The Food and Drug Administration (FDA) Vaccines, and Related Biologic Products Advisory Committee selected vaccine strains for the 2022–2023 influenza vaccine. Also, the World Health Organization recommended the Northern Hemisphere as the basis for the 2022-2023 influenza vaccine composition.
Billing/Reporting Influenza Vaccines for Medicaid Beneficiaries
Depending on the age of the beneficiaries and vaccine formulation, the vaccine codes listed below may either be reported (with no charge) or billed (with a charge as usual and customary). The tables also show the administration codes that may be billed, depending on the beneficiaries’ age and vaccine(s) provided to them.
Vaccine CPT Codes to Report
Source: North Carolina Department of Health and Human Services (NCDDHS).
Table 1. A list of influenza billing codes for Medicaid beneficiaries under 19 years of age who receive the VFC influenza vaccine. The reporting of these codes results in a 0.00 dollar amount.
Providers should use the NDC on the actual vial used for administration listed at the bottom of this bulletin when processing claims.
Important Note: In the Health Check Billing Guide, you can find specific information about billing immunization administration codes for Health Check beneficiaries.
Source: North Carolina Department of Health and Human Services (NCDDHS)
Table 2: Influenza Billing Codes for Medicaid Beneficiaries 19 to 21 Years of Age
Providers should use the following codes to bill for influenza vaccines purchased and administered for Medicaid beneficiaries between the ages of 19 and 21.
Important Note: The VFC/NCIP provides influenza vaccines only to recipients between the ages of six months and 18 years old. However, those 19 years and older will not receive the influenza vaccine.
Vaccine CPT Codes to Report
Source: North Carolina Department of Health and Human Services (NCDDHS)
Administrative CPT Codes to Report
Source: North Carolina Department of Health and Human Services (NCDDHS)
Table 3: Influenza Billing Codes for Medicaid Beneficiaries 21 Years of Age and Older
The administrative CPT code 90472 will only be used if another vaccine is also administered along with the influenza vaccine. Moreover, it’s possible for providers to bill 90472 in more than one unit, if necessary.
In the event that beneficiaries 21 years of age and older purchase or receive an influenza vaccine, providers should use the following codes to bill Medicaid.
Important Note: Only VFC-age beneficiaries (6 months through 18 years of age) are eligible for influenza products under the VFC/NCIP. However, those 19 years and older will not receive the influenza vaccine.
Vaccine CPT Code to Report
Source: North Carolina Department of Health and Human Services (NCDDHS)
The administrative CPT code 90472 will only be used if another vaccine is also administered along with the influenza vaccine. Moreover, it’s possible for providers to bill 90472 in more than one unit, if necessary.
For beneficiaries 21 years or older receiving an influenza vaccine, an evaluation and management (E/M) code cannot be reimbursed to any provider on the same day that injection administration fee codes (e.g., 90471 or 90471 and +90472) are reimbursed.
Any healthcare provider cannot reimburse an evaluation and management (E/M) code for beneficiaries 21 years and older who are receiving influenza vaccinations on the same day as injection administration fee codes (e.g., 90471 and +90472). For billing a separately identifiable service, the provider must add modifier 25 to the E/M code.
Flu Vaccination Coding and Billing for 2022-2023
As shown in Table A, Medicare Part B payment allowances increased slightly for the 2022-2023 flu season.
Table A: Comparison of CPT® code and Medicare Part B payment allowances for 2021-2022 and 2022—2023 flu seasons
Medicare Part B payment allowances are 95 percent of the average wholesale price (AWP) for influenza vaccines, except in cases where vaccines are provided in outpatient departments of hospitals, rural health clinics, or Federally Qualified Health Centers.
Important Note: In one calendar year, Medicare patients can receive two fully-covered flu vaccinations due to the annual flu season that runs from Aug. 1 to July 31.
When a patient receives a flu shot on Jan. 5, 2022, and again on Aug. 29, 2022, Medicare will pay for both vaccinations.
As usual, vaccinations against the influenza virus do not apply toward the annual Part B deductible or coinsurance amounts.
In accordance with Medicare guidelines, providers must report ICD-10-CM code Z23 Encounter for immunization together with administration code G0008 Administration of influenza virus vaccine.
Important Safety Information for Physicians Administering Flu Vaccines
It is not recommended to administer Fluzone Quadrivalent, Flublok Quadrivalent, or Fluzone High-Dose Quadrivalent to anyone who has had a severe allergic reaction (e.g., anaphylaxis) to any component of the vaccines (including egg protein for Fluzone Quadrivalent and Fluzone High-Dose Quadrivalent) or after a previous dose.
It is also not recommended to administer Fluzone Quadrivalent or Fluzone High-Dose Quadrivalent to anyone who has had an allergic reaction to any influenza vaccine in the past.
The Fluzone Quadrivalent injection site reactions in pain, tenderness, erythema, and swelling in children 6 months to 35 months of age. Acute injection-site reactions (pain, erythema, and swelling) are the most common in children 3 years through 8 years of age. Systemic adverse reactions include myalgia, malaise, and headaches. The most common solicited systemic adverse reactions in adults 18 years, and older were myalgia, headache, and malaise.
There was a higher frequency of pain at the injection site in adults 65 years of age and older, as well as headache, malaise, and myalgia in systemic adverse reactions to Fluzone High-Dose Quadrivalent.
It is possible that other adverse reactions will occur with Fluzone Quadrivalent, Flublok Quadrivalent, and Fluzone High-Dose Quadrivalent.
Using this article as a guide, we hope you will be able to administer flu vaccination codes more easily. For more information, you can also refer to this source.
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The American Academy of Family Physicians (AAFP) encourages safe, secure online interactions between physicians and patients, such as electronic visits or “virtual e-visits.” In non-emergency situations, e-visits can substitute for office visits with primary care providers. It is a fast and easy online procedure for patients to receive a diagnosis and treatment plan.
This article will give you the best guide to e-visit documentation, coding, and billing.
What Should Providers Know About E-visits?
An encounter must meet the following criteria to be considered an e-visit:
The practice must have a well-established relationship with its patients.
E-visits require patient consent and a communication request.
The patient must initiate non-face-to-face electronic communication. For example, patient portal systems.
Patients must not have seen an office visit to a physician or therapist for the same clinical concern in the past seven days.
It is only possible to report e-visits every seven days.
An e-visit is not the same as typical therapy sessions.
For e-visits, the following documentation requirements are needed:
The main complaint with all evaluation and management services (E/M).
The specifics of treatments, assessment of diagnoses or symptoms, evaluation, and conversation.
An official patient consent record is backed up by a signature and captured in the clinical note. Moreover, e-visit software platforms accept scanned copies of signed consents. Some systems allow electronic signatures.
The total time recorded over the seven days supporting the billable service.
List of Current Procedural Terminology (CPT) Codes That Require Providers to Follow Policies Set by Payers
The codes for online digital evaluation services (e-visits) used by doctors are complex. Below are the codes used:
Medicare uses the following HCPCS codes and descriptors for qualified non-physician professionals for its online digital evaluation service (e-visit):
Private payers and workers’ compensation are using the following online digital evaluation service (e-visit) CPT codes and descriptors:
Do’s and Don’ts in Billing E-Visits
When the following conditions are met, you can bill an e-visit:
The provider establishes a relationship with the patient.
Response time by the provider is longer than five minutes.
A provider responds through the patient portal to a message initiated by the patient.
A visit meets the 2021 E/M guidelines.
It has been seven days since the clinician last saw the patient.
