HIT CPT Medicine

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CPT Medicine


  • 90281-99607

  • Services (x2)
    1. Diagnostic
    2. Therapeutic
  • Generally Noninvasive
  • Some Invasive
    (Cardiac Catherization, Percutaneous Thrombectomy)



  • Diagnostic and Therapeutic Procedures
  • Most procedures noninvasive (not entering body)
    • Contains some Invasive procedures
      • Example: Percutaneous transluminal coronary thrombectomy (92973)
  • Numerous notes throughout
  • The various subsections contain many specific notes to be used with certain groups of codes;
    these notes are important for coders to read so they can code services appropriately
  • Subsections
    • Wide variety of services
    • Many specialized tests
      • Example:
        • Audiology (Audiologic Function tests)
        • Biofeedback
        • Electrocardiogram
    • The codes in the Medicine section usually do not include the supplies used in testing,
      therapy, or diagnostic treatment, unless specifically stated in the code description
  • Supplies reported separately (99070)
    • Drugs
    • Trays
    • Supplies
    • Materials
    • Corneal Contact Lenses (92310)

Introduction to Immunizations


  • Active Immunization
  • Passive Immunization
  • Often used
  • Two types of Immunizations
    • Active and Passive
  • Immunization Correct Coding Includes
    • Supply Injected
    • Administration of Injection
  • Active Immunization
    • Given When it is Anticipated That the Person Will be in Contact with the Disease
    • Bacteria or Viruses
    • Bacteria that Cause Disease made Nontoxic (Toxoid)
      • Injected to build Immunity
    • Small Dose Active Virus Injected (Vaccine)
      • Injected to Build Immunity
        • Example: Poliovirus
    • Active Immunizations can be Toxoids or Vaccines
      • Toxoids (Bacteria that have been made nontoxic)
      • Vaccines (Viruses that are given in small doses and cause an immune response)
  • Passive immunization
    • Does NOT cause an Immune Response
    • Injected Material [i.e., Immune Globulins]
      Contains a High Level of Antibody Against a Disease
    • Immune Globulins (Contains Antibodies Against Certain Diseases)
    • Name a Disease for which Passive Immunization is used
      (Rabies, hepatitis B, or tetanus)

Immune Globulins - Immunization (90281-90399)


  • Passive Immunization Agents
    • Obtained from Pooled Human Plasma
    • Immune to a Particular Disease
  • Identifies Immune Globulin Product Only
    • Example: Botulism antitoxin
  • Report administration separately
    • Administration must be Reported (96365-96368, 96372, 96374, 96375)
  • Immune Globulin subsection is relatively new to the CPT manual
  • Only the Immune Globulin product reported and
    must be reported in addition to the appropriate administration code from the appropriate subsection
  • Codes divided by:
    • Type
      • e.g., Rabies, hepatitis B
    • Method
      • e.g., Intramuscular, intravenous, subcutaneous
    • Dose
      • e.g., Full dose, mini-dose

Immunization Administration for Vaccines/Toxoids- Immunization (90460-90474)


  • Reporting Administration Codes with Vaccines (codapedia.com)
    • 90465-90468
      Used when the physician provides face-to-face counseling to the patient and/or family for patients younger than 8 years old
    • 90470-90474
      Used when there is no face-to-face counseling for patients of any age
    • HCPCS G-codes
      Used on a limited number of vaccines, based on carrier