICD-10-CM codes are used to report medical conditions
• ICD-10-PCS codes are reported on inpatient hospital (institutional) claims only to reflect the facility bill
• Continue reporting CPT & HCPCS codes for services rendered by physicians
• Continue reporting ICD-9-CM codes for services rendered through September 30, 2015
• Claims submitted with ICD-10 codes for services rendered now through September 30, 2015 will be denied
• Begin reporting ICD-10-CM codes for services rendered on or after October 1, 2015
• Claims submitted with ICD-9-CM codes for services rendered on or after October 1, 2015 will be denied
HIV/AIDS Diagnosis Coding
According to the ICD-10-CM coding guidelines, ICD-10-CM code B20 includes the following terms:
• Acquired immune deficiency syndrome;
• Acquired immunodeficiency syndrome;
• AIDS;
• AIDS-like syndrome;
• AIDS-related complex; and
• HIV infection, symptomatic
• HIV 1
Use additional code(s) to identify all manifestations of HIV
Use additional code to identify HIV-2 infection (B97.35)
EXCLUDES:
– asymptomatic HIV infection status (Z21)
– exposure to HIV virus (Z20.6)
– nonspecific serologic evidence of HIV (R75)
Report code B97.35 for Human immunodeficiency virus, type 2 [HIV-2]
“ICD-10-CM Official Coding Guidelines” Code Book Excerpts:
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) a. Human Immunodeficiency Virus (HIV)
Infections
2) Selection and sequencing of HIV codes
(d) Asymptomatic human immunodeficiency virus Z21, Asymptomatic human immunodeficiency
virus [HIV] infection status, is to be applied when the patient without any documentation of
symptoms is listed as being “HIV positive,” “known HIV,” “HIV test positive,” or similar
terminology. Do not use this code if the term “AIDS” is used or if the patient is treated for any
HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive
status; use B20 in these cases.
(f) Previously diagnosed HIV-related illness Patients with any known prior diagnosis of
an HIV-related illness should be coded to B20. Once a patient has developed an HIVrelated illness, the patient should always be assigned code B20 on every subsequent
admission/encounter. Patients previously diagnosed with any HIV illness (B20) should
never be assigned to R75 or Z21, Asymptomatic human immunodeficiency virus [HIV]
infection status.
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Inconclusive HIV Diagnosis Coding
• Newborn babies born to HIV+ mothers often have a diagnosis of HIV+ as a result of the mother’s antibody
status instead of the newborn
• The diagnosis of HIV+ in newborns lasts up to 18 months after without the newborn ever becoming infected.
This is known as a “False Positive” result
• Another term for “False Positive” is inconclusive HIV test results
• Inconclusive test results are reported with ICD-10-CM code R75
• People with healthy immune systems can be exposed to four (4) types of infections with no reaction: viral,
bacterial, fungal and parasitic
• People living with HIV/AIDS are not as fortunate
• HIV/AIDS related “opportunistic infections” take advantage of the weakened immune system resulting in
life threatening illnesses
• The most severe OI’s occur when the CD4 count is below 200 cells/mm3
• Patients diagnosed with any OI’s are no longer considered to be HIV+
The CDC has a comprehensive list of OI’s located on their web page.
Most common OI’s:
• Candidiasis (Thrush)
• Cytomegalovirus (CMV)
• Herpes simplex viruses (chronic)
• Kaposi Sarcoma
• Pneumocystis pneumonia (PCP)
• Mycobacterium avium complex (MAC or MAI)
• Toxoplasmosis (Toxo)
• Tuberculosis (TB)
• Recurrent severe bacterial pneumonia
• Wasting Syndrome
• Malaria
ICD-10-CM Code Tips
• Only confirmed cases of AIDS or HIV infection should be coded
• Chart documentation that states “possible”, “probably”, “rule out”, “suspected” or “suspicion of” are
never reported as AIDS (Dx B20)
• A diagnosis of HIV+ and asymptomatic HIV (Z21) is not the same as a diagnosis of HIV infection,
symptomatic HIV/AIDS and AIDS (B20)
• Patients may test positive for HIV but may not become sick for many years
• Once a diagnosis of HIV infection, symptomatic HIV/AIDS or AIDS is documented in the health record,
report ICD-9-CM code B20
• Symptomatic HIV (code Z21) and inconclusive HIV (code R75) are never reported once a patient has a
confirmed diagnosis of AIDS (code B20)
• Health record documentation which states that the patient has:
– HIV+, has not been diagnosed with an HIV-related illness (past or present), they are considered to be
asymptomatic; assign code is Z21
– HIV asymptomatic but is currently being treated for any HIV-related illness or is described as having
any condition(s) resulting from HIV+ status; assign code B20
– HIV 2 infection; assign code B20 and code B97.35
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– Inconclusive or nonspecific HIV test results; assign code R75
– Exposure to or contact with someone who has HIV/AIDS; assign code Z20.6 (note that this code is
reported as an SDX; never as the PDx)
– Engaged in unsafe sex practices that increases their risk; assign code Z72.89
– Present for a well visit encounter that includes HIV testing and counseling; assign codes Z00.00/Z00.01
and Z71.7
• Present for HIV testing and counseling; assign codes Z11.4 and Z71.7
• Once medical record documentation states any of the common OI’s, assign ICD-9-CM code B20 as the
principal diagnosis and the OI condition as the secondary diagnosis.
• Some opportunistic infections (OI’s), are inherent to HIV, such as pneumocystis carinii pneumonia (B59)
and Kaposi’s sarcoma (C46.-)
ICD-10-CM Code Sequencing
• When it is necessary to report multiple diagnoses codes, accurate interpretation of coding guidelines
ensures proper code sequencing
• Coding guidelines that denote “principle diagnosis” vs “secondary diagnosis” only, must be adhered to
• OI infections codes are always assigned as the secondary diagnoses (when reported)
• The HIV-2 code is always assigned as the secondary diagnosis code (when reported)
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Modifiers
E&M
MODIFIER
25
NARRATIVE DESCRIPTION
Significant, separately, identifiable E&M service by same MD on same day as another
procedure/service
MODIFIERS
QW
92
NARRATIVE DESCRIPTION
CLIA waived test
Alternative laboratory platform testing
E&M CPT Codes
E&M CPT
CODES
99201-99205
NARRATIVE DESCRIPTION
OFFICE/OUTPATIENT VISITS - NEW PATIENT:
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99211-99215
OFFICE/OUTPATIENT VISITS - ESTABLISHED PATIENT:
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99381-99387
99391-99397
99401-99404
99201 – Level 1
99202 – Level 2
99203 – Level 3
99204 – Level 4
99205 – Level 5
99211 – Level 1
99212 – Level 2
99213 – Level 3
99214 – Level 4
99215 – Level 5
INITIAL PREVENTIVE/WELL VISITS - NEW PATIENT:
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99381 - Age Younger Than 1 Year
99382 - Early Childhood (Age 1 to 4 Years)
99383 - Late Childhood (Age 5 to 11 Years)
99384 - Adolescent (Age 12 to 17 Years)
99385 - Early Adult (Age 18 to 39 Years)
99386 - Adult (Age 40 to 64 Years)
99387 - Late Adult (65 Years of age and older)