There is no global period for the same or similar condition for the patient.
In this case, the provider is making a clinical decision that would normally be performed in the office (e.g., medication dose adjustment, ordering a test, or prescribing a new medication).
A patient has consented to the e-visit and understands that he may be billed.
For online digital E/M services, the service period includes all related work done within seven days by the reporting individual and other registered healthcare providers (RHPs) in the same group practice.
The 7-day period begins when the reporting provider reviews the patient’s inquiry personally for the first time.
A new/unrelated problem from the patient arises within seven days of the previous E/M visit for a different issue.
Do not bill an E-visit in the following situations:
During the 7-day period, the provider may bill for other separately reported services (such as care management, INR monitoring, remote monitoring, etc.)
The same or similar condition was billed to the patient for an e-visit within the past 7 days.
The patient inquires about a surgical procedure that happens during the surgery’s postoperative period (global).
Providers are simply disseminating results, processing medication requests, or scheduling appointments (for billing, E/M services must be performed).
A separate face-to-face E/M service (either in person or via telehealth) happens (included in the E/M) during the 7-day period of the e-visit.
Besides clinical staff time, only provider time can be included.
The AAFP published an algorithm in response to the growing number of virtual visits. It was developed by James Dom Dera, MD, FAAFP, to determine which code should be used for virtual services.
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Many things have changed in the healthcare industry since the emergence of COVID-19 (2019-Novel Coronavirus). Besides straining medical supplies and personnel, it also sped up the process of producing and publishing coding guidelines.
This blog article provides a guide to 2022 coding and billing updates for COVID-19 services and testing.
When to use the cs modifier for COVID-19?
We use modifier CS on visits related to testing for COVID-19. The latest COVID-19 billing guidelines also state that physicians can apply it to two contexts relating to coding and billing.
The visit could be virtual or in-person for suspected or probable exposure to COVID-19.
Tests for diagnosing COVID-19 without including a COVID-19 test
Let’s examine each case individually.
Suspected or Probable Exposure to COVID-19
When billing for virtual/in-person for suspected COVID-19 exposure, you typically use the following E/M codes:
ICD-10 codes Z03.818, Z20.822, and Z20.828
Modifier CS
If the patient is receiving virtual care, append the modifier GQ, GT, or 95
Modifier CS can also apply for these services:
If the result of the service involves the order for or the administration of a COVID-19 test
If the service relates to delivering or administering tests
If the purpose of the service is to evaluate and determine if the patient needs COVID-19 testing
The cost-share will be waived through April 20th, 2021. Thus, providers need to understand that the cost-share will be waived only when they bill the correct ICD-10 code and modifier CS.
What is Modifier CR?
It indicates whether Medicare payment for a service is subject to the Centers for Medicare & Medicaid Services (CMS) approval. As a reminder, the CMS has informed us that the CR modifier does not apply to claims recently added to the CMS list of services that may be provided by telehealth.
It is also possible to bill modifier CR or condition code DR in place of modifier CS. Also, a customer cost-share will apply to services unrelated to COVID-19.
Tests for Diagnosing COVID-19
These are the common codes used for tests relating to COVID-19:
ICD-10 codes Z03.818, Z20.822, or Z20.828
Modifier CS
These codes are used for laboratory tests in cases where COVID-19 may be suspected. These tests must be reasonable practices to rule out the presence of COVID-19.
Only the code for the panel test will be reimbursed if the COVID-19-related test is part of the laboratory panel code.
If the test is not part of a laboratory panel but rather part of a series of pathogen tests, the relevant unbundling edits may be applicable.
Source: Journal of Ahima, 2021
Monoclonal Antibody Treatment Administration for Commercial Health Plans
This billing guidance applies only to urgent care facilities with an all-inclusive rate per case, per diem, per visit, and per unit.
We are following the place of service testing and case rate guidelines per the Centers for Medicare & Medicaid Services (CMS).
An in-network urgent care center must bill with the place of service 20 on a CMS-1500 form
Accordingly, we will pay 100% of the CMS allowable rate for the codes below.
Service: COVID-19 Testing at Urgent Care Facilities
Through the end of the Public Health Emergency (PHE), COVID-19 testing at urgent care facilities will be reimbursed if billed with a COVID-19 procedure code along with one of the appropriate Z codes (Z20.828, Z03.818, and Z20.822). Whenever a health care professional bills a visit code on the same date of service as a COVID-19 testing code, the assigned medical practice will deny the testing code with remark Code: I4.
COVID-19 vaccine administration at urgent care facilities
*0001A *0002A *0003A *0011A *0012A *0013A
Through the end of the public health emergency, COVID-19 vaccine administration will be reimbursed for in-network health care professionals if billed with the appropriate codes. Whenever a health care professional bills a visit code on the same date of service as a COVID-19 vaccine code claim for the same patient, the assigned medical practice will deny the vaccine code.
*These codes will price at $0 because of funds provided by the government. Whenever a health care professional bills a visit code on the same date of service as a COVID-19 monoclonal antibody treatment claim for the same patient, the assigned medical practice will deny the vaccine code.
Newly Added Vaccine and Administration CPT Codes 2022
CPT Code
Description
0074A
Administration, booster dose
91309
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use (Report 91309 with administration code 0094A) (Do not report 91309 in conjunction with administration codes 0011A, 0012A, 0013A, 0064A) Moderna
0094A
Administration, booster dose
91310
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, monovalent, preservative free, 5 mcg/0.5 mL dosage, adjuvant AS03 emulsion, for intramuscular use (Sanofi Pasteur)(Report 91310 with administration code 0104A)
0104A
Administration, booster dose
New Guidelines for Outpatient Services Under COVID-19 Cost Share Waiver
Use the CS modifier on appropriate outpatient claim lines for services provided through the end of the Public Health Emergency (PHE). This illustrates that the service is eligible for a cost-share waiver for COVID-19 testing-related services contracted for and related to the provision or administration of a COVID-19 test.
Providers will receive a waiver of cost-share when they:
Submitting a claim line with CS modifier (professional, facility, telehealth) with a specific outpatient E&M or HCPCS code and when billed of probable or suspected exposure to COVID-19: ICD Z20.822 as the primary diagnosis, as needed.
Submits a COVID-19 CPT/HCPCS claim line testing for preoperative procedures.
For each additional lab test other than the COVID-19 diagnostic test, a CS modifier must be added to each claim line. If the lab test was ordered specifically to determine a diagnosis of COVID-19 and if billed with probable or suspected exposure to COVID-19, a primary diagnosis of Z20.822 should be put forth.
For
Billing Guidelines
Dates of service on or after March 1, 2020, and for the duration of the PHE
Effective January 1, 2022
The POS 02 description was revised and a new code, POS 10, was developed. The place of service billed is dependent on where the patient is located during the telehealth service. When billing for telehealth services, use:
POS 02: Telehealth Provided Other than in Patient’s Home Patients are not located in their homes when they receive health services or related services via telecommunication.
POS 10: Telehealth Provided in Patient’s Home In the case of receiving health services or health-related services via telecommunication, the patient is located at home (other than a hospital or other facility where they receive care in a private residence).
We hope that this guide to COVID-19 updates in coding and billing for 2022 has been useful to you. Visit the American Medical Association (AMA) for more information on COVID-19 codes, services, and vaccine updates.
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The ability to understand medical terminology has always been an essential requirement for medical coders. To better understand the language of the new codes, they should review anatomy and physiology terms.
Troubleshooting is another important recommendation for ICD-10-compatible software and computer formats. This knowledge will assist healthcare providers in resolving any technical problems in time. Thus, healthcare providers must be aware of the potential impact of coding system changes on existing and new insurance programs.
In this article, we’ll find out what to expect from new pain management coding updates and guidelines 2022.
Pain Management Coding Updates 2022
As of 2022, two CPT codes have been deleted and replaced with new ones that provide more detail about procedures.
01935—
(Anesthesia for percutaneous image guided procedures on the spine and spinal cord; diagnostic)
01936—
(Anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic) are deleted in CPT®2022.
Moreover, the new codes 01937-01942 identify the type of surgical procedure performed under anesthesia and whether it’s done on the cervical, thoracic or lumbar spines.
New CPT codes for 2022
In the table below, you can refer to the new CPT code changes for 2022 applicable to anesthesia and pain medicine:
01937—
Anesthesia for percutaneous image-guided injection, drainage, or aspiration procedures on the spine or spinal cord; cervical or thoracic
01938—
Anesthesia for percutaneous image-guided injection, drainage, or aspiration procedures on the spine or spinal cord; lumbar or sacral
01939—
Anesthesia for percutaneous image-guided destruction procedures by a neurolytic agent on the spine or spinal cord; cervical or thoracic
01940—
Anesthesia for percutaneous image-guided destruction procedures by a neurolytic agent on the spine or spinal cord; lumbar or sacral
01941—
Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic
01942—
Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral
64628—
Thermal destruction of the intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral
64629—
Thermal destruction of the intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure)
93319—
3D echocardiographic imaging and postprocessing during transesophageal echocardiography, or transthoracic echocardiography for congenital cardiac anomalies, for the assessment of cardiac structure(s) (eg, cardiac chambers and valves, left atrial appendage, interatrial septum, interventricular septum) and function, when performed (List separately in addition to code for echocardiographic imaging)
These codes and other information you need to know for coding/billing in 2022 are copyrighted by American Medical Association.
Likewise, we’ll discuss some other commonly used pain management CPT codes. These include acupuncture, dry needling, and radiofrequency ablation.
Acupuncture
In accordance with NCD 30.3.3, Medicare now covers all types of acupuncture as a treatment for lower back pain. Patients with chronic lower back pain can receive acupuncture treatment for up to 12 sessions within a 90-day period through Medicare.
The purpose of acupuncture is to relieve pain and restore energy flow by inserting tiny needles through the skin. According to the National Center for Complementary and Integrative Health Trusted Source, acupuncture effectively treats back pain, osteoarthritis, and knee pain. Furthermore, it stimulates the body’s natural healing processes and promotes health and happiness.
Acupuncture CPT Codes
97810—
Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97811—
Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles
97813—
Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814—
Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles
Acupuncture data is reported based on 15-minute increments of personal contact (face-to-face) with the patient, not on the intensity or duration of the acupuncture treatment.
When electrical stimulation is not used during a 15-minute increment, report CPT codes 97810 or 97811.
Electrical stimulation of any needle during a 15-minute increment are reported by using CPT codes 97813 or 97814.
For each 15-minute increment, you should report only one code
Use CPT code 97810 or 97813 for the initial 15-minute increment
Each day you should only report one initial code
Dry Needling
The following CPT codes are used for dry needling, which is also known as trigger point acupuncture.
20560—
(Needle insertion(s) without injection(s); 1 or 2 muscle(s)
20561—
(Needle insertion(s) without injection(s); 3 or more muscles)
20551—
Origin or insertion of a tendon is injected
20550—
Injection of the tendon sheath
The Current Procedural Terminology specifies that CPT codes 20552 or 20553 (trigger point injections) must not be reported with CPT codes 20560 or 20561 for the same muscle group.
Radiofrequency Ablation
The radiofrequency ablation (RFA) procedure involves delivering an electric current to a small nerve tissue area to prevent pain signals from being transmitted through that area. It can relieve chronic pain, specifically in the lower back, neck, and arthritic joints.
These are the RFA CPT codes 2022:
64625—
Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)
64999—
Unlisted procedure, nervous system
If radiofrequency ablation is used with traditional or cooled radiofrequency (80 degrees Celsius), report it with CPT code 64625.
Report pulsed radiofrequency ablation by using CPT code 64999.
CPT Code Changes for Important Diagnoses
C56.3 Malignant neoplasm of bilateral ovaries (previously only left, right, unspecified existed)
C79.63 Secondary malignant neoplasm of bilateral ovaries (previously only left, right, unspecified existed)
G44.86 Cervicogenic headache
K22.81 Esophageal polyp
K22.82 Esophagogastric junction polyp
K22.89 Other specified diseases of esophagus (previously codes as K22.8, 5th character added)
K31.A—Gastric intestinal metaplasia (code to appropriate 6th character)
L24.A- Irritant contact dermatitis due to friction or contact with body fluids (code to appropriate 5th character)
L24.B- Irritant contact dermatitis related to stoma or fistula (code to appropriate 5th character)
M54.A- Non-radiographic axial spondyloarthritis (code to appropriate 5th character)
M54.50 Low back pain, unspecified
M54.51 Vertebrogenic low back pain
M54.59 Other low back pain
Any ambulatory surgical centers performing pain management procedures need to be aware of these low back pain diagnosis changes. In order to avoid an unspecified diagnosis, surgeons must understand how the revisions affect their documentation. They must be as specific as possible about the type of low back pain treated.
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Medical coders might face some new challenges in light of the new pain management billing codes and guidelines. As a result, healthcare providers should evaluate how medical coding changes will affect their programs and take steps to ensure a smooth transition.
At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
Every year, the American Medical Association releases a new Current Procedural Terminology set that takes effect on January 1.
Most of this year’s changes come from new guidance language rather than code additions, deletions, or edits for podiatry practices. Let’s first define podiatry care in detail before moving on to the CPT updates.
The Role of Podiatry in Healthcare
The field of podiatry deals with the diagnosis and treatment of diseases, injuries, and deformities of the foot. It involves the diagnosis, medical, and surgical treatment of the foot, ankle, and lower extremity problems. In addition to medical and surgical treatments, mechanical and physical therapies are also available. Like other disciplines, podiatry requires regular collections to survive.
On the other hand, coding is complex in podiatry due to multiple procedures performed on the same structure or organ, requiring various codes.
The Current Procedural Terminology adds the following clarification for 2022: “All services that appear in the Musculoskeletal System section include the application and removal of the first cast, splint, or traction device when performed. Supplies may be reported separately.”
Several third-party payers, such as Medicare, have long followed this guidance, which applies everywhere CPT codes are used, regardless of the payer.
This guidance does not change based on where you receive your services. If the triple arthrodesis is performed in the operating room, the CPT code representing the cast application should not be submitted.
Similarly, suppose any fracture care code is submitted in an office setting, such as closed fracture treatment without manipulation. In that case, the CPT code corresponding to the cast application should not be submitted.
Podiatrists managing fractures often have to decide whether to perform closed treatment with manipulation or closed treatment without manipulation CPT codes.
The new language in the 2022 CPT code set clarifies what “manipulation” actually means when used in code descriptors in CPT. Manipulation is defined as: “reduction by the application of manually applied forces or traction to achieve satisfactory alignment of the fracture or dislocation.” Usually, this is referred to as closed reduction.
The CPT clarified the following codes for external fixation this year:
“Codes for external fixation are reported separately only when external fixation is not listed in the code descriptor as inherent to the procedure.”