FOLLOW UP PREVENTIVE/WELL VISITS - ESTABLISHED PATIENT:






99391 - Age Younger Than 1 Year
99392 - Early Childhood (Age 1 to 4 Years)
99393 - Late Childhood (Age 5 to 11 Years)
99394 - Adolescent (Age 12 to 17 Years)
99395 - Early Adult (Age 18 to 39 Years)
99396 - Adult (Age 40 to 64 Years)
99397- Late Adult (65 Years of age and older)

PREVENTIVE MEDICINE COUNSELING AND/OR RISK FACTOR
REDUCTION (WITHOUT HISTORY AND PHYSICAL EXAM) PROVIDED TO
AN INDIVIDUAL:




Approximately 15 minutes
Approximately 30 minutes
Approximately 45 minutes
Approximately 60 minutes
NOTE: Well/preventive visit services are comprehensive in nature and include counseling and anticipatory
guidance. These services can be reported by physicians and other qualified physician practitioners (i.e. Nurse
Practitioners, Physician Assistants). Refer to page#10 for preventive services documentation requirements.
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HIV/AIDS ICD-10-CM CODES
ICD-9-CM
CODES
V08
V01.79
V69.2
V65.44
042
079.53
795.71
V69.8
V73.89
NARRATIVE DESCRIPTION
Asymptomatic HIV
Includes:
 HIV+
 HIV+ status
Exposure to HIV/AIDS
Includes:
 Pre-exposure to HIV/AIDS
High risk sexual behavior
HIV Counseling
HIV Disease
Includes:
 AIDS
 AIDS like syndrome
 AIDS related complex (ARC)
 Symptomatic HIV infection
 HIV 1
HIV 2
Report as secondary diagnosis code ONLY (when
applicable)
Nonspecific Evidence of HIV
Includes:
 Inconclusive HIV test
 False positive results
 False +
Other Problems Related to Lifestyle
Includes:
 Asymptomatic high risk
Report as secondary diagnosis code (when applicable)
Special Screening for Other Specified Viral Diseases
Includes:
 HIV/AIDS
ICD-10-CM
CODES
Z21
Z20.6
Z72.51-Z72.53
Z71.7
B20
B97.35
R75
Z72.89
Z11.4
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AIDS RELATED CONDITION ICD-10-CM CODES
ICD-9-CM
CODES
112.84
112.4
112.0
078.5
054.9
176.0-176.9
031.2
136.3
130.0
011.90
482.9
348.30
799.40
NARRATIVE DESCRIPTION
Candidiasis - Esophageal
Candidiasis – Lungs, Bronchi & Trachea (Pulmonary)
Candidiasis – Oral
 Thrush
Cytomeglavirus
Herpes Simplex Virus – Chronic
 HSV
Kaposi Sarcoma
Mycobacterium avium complex or M. kansasii, disseminated or
Extrapulmonary
 DMAC, MAC, MAI
Pneumocystis pneumonia
 PCP
Toxoplasmosis of brain
Pulmonary TB
Bacterial Pneumonia
 Bacterial PNA
HIV related Encephalopathy
Wasting Syndrome
 Cachexia
ICD-10-CM
CODES
B37.81
B37.1
B37.0
B25.0-B25.9
B00.9
C46.0-C46.9
A31.2
B59
B58.2
A15.0
J15.9
G93.40-G93.49
R64
NEW ICD-10-CM CODE CHANGES
Some codes now require the following 7th character values:
Injury, Poisoning and Certain Other Consequences of External Causes
Diseases of the musculoskeletal system (pathological fractures)
7th Digit
Description
Coding Guidelines
Initial Encounter (for active treatment)
Patient receiving active treatment i.e. surgery, ED,
A
D
S
Subsequent encounter (routine follow up
once active treatment completed)
Sequela (new condition develops as a
result of previous injury or condition)
Physician clinic/Office visit
Patient completes active treatment and presents for