Therefore, providers can only submit external fixation CPT codes. CPT does not include the application of external fixation in its code descriptor for the primary procedure.
Below is the CPT code corresponding to a first metatarsophalangeal joint arthrodesis:
CPT 28750—Arthrodesis, great toe; metatarsophalangeal joint
Code descriptor doesn’t include external fixation in the list. Hence, the CPT code for the first metatarsophalangeal joint arthrodesis and the CPT code for the external fixation can both be submitted if external fixation is used.
In the case of an open reduction and internal fixation (ORIF) of a metatarsal fracture that is fixed with external fixation, the CPT code for the external fixation would be:
CPT 28485—Open treatment of metatarsal fracture, with or without internal or external fixation, each
This is listed in the code descriptor. Thus, if external fixation is used with this procedure, only the ORIF CPT code can be submitted; the external fixation CPT code cannot be submitted as well.
Foreign Body vs Implant
If a joint prosthesis becomes loose or isn’t functioning, is it considered a foreign body removal? The CPT clearly answers this question that has been asked for a while now.
According to the new language on page 525 of the CPT book for 2022, it states that:
“An object intentionally placed by a physician or other qualified health care professional for any purpose (eg, diagnostic or therapeutic) is considered an implant.”
“An object that is unintentionally placed (eg, trauma or ingestion) is considered a foreign body.”
“If an implant (or part thereof) has moved from its original position or is structurally broken and no longer serves its intended purpose or presents a hazard to the patient, it qualifies as a foreign body for coding purposes, unless CPT coding instructions direct otherwise or a specific CPT code exists to describe the removal of that broken/moved implant.”
Wound Repair
This year, a new language adds that only one CPT code is required to represent the closure of one wound when multiple products and/or multiple techniques are used to close it.
Further information on wound repair is provided in the 2022 CPT book, on page 106, where it is stated that wounds treated with chemical cauterization, electrocauterization, or adhesive strips cannot be coded with wound repair CPT codes.
Clarification of simple wound repair is on the list this year:
“Simple repair is used when the wound is superficial (eg, involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures) and requires simple one-layer closure.”
Moreover, anesthesia and hemostasis should not be reported separately when combined to treat simple wounds.
Key Takeaway
These are just a few changes relevant to podiatrist practices in 2022’s CPT codes. The podiatry providers who submit CPT codes should know the entire CPT code set or use experts who are familiar with it. From January 1, 2022, they should utilize the most current CPT code set.
The CPT is a trademark of and copyright (2021) of the American Medical Association, with all rights reserved.
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As fall approaches, not only do the leaves change but healthcare practices should also be prepared for ICD-10 changes, which take effect every October 1. The Big Question: Is Your Practice Already Prepared for the New ICD-10 2022 Guidelines? Worry no more! With this article, you can adhere to the New ICD-10 Coding Guidelines FY 2022.
So, what are ICD-10 Guidelines?
In every healthcare setting, ICD-10-CM guidelines are used to classify diagnoses, morbidities, and reasons for patient visits. Healthcare providers and coders must use these guidelines and reporting requirements as companion documents to the official version of the ICD-10-CM. ICD-10-CM and the ICD-10 code set under the new guidelines, including new, revised, and retired codes, are updated. Also, the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) implement the newly updated International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), and the ICD-10 code set. A total of 72,748 codes are available this year including 159 new codes, 32 deleted codes, and 20 revised codes.
New Codes for COVID-19 Infection
New codes are available for FY 2022 to report conditions secondary to COVID-19 infection (sequelae):
J12.82: Pneumonia due to Coronavirus disease 2019 (MCC)
M35.81: Multisystem inflammatory syndrome (CC)
M35.89: Other specified system involvement of connective tissue (CC)
Z11.52: Encounter for screening for COVID-19
Z20.822: Contact with and (suspected) exposure to COVID-19
Z86.16: Personal history of COVID-19
Below is the latest code in a series of six codes added on January 1, 2021:
U09.9: Post COVID-19 condition, unspecified
New codes for conditions affecting the nervous system
The ICD-10 now includes 10 new codes in this category, with many of them classified as MCC or CC codes (please see above). Some of these new codes include:
ICD-10-CM coding guideline changes for 2022 include a number of corrections to spelling errors, as well as significant changes to diseases and conditions. Code additions and deletions are also major areas of change. The table below is a high-level breakdown of additions and deletions to the ICD-10-CM coding guidelines for 2022.
Chapter
Action
2022 Codes
2022 Code Descriptions
1
New Code
A79.82
Anaplasmosis [A. phagocytophilum]
2
New Code
C56.3
Malignant neoplasm of bilateral ovaries
2
New Code
C79.63
Secondary malignant neoplasm of bilateral ovaries
2
New Code
C84.7A
Anaplastic large cell lymphoma, ALK-negative, breast
3
New Code
D55.21
Anemia due to pyruvate kinase deficiency
3
New Code
D55.29
Anemia due to other disorders of glycolytic enzymes
Sjögren syndrome with peripheral nervous system involvement
13
New Code
M35.07
Sjögren syndrome with central nervous system involvement
13
New Code
M35.08
Sjögren syndrome with gastrointestinal involvement
13
New Code
M35.0A
Sjögren syndrome with glomerular disease
13
New Code
M35.0B
Sjögren syndrome with vasculitis
13
New Code
M35.0C
>Sjögren syndrome with dental involvement
13
New Code
M45.A
Non-radiographic axial spondyloarthritis
13
New Code
M45.A0
Non-radiographic axial spondyloarthritis of unspecified sites in spine
13
New Code
M45.A1
Non-radiographic axial spondyloarthritis of occipito-atlanto-axial region
13
New Code
M45.A2
Non-radiographic axial spondyloarthritis of cervical region
13
New Code
M45.A3
Non-radiographic axial spondyloarthritis of cervicothoracic region
13
New Code
M45.A4
Non-radiographic axial spondyloarthritis of thoracic region
13
New Code
M45.A5
Non-radiographic axial spondyloarthritis of thoracolumbar region
13
New Code
M45.A6
Non-radiographic axial spondyloarthritis of lumbar region
13
New Code
M45.A7
Non-radiographic axial spondyloarthritis of lumbosacral region
13
New Code
M45.A8
Non-radiographic axial spondyloarthritis of sacral and sacrococcygeal region
13
New Code
M45.AB
Non-radiographic axial spondyloarthritis of multiple sites in spine
13
New Code
M54.50
Low back pain, unspecified
13
New Code
M54.51
Vertebrogenic low back pain
13
New Code
M54.59
M54.59
16
New Code
P00.82
Newborn affected by (positive) maternal group B streptococcus (GBS) colonization
16
New Code
P09.1
Abnormal findings on neonatal screening for inborn errors of metabolism
16
New Code
P09.2
Abnormal findings on neonatal screening for congenital endocrine disease
16
New Code
P09.3
Abnormal findings on neonatal screening for congenital hematologic disorders
16
New Code
P09.4
Abnormal findings on neonatal screening for cystic fibrosis
16
New Code
P09.5
Abnormal findings on neonatal screening for critical congenital heart disease
16
New Code
P09.6
Abnormal findings on neonatal screening for neonatal hearing loss
16
New Code
P09.8
Other abnormal findings on neonatal screening
16
New Code
P09.9
Abnormal findings on neonatal screening, unspecified
18
New Code
R05.1
Acute cough
18
New Code
R05.2
Subacute cough
18
New Code
R05.3
Chronic cough
18
New Code
R05.4
Cough syncope
18
New Code
R05.8
Other specified cough
18
New Code
R05.9
Cough, unspecified
18
New Code
R35.81
Nocturnal polyuria
18
New Code
R35.89
Other polyuria
18
New Code
R45.88
Nonsuicidal self-harm
18
New Code
R63.30
Feeding difficulties, unspecified
18
New Code
R63.31
Pediatric feeding disorder, acute
18
New Code
R63.32
Pediatric feeding disorder, chronic
18
New Code
R63.39
Other feeding difficulties
18
New Code
R79.83
Abnormal findings of blood amino-acid level
19
New Code
S06.A
Traumatic brain compression and herniation
19
New Code
S06.A0
Traumatic brain compression without herniation
19
New Code
S06.A1
Traumatic brain compression with herniation
19
New Code
T40.71
Poisoning by, adverse effect of and underdosing of cannabis (derivatives)
19
New Code
T40.711
Poisoning by cannabis, accidental (unintentional)
19
New Code
T40.712
Poisoning by cannabis, intentional self-harm
19
New Code
T40.713
Poisoning by cannabis, assault
19
New Code
T40.714
Poisoning by cannabis, undetermined
19
New Code
T40.715
Adverse effect of cannabis
19
New Code
T40.716
Underdosing of cannabis
19
New Code
T40.72
Poisoning by, adverse effect of and underdosing of synthetic cannabinoids
19
New Code
T40.721
Poisoning by synthetic cannabinoids, accidental (unintentional)
19
New Code
T40.722
Poisoning by synthetic cannabinoids, intentional self-harm
19
New Code
T40.723
Poisoning by synthetic cannabinoids, assault
19
New Code
T40.724
Poisoning by synthetic cannabinoids, undetermined
19
New Code
T40.725
Adverse effect of synthetic cannabinoids
19
New Code
T40.726
Underdosing of synthetic cannabinoids
19
New Code
T80.82
Complication of immune effector cellular therapy
20
New Code
Y35.899
Legal intervention involving other specified means, unspecified person injured
21
New Code
Z55.5
Less than a high school diploma
21
New Code
Z58
Problems related to physical environment
21
New Code
Z58.6
Inadequate drinking-water supply
21
New Code
Z59.00
Homelessness unspecified
21
New Code
Z59.01
Sheltered homelessness
21
New Code
Z59.02
Unsheltered homelessness
21
New Code
Z59.41
Food insecurity
21
New Code
Z59.48
Other specified lack of adequate food
21
New Code
Z59.81
Housing instability, housed
21
New Code
Z59.811
Housing instability, housed, with risk of homelessness
21
New Code
Z59.812
Housing instability, housed, homelessness in past 12 months
21
New Code
Z59.819
Housing instability, housed unspecified
21
New Code
Z59.89
Other problems related to housing and economic circumstances
21
New Code
Z71.85
Encounter for immunization safety counseling
21
New Code
Z91.014
Allergy to mammalian meats
21
New Code
Z91.51
Personal history of suicidal behavior
21
New Code
Z91.52
Personal history of nonsuicidal self-harm
21
New Code
Z92.85
Personal history of cellular therapy
21
New Code
Z92.850
Personal history of Chimeric Antigen Receptor T-cell therapy
21
New Code
Z92.858
Personal history of other cellular therapy
21
New Code
Z92.859
Personal history of cellular therapy, unspecified
21
New Code
Z92.86
Personal history of gene therapy
22
New Code
U09
Post COVID-19 condition
22
New Code
U09.9
Post COVID-19 condition, unspecified
The deleted codes:
19
Deleted Code
T40.7X
Poisoning by, adverse effect of and underdosing of cannabis (derivatives)
19
Deleted Code
T40.7X1
Poisoning by cannabis (derivatives), accidental (unintentional)
19
Deleted Code
T40.7X2
Poisoning by cannabis (derivatives), intentional self-harm
19
Deleted Code
T40.7X3
Poisoning by cannabis (derivatives), assault
19
Deleted Code
T40.7X4
Poisoning by cannabis (derivatives), undetermined
19
Deleted Code
T40.7X5
Adverse effect of cannabis (derivatives)
19
Deleted Code
T40.7X6
Underdosing of cannabis (derivatives)
Note: There was no change or deletion to chapters not listed above.
Implementing Diagnosis Code Changes
To ensure your claims are paid, healthcare practices should integrate the 2022 ICD-10-CM coding guideline changes into their system.
Billing/medical records software systems are a huge risk for your practice (if you use them). It can be disastrous if you blindly rely on your software system to implement ICD-10-CM updates in a timely manner. If there is a problem with your system, the software company is not responsible. The responsibility lies with you. Thus, you should compare the current year’s diagnosis code changes with those added to your software system to identify errors as soon as possible.
Lastly, you must teach your staff and providers about the key changes to the 2022 ICD-10-CM coding guidelines – based on your specialty. By doing so, you will be improving efficiency and accuracy when choosing diagnosis codes – either electronically or on paper.
Key Takeaway
To enhance the quality of reported data, the continuity of care, and patient outcomes, we endeavor to improve ICD-10 codes and clinical documentation throughout the process.
Tap Into Our Expertise
At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
The American Medical Association (AMA) has released the latest version of the Current Procedure Terminology (CPT) code set for 2022. AMA made 405 changes to the current procedure code set in 2022, including 249 new codes, 63 deletions, and 93 revisions. These changes will take effect on January 1.
What is a CPT® code?
Current Procedural Terminology (CPT®) codes provide doctors and healthcare professionals a uniform language to code medical services and procedures to simplify reporting, improve accuracy, and increase efficiency. CPT codes are also used to manage administrative tasks like claims processing and medical care reviews. Electronic medical billing utilizes CPT codes as well as ICD-9-CM or ICD-10-CM numerical diagnostic coding. Throughout the country, CPT terminology is used to report medical, surgical, radiology, laboratory, anesthesia, genomic sequencing, evaluation, and management (EM) services under public and private health insurance programs.
The following AMA CPT codes were announced for new vaccine-specific immunizations against the novel coronavirus.
With the help of the Centers for Disease Control and Prevention (CDC), the AMA’s CPT editorial panel approved unique immunization codes for two coronavirus vaccines — as well as administration codes unique to each vaccine. In a press release, the AMA stated that the new CPT codes differentiate each coronavirus vaccine for better tracking, reporting, and analysis for data-driven planning and allocation.
The new Category I CPT codes and long descriptors for the vaccine products are:
91300
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative-free, 30 mcg/0.3 mL dosage, diluent reconstituted, for intramuscular use (Report 91300 with administration codes 0001A, 0002A, 0003A, 0004A) ◄ Do not report 91300 in conjunction with administration codes 0051A, 0052A, 0053A, 0054A, 0071A, 0072A)
November 10, 2020 July 30, 2021
September 3, 2021 October 6, 2021
0001A, 0002A, 91300: December 11, 2020 0003A: August 12, 2021 0004A: September 22, 2021 0071A, 0072A: October 29, 2021 0051A, 0052A, 0053A, 0054A: Effective upon receiving Emergency Use Authorization or approval from the Food and Drug Administration (FDA)
CPT® 2022/2023
91301
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative-free, 100 mcg/0.5 mL dosage, for intramuscular use (Report 91301 with administration codes 0011A, 0012A, 0013A)
November 10, 2020
August 16, 2021
0011A, 0012A, 91301: December 18, 2020 0013A: August 12, 2021
CPT® 2022/2023
Here are the new Category I CPT codes and long descriptors for vaccines:
To comply with new CPT codes for vaccine-specific products, the CPT editorial panel collaborated with the Centers for Medicare & Medicaid Services. Their purpose is to develop vaccine administration codes that are distinct for each Coronavirus vaccine and the specific dose used in the schedule.