routine follow
Patient follow up for sequale or residual effect
ACCIDENTAL FINGERSTICK ICD-10-CM CODES
ICD-9-CM
CODES
E920.5 –
accident caused
by hypodermic
needle
(needlestick)
ICD-10 NARRATIVE DESCRIPTION
(Report as secondary diagnosis code ONLY)
Contact with hypodermic needle, initial encounter
Contact with hypodermic needle, subsequent encounter
Contact with hypodermic needle, sequela
Contact with contaminated hypodermic needle, initial encounter
Contact with contaminated hypodermic needle, subsequent
encounter
Contact with contaminated hypodermic needle, sequela
ICD-10-CM
CODES
W46.0xxA
W46.0xxD
W46.0xxS
W46.1xxA
W46.1xxD
W46.1xxS
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HIV/AIDS SCREENING SERVICE CODES
CPT CODES
36415
NARRATIVE DESCRIPTION
CPT/HCPCS CODES
*86701
*G0435
*86702
*86703
86689
CPT/HCPCS CODES
87389
G0432
87390
87391
G0433
87534
87535
87536
87537
87538
87539
Venipuncture
Includes:
 Includes collection of blood by venipuncture
 Routine venipuncture
 Phlebotomy
NARRATIVE DESCRIPTION (ANTIBODY)
HIV 1; single result
HIV 1 and/or HIV 2; single result
HIV 2, single result
HIV 1 & HIV 2; single result
HIV confirmatory (Western Blot)
NARRATIVE DESCRIPTION (ANTIGEN)
EIA HIV 1 antibody with HIV 1 & HIV2 antigens; qualitative or semiquantitative; single step
EIA; HIV 1 and/or HIV 2
EIA HIV 1; qualitative or semi-quantitative; multi-step
EIA HIV 2; qualitative or semi-quantitative; multi-step
ELISA; HIV 1 and/or HIV 2
DNA/RNA; HIV 1; direct probe
DNA/RNA; HIV 1; amplified probe
DNA/RNA; HIV 1; quantification
DNA/RNA; HIV 2; direct probe
DNA/RNA; HIV 2; amplified probe
DNA/RNA; HIV 2 quantification
NOTE:
* Describes Quick /Rapid HIV Test performed in an office or clinic setting. Must possess a valid CLIA Certificate of
Waiver issued by CMS and you must append modifier QW to CPT code 87880. Please go to CMS’ website for a list of CLIA
waived tests that require a CLIA Certificate.
All other codes can only be reported by an Internist, Family Practitioner, etc if you possess a valid CLIA license.
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WELL VISIT ICD-10-CM CODES
ICD-9-CM
CODES
NARRATIVE DESCRIPTION
ICD-10-CM
CODES
V20.2
Routine infant, child or adolescent checkup/exam – Ages 29 days to – 17 years old
V20.31
V20.32
V70.0
V70.3
Routine newborn checkup/exam – Newborn 0 to 7 days old
Routine newborn checkup/exam – Newborn 8 days to 28 days old
Routine adolescent or adult checkup/exam – Ages 18 years and older
General medical exam for:
 Camp
 School admission
 Sports competition
General exam for pre-school age children
Health examination in population surveys
Other specified general medical examinations
Unspecified general medical examination
V70.5
V70.6
V70.8
V70.9
Z00.121,
Z00.129
Z00.110
Z00.111
Z00.00-Z00.01
Z02.0, Z02.2,
Z02.4-Z02.6,
Z02.82, Z02.89
Z00.6, Z00.8
Z00.8
Z02.9
NOTE: When assigning any ICD-10-CM codes from category Z00.- as the principal diagnosis code, an
additional code may be required (as a secondary diagnosis code) to identify special screening examinations for:










Viral and chlamydial diseases
Bacterial and spirochetal diseases
Other specified infectious diseases
Malignant neoplasms/cancer conditions
Endocrine, nutritional, metabolic & immunity disorders
Blood & blood forming organs
Mental disorders and developmental handicaps
Neurologic, eye and ear diseases
Cardiovascular, respiratory, and genitourinary diseases
Other conditions
MISCELLANEOUS VISIT CODES
ICD-9-CM
CODES
V15.81
V58.61-V58.67
V58.69
*V68.1
NARRATIVE DESCRIPTION
ICD-10-CM CODES
Noncompliance with medical treatment

Against medical advice
Long term (current) use of medication
Long term (current) use of other specified medication such as:

High risk medication

Methadone

Opiate analgesic
Prescription refill
Z91.11, Z91.120- Z91.128,
Z91.130- Z91.138, Z91.14, Z91.19
Z79.01-Z79.899
Z79.891

Z76.0
NOTE:
Disclaimer: Please refer to the latest coding reference books to verify all codes contained in this packet. Where applicable,
some ICD-10-CM codes must be assigned to the highest level of specificity (7th character designation). CPT codes and some
HCPCS codes may require add-on codes to accurately report services rendered. Reporting services with invalid codes could
result in payment denial or delay in payment.
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Coding Resources
•
CPT® 2016 Professional Edition. Publisher: American Medical Association.
•
Pocket Guide to E&M Coding and Documentation. Publisher: Healthcare Quality
Consultants.
•
HCPCS Level II 2016. Publisher: Ingenix Optum.
•
ICD-9-CM, Volumes 1 & 2, Professional. Publisher: Ingenix Optum.
•
ICD-10-CM and ICD-10-PCS Coding Handbook 2016, Nelly Leon-Chisen, RHIA.
Publisher: American Hospital Association.
•
ICD-10-CM Fast Finder Sheets. Publisher: Ingenix Optum.
Note: Coding resources are updated annually. Please be sure to update coding resources each year.
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WEB RESOURCES
•
Centers for Medicare and Medicaid Services (CMS) –
http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html
http://www.cms.gov/center/coverage.asp
•
Food and Drug Administration (FDA) –
http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDRegulatoryAssista
nce/default.htm
•
American Medical Association (AMA) –
http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-yourpractice/coding-billing-insurance/cpt.page
•
National Center for Health Statistics (NCHS)
http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html
•
Centers for Disease Control (CDC)
http://www.cdc.gov/mmwr/index.html
•
American Academy of Professional Coders (AAPC)
http://www.aapc.com/resources/index.aspx
•
American Health Information Management Association (AHIMA)
http://www.ahima.org/resources/default.aspx
•
The American Academy of Family Physicians (AAFP) www.aafp.org/online/en/home/practicemgt/codingresources.html
•
American Hospital Association (AHA)
http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml
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State Medicaid Agencies
The following is a list of Medicaid Agencies for the United States and the surrounding territories.
Complete mailing address, telephone number, fax number, email address and web page information is
available for your convenience. To access the web page, click on Contact the STATE NAME HERE
Department of Health hyperlink. To narrow your search, type any of the following to:
Medicaid Billing
Provider Billing
HIV Coding Guidelines
State Health Departments
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Territorial Health Departments
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
U.S. Virgin Islands
REVISED 02/11/2016
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National Center
for Health Care
Capacity Building
Syncing Innovative Approaches with Successful Outcomes
E-mail: [email protected]
Telephone: 202.232.6749
Fax: 202.232.6750
Website: www.HealthHIV.org
@HealthHIV
www.Facebook.com/HealthHIV
http://www.YouTube.com/HealthHIV
http://tinyurl.com/HealthHIVLinked