According to AMA, the level of specificity is a first for vaccine CPT codes. However, it allows tracking all vaccine doses, even when the vaccine product is not reported, like when a vaccine may be given free to the patient. Moreover, these CPT codes report the actual act of administering the vaccine and all counseling needed to the patient or caregiver. They also update the electronic records.
The AMA site provides a number of resources regarding the new vaccine administration CPT codes and long descriptors. As soon as each newly developed Coronavirus vaccine receives Emergency Use Authorization or FDA approval, all the new vaccine-specific CPT codes will be available for use.
AMA’s website offers short and medium descriptors for these new vaccine-specific CPT codes. They also provide recent changes to the set of CPT codes that have streamlined the public health response to SAR-CoV-2 and COVID-19 disease.
In addition to releasing the standard code descriptor PDF of SARS-CoV-2-related CPT codes, we are also providing an easy-to-use Excel file of SARS-CoV-2-related CPT codes. It contains all the SARS-CoV-2 CPT codes, some may not be included in the 2022 CPT data file, and it includes:
CPT code descriptors (long, medium, and short)
Published date
Effective date
Type of change.
AMA will update these files as new CPT codes are approved by the CPT Editorial Panel:
CPT code set for 2022 includes five new codes (98975, 98976, 98977, 98980, 98981) for reporting therapeutic remote monitoring. These codes reflect the rise of digital care during the pandemic. In a news release, the AMA referred to codes 99453, 99454, 99457, and 99458 as “codes that expand upon the remote physiologic monitoring codes created in 2020.”
According to the AMA, the new code set includes a taxonomy that supports “increased awareness and understanding of approaches to patient care through diverse digital medicine services available for reporting.”
As of 2020, new CPT codes also apply to the principal care management program. Patients with a single chronic condition can receive reimbursement under that policy. Whereas before, only patients with multiple chronic conditions were eligible.
The AMA wrote that the new codes – 99424, 99425, 99426, 99427 – and changes to existing codes, “better align with Medicare guidelines.” Thus, a data file can be used to download the codes and descriptors into a provider’s software solution.
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At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
Billing and coding for general surgery include a wide range of procedures, from gastrointestinal (GI) tract surgery, kidney, pancreas, liver, and thoracic and abdominal surgery to breast surgery and elective surgery. The coding and billing of general surgery can be challenging due to numerous guidelines. Moreover, the general surgeons in 2019 faced 135 changes to ICD-10 codes and more than 69 changes to CPT codes.
The Health Common Procedure Coding (HCPCS) describes medical devices, supplies, products, and services and aids Medicare and other insurance companies in processing health claims. Physician billing companies should be up to date with all the latest changes in CPT, ICD, and HCPCS codes to submit accurate claims to payers.
In this article, we’ll discuss billing and coding guidelines for general surgery.
CPT Codes 20000-29999: Top Surgical Procedures
Surgery CPT Codes
Description
20610
DRAIN/INJECT, JOINT/BURSA
29581
APPLY MULTLAY COMPRS LWR LEG
29125
APPLY FOREARM SPLINT
29515
APPLICATION LOWER LEG SPLINT
20552
INJ TRIGGER POINT, 1/2 MUSCL
29105
APPLY LONG ARM SPLINT
29881
KNEE ARTHROSCOPY/SURGERY
20680
REMOVAL OF SUPPORT IMPLANT
29126
APPLY FOREARM SPLINT
23430
REPAIR BICEPS TENDO
25605
TREAT FRACTURE RADIUS/ULNA
23650
TREAT SHOULDER DISLOCATION
23350
INJECTION FOR SHOULDER X-RAY
20553
INJECT TRIGGER POINTS, =/> 3
29826
SHOULDER ARTHROSCOPY/SURGERY
29877
KNEE ARTHROSCOPY/SURGERY
26055
INCISE FINGER TENDON SHEATH
20605
DRAIN/INJECT, JOINT/BURSA
29823
SHOULDER ARTHROSCOPY/SURGERY
22513
PERQ VERTEBRAL AUGMENTATION
29824
SHOULDER ARTHROSCOPY/SURGERY
26010
DRAINAGE OF FINGER ABSCESS
24640
TREAT ELBOW DISLOCATION
29882
KNEE ARTHROSCOPY/SURGERY
28485
TREAT METATARSAL FRACTURE
27096
INJECT SACROILIAC JOINT
29505
APPLICATION, LONG LEG SPLINT
28291
CORRJ HALLUX RIGIDUS W/IMPLT
26605
TREAT METACARPAL FRACTURE
23515
TREAT CLAVICLE FRACTURE
28285
REPAIR OF HAMMERTOE
22514
PERQ VERTEBRAL AUGMENTATION
29888
KNEE ARTHROSCOPY/SURGERY
27792
TREATMENT OF ANKLE FRACTURE
27093
INJECTION FOR HIP X-RAY
25608
TREAT FX RAD INTRA-ARTICULAR
27570
FIXATION OF KNEE JOINT
29822
SHOULDER ARTHROSCOPY/SURGERY
27447
TOTAL KNEE ARTHROPLASTY
29806
SHOULDER ARTHROSCOPY/SURGERY
25565
TREAT FRACTURE RADIUS ULNA
25607
TREAT FX RAD EXTRA-ARTICUL
25115
REMOVE WRIST/FOREARM LESION
26770
TREAT FINGER DISLOCATION
Coding updates for Surgery Section 2021:
Integumentary System-Breast Repair and Reconstruction
In the breast repair and reconstruction subsection (19316-19499) of the Integumentary System, 15 codes were updated, and two were deleted (19324 and 19366) in 2021. Moreover, this subsection includes new instructions for each code and new fundamental guidelines for coders.
Breast Reconstructions
The following code descriptions were updated:
Code
Descriptions
19357–
Tissue expander placement in breast reconstruction, including subsequent expansion(s)(previously stated breast reconstruction, immediate or delayed, including subsequent expansion) The subsequent expansions of the tissue expander are included in code 19357.
19361–
Breast reconstruction; with latissimus dorsi flap (had said the same plus “without prosthetic implant”) The extensive notes for this code explain what not to report. If there is the insertion of an implant in addition to latissimus dorsi flap on the same day, additionally code 19340 to 19361. If it is on a separate day, use 19342.
Codes 19364-19369 cover breast reconstruction using different types of flaps, such as fTRAM, DIEP, SIEA, bi=pedicled TRAM, TRAM with and without separate microvascular anastomosis or “supercharging.” The supercharging procedure increases blood flow in TRAM flaps with marginal circulation to ensure flap survival. All of these procedures are the same as in 2020. The only difference is that they now all mention: “including the closure of donor sites.” Of course, this is just part of the code. Notes before each code explain what each type of flap entails.
Revisions for Breast Procedures
In the past, coders found it difficult to distinguish between breast reconstruction and revision. The descriptions of the three codes were revised:
Code
Descriptions
19370–
Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy (had stated open periprosthetic capsulotomy, breast) In most cases, this is done to fix a displacement of an implant.
19371–
Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (had stated open periprosthetic capsulectomy, breast) Complete capsulectomy with implant removal is the key here. This was added for clarity. A partial capsulectomy is 19370. Physicians must document clearly.(Do not report 19371 with 19328, 19330, or 19370 in the same breast. For removal and replacement with a new implant, use 19342)
19380–
Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction (had stated revision of reconstructed breast). In terms of revisions, this code description has been revised extensively. There is a full listing of codes not to report this within the CPT tabular, so coders must refer to it.
Indeed, the documentation of all breast procedures codes is crucial. It may be good to discuss with surgeons to review the changes above so the documentation needed for coders will be included in operative reports.
Thus, we encourage coders to use the Breast Reconstruction in CPT Action Plan and to look at photos of the various breast reconstruction techniques online. Visualizing these can sometimes make it easier to understand what should be done.
On the other hand, the guidelines clarify which reconstruction method should be used for each breast. Codes have been updated: mammary is now known as breast, and language has been added that indicates whether a breast implant was inserted simultaneously or after a significant mastectomy.
Respiratory System: The Nose
Code
Descriptions
30468–
Unique, and was created to explain the repair of a nasal valve collapse with subcutaneous or submucosal lateral wall implants. Furthermore, a code was also required to recognize the opening of the nasal collapse using minimally invasive methods and absorbable lateral wall implants.
30468–
Report for a bilateral system Add modifier 52 to the process if it is performed unilaterally.
Respiratory System: The Lungs and Pleura
Code
32408–
For 2021, to report core needle biopsy of the lung or mediastinum using all imaging guidance types, including, but not restricted to, CT, MRI, ultrasound, and fluoroscopy. The current guidelines for 32408 state that imaging guidance is not to be listed separately, and the code is only used once per lesion tested in a single session. If multiple lesions are tested on a corresponding day, select 32408 for each lesion examined simultaneously, including modifier 59.
Male Genital System: Prostate
Code
Description
55880–
Code is used to report transrectal, high-intensity-focused ultrasound (HIFU) guided ablation of malignant prostate tissue.
Before 2021, coders were following an unrecorded code to communicate that method.
Female Genital System: The Cervix Uteri
Code
Description
57465–
A unique add-on code generated to report computer-aided colposcopy to assist in the cervix’s biopsy.
57465–
Used in combination with vaginal colposcopy procedures (57420, 57421) and cervical colposcopy procedures (57452-57461).
57465–
The specification states that it combines optical dynamic spectral imaging that aids in the mapping of abnormal measures for biopsy.
Auditory System—Other Procedures:
There are new codes designed to practice the nasopharyngoscopy technique for the dilation of the eustachian tube. Eustachian tube balloon dilation (ETBD) is the name of this procedure. In the past, coders reported this procedure using unlisted code 69799 because no specific code was available.
Code
Description
CPT
69705–
Nasopharyngoscopy, surgical, with dilation of the eustachian tube (i.e., balloon dilation); unilateral (effective 1/1/2021)
69706–
Nasopharyngoscopy, surgical, with dilation of the eustachian tube (i.e., balloon dilation); bilateral (effective 1/1/2021)
69799–
Unlisted procedure, middle ear HCPCS C9745 Nasal endoscopy, surgical; balloon dilation of the eustachian tube
Notice: CPT codes, descriptions, and materials are the property of the American Medical Association (AMA). The Centers for Medicare and Medicaid Services (CMS) owns the copyright to HCPCS codes, descriptions, and materials.
Therefore, the following surgery coding guidelines 2021 have been updated recently. For more accurate billing and coding for general surgery, refer to this website.
Tap Into Our Expertise
At 5 Star Billing Billing Services Inc, we offer the highest level of performance for high-quality medical billing and coding. Save your money by outsourcing to a professional billing service.
In simple terms, substance abuse refers to the pattern of harmful use of any substance to change one’s mood. Furthermore, the term “substances” can encompass not only alcohol and drugs ( legal or illegal) but also substances that do not technically qualify as drugs. On the other hand, “abuse” involves using a substance in a way that is not intended or recommended or when you consume too much of it.
The substance abuse medical billing process is only one element of revenue cycle management, which begins with gathering accurate patient information. In this guide, we’ll guide you all you need to know about the Medical Billing and Coding Guide for Substance Abuse.
This table shows Outpatient SUD Services:
HCPCS or CPT® Code
Modifier
Description
Service
Taxonomy
H0001
HD
Alcohol and/or drug assess
Substance use disorder assessment, Pregnant and Parenting Women (PPW)
261QR0405X
H0001
HF
Alcohol and/or drug assess
Substance use disorder assessment
261QR0405X
H0004
HF
Alcohol and/or drug services
Individual therapy, without family present, per 15 minutes
261QR0405X
H0038
HF
Selfhelp/peer svc
SUD Peer Services
261QR0405X
H0020
HF
Alcohol and/or drug services
Opiate Substitution Treatment, methadone administration See the Opioid Treatment Programs (OTP) section of this guide for more information about Opioid Substitution Treatment.
261QM2800X
T1017
HF
Targeted case management
Case management, each 15 minutes
251B00000X
96164
HF
Health behavior intervention, group, face-to-face; initial 30 minutes
Group/ Face to face
261QR0405X
96165
HF
Health behavior intervention, group, face-to-face; each additional 15 minutes
Group/ Face to face
261QR0405X
96167
HF
Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes
Family w/ patient present/ face to face
261QR0405X
96168
HF
Health behavior intervention, family (with the patient present), face-to-face; each additional 15 minutes
Family w/ patient present/ face to face
261QR0405X
96170
HF
Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes
Family without patient present, face to face
261QR0405X
96171
HF
Health behavior intervention, family (without the patient present), face-to-face; additional 15 minutes
Family without patient present, face to face
261QR0405X
This table shows Residential SUD Services:
HCPCS or CPT® Code
Modifier
Description
Service
Taxonomy
H0010
HA
Alcohol and/or drug services
Youth subacute withdrawal management
3245S0500X
H0010
HF
Alcohol and/or drug services
Adult subacute withdrawal management
324500000X
H0011
HA
Alcohol and/or drug services
Youth acute withdrawal management
3245S0500X
H0011
HF
Alcohol and/or drug services
Adult acute withdrawal management
324500000X
H0018
HA
Alcohol and/or drug services
Youth recovery house
3245S0500X
H0018
HF
Alcohol and/or drug services
Adult recovery house
324500000X
H0018
HV
Alcohol and/or drug services
Adult intensive inpatient residential, w/o room and board, per diem
324500000X
H0019
HA
Alcohol and/or drug services
Youth intensive inpatient residential, w/o room and board, per diem
3245S0500X
H0019
HB
Alcohol and/or drug services
Residential treatment, Pregnant and Parenting Women (PPW) w/Children, w/o room, and board, per diem
324500000X
H0019
HD
Alcohol and/or drug services
Residential treatment, Pregnant and Parenting Women (PPW) w/o Children, w/o room and board, per diem
324500000X
H0019
TG
Alcohol and/or drug services
Residential treatment, long term recovery
324500000X
H2036
HA
A/D Tx program, per diem
Youth room and board*
3245S0500X
H2036
HF
A/D Tx program, per diem
Adult Room & Board*
324500000X
H2036
HD
A/D Tx program, per diem
PPW room and board*
324500000X
For more assistance on the billing guide, refer to this site.
Substance Abuse Diagnosis
Psychiatrists, psychologists, and licensed drug counselors are often involved in the evaluation process for diagnosing alcoholism, drug addiction, or other substance use disorders. Testing blood, urine, or other tests can assess drug use but not a diagnostic test for addiction. These tests can help monitor recovery as well as treatment.
Mental health professionals diagnose substance abuse using criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.
How to identify correct substance abuse ICD-10-CM codes?
ICD-10-CM uses the format F1x.xxx for substance use codes. In ICD-10-CM, the letter F indicates that the code belongs to Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders. Furthermore, the number 1 represents a mental or behavioral disorder due to the use of psychoactive substances. The first x, the next digit, indicates the problematic substance (see table below in Step 1). After the decimal point, all numbers indicate the severity and nature of the problem (see Table in Step 2 below). For example, F10.121 refers to alcohol abuse with intoxication delirium. Not all specifiers are used for every substance (primarily perceptual disturbance), so users should refer to the complete ICD-10-CM code set.
Code1
Mental and Behavioral Disorders due to…
F10
…use of alcohol
F11
…use of opioids
F12
…use of cannabis
F13
…use of sedatives, hypnotics, anxiolytics
F14
…use of cocaine
F15
…use of other stimulants, including caffeine
F16
…use of hallucinogens
F17
…use of nicotine
F18
…use of inhalants
F19
…use of other psychoactive substances and multiple drug use
Specifiers for Substance Coding
Code1
Abuse
.1
Uncomplicated
.10
With intoxication
.12
…uncomplicated
.120
…delirium
.121
…with perceptual disturbance
.122
…unspecified
.129
With [insert substance] – induced mood disorder
.14
With [insert substance] – induced psychotic disorder
.15
…with delusions
.150
…with hallucinations
.151
…unspecified
.159
With other [insert substance] – induced disorder
.18
…anxiety disorder
.180
…sleep disorder
.182
…other [same-substance] – induced disorder
.188
With unspecified [insert substance] – induced disorder
.19
Dependence
.22
Uncomplicated
.20
In remission
.21
With intoxication
.22
…uncomplicated
.220
…delirium
.221
…with perceptual disturbance
.222
…unspecified
.229
With withdrawal
.23
…uncomplicated
.230
…delirium
.231
…with perceptual disturbance
.232
…unspecified
.239
With [insert substance] – induced mood disorder
.24
With [insert substance] – induced psychotic disorder
.25
…with delusions
.250
…with hallucinations
.251
…unspecified
.259
With [insert substance] – induced persisting amnestic disorder
.26
With [insert substance] – induced persisting dementia
.27
With other [insert substance] – induced disorders
.28
…anxiety disorder
.280
…sexual dysfunction
.281
…sleep disorder
.282
…other [same-substance] – induced disorder
.288
With unspecified [insert substance] – induced disorder
.29
Use, unspecified
.9
With intoxication
.92
…uncomplicated
.920
…delirium
.921
…with perceptual disturbance
.922
…unspecified
.929
With withdrawal
.93
…uncomplicated
.930
…delirium
.931
…with perceptual disturbance
.932
…unspecified
.939
With [insert substance] – induced mood disorder
.94
With [insert substance] – induced psychotic disorder
.95
…with delusions
.950
…with hallucinations
.951
…sleep disorder
.959
With [insert substance] – induced persisting amnestic disorder
.96
With [insert substance] – induced persisting dementia
.97
With other [inset substance] – induced disorders
.98
…anxiety disorder
.980
…sexual dysfunction
.981
…sleep disorder
.982
…other [same-substance] – induced disorder
.988
With unspecified [insert substance] – induced disorder
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The term cardiovascular disease (CVD) refers to conditions that affect the heart or blood vessels. Also, the World Health Organization (WHO) estimates 17.9 million people died from cardiovascular diseases in 2019, representing 32% of all global deaths. A majority of these deaths resulted from heart attacks and strokes. Overall, CVD is the most severe disorder afflicting the majority of Americans.
Before discussing CVD in further detail, let’s examine documentation and diagnosis coding for cardiac conditions to ensure accurate and compliant practices.
The table below shows the ICD-10 diagnosis codes for common cardiac conditions.
COMMON DIAGNOSES
ICD-10 DIAGNOSES CODES
DEFINITION
Arch obstruction
Q25.1
Coarctation of the aorta
Q25.21
Interrupted aortic arch
Arrhythmias
I47.0-I47.9
Re-entry ventricular arrhythmia
I47.1
Supraventricular tachycardia
147.2
Ventricular tachycardias
147.9
Paroxysmal tachycardia, unspecified
Cardiac arrest
I46.2
Cardiac arrest due to underlying cardiac condition
I46.8
Cardiac arrest, due to other underlying condition
I46.9
Cardiac arrest, due to unspecified condition
Cardiomyopathies
I42.0
Dilated cardiomyopathy
142.1
Obstructive hypertrophic cardiomyopathy
142.2
Other hypertrophic cardiomyopathy
142.3
Endomyocardial (eosinophilic) disease
142.4
Endocardial fibroelastosis
142.5
Other restrictive cardiomyopathy
142.6
Alcoholic cardiomyopathy
142.7
Cardiomyopathy due to drug and external agent
142.8
Other cardiomyopathies
142.9
Cardiomyopathy, unspecified
Source: Extracorporeal Life Support Organization 2021
Heart failure includes systolic, diastolic, and combined heart failure as well acute heart failure, chronic heart failure, and acute chronic heart failure.
I50.41
Acute systolic (congestive) and diastolic (congestive) heart failure
I5.43
Acute on chronic systolic (congestive) and diastolic (congestive) heart failure
I50.9
Heart failure, unspecified
Hypoplastic left heart syndrome
Q23.4
HLHS includes all combinations of mitral stenosis/atresia and aortic stenosis/atresia
Q21.0
Ventricular septal defect
Atrial septal defect
Q21.1
Includes PFO, Secundum ASD, coronary sinus ASD, and sinus venosus ASD. Does not include ostium primum ASD
Atrioventricular septal defect
Q21.2
Includes all forms of AVSD or endocardial cushion defects including primum ASD
Tetralogy of Fallot
Q21.3
Includes TOF, TOF with pulmonary atresia, and TOF with absent pulmonary valve
Q21.4
Aortopulmonary septal defect
Q21.8
Other congenital malformations of cardiac septa
Q21.9
Congenital malformation of the cardiac septum, unspecified
Total anomalous pulmonary venous connection
Q26.2
Includes cardiac, supra cardiac, and infra cardiac TAPVC
Source: Extracorporeal Life Support Organization 2021
Through this guide, ordering physicians can ensure accurate ICD-10 diagnostic codes for cardiac conditions.
Coronary Artery Disease (CAD)
The other term for coronary artery disease (CAD) is sometimes called ischemic heart disease. CAD is the narrowing and hardening of the coronary arteries (the blood vessels that supply oxygen and blood to the heart). According to the Centers for Disease Control and Prevention (CDC), coronary artery disease (CAD) is the most common form of heart disease in the United States.
The table below shows ICD-10 codes for CAD:
ICD-10 CODES CAD
DESCRIPTION
I25
Chronic ischemic heart disease
I25.1
Atherosclerotic heart disease of native coronary artery
I25.10
Atherosclerotic heart disease of native coronary artery, without angina pectoris
I25.11
Atherosclerotic heart disease of native coronary artery with angina pectoris
I25.110
Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.111
Atherosclerotic heart disease of native coronary artery with unstable angina pectoris, with documented spasm
I25.118
Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119
Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
Tap Into Our Expertise
For professionals in the healthcare industry, knowledge of ICD-10 codes is essential in reporting common cardiovascular diseases. Our team can ensure accurate medical billing and coding for optimal reimbursement, as well!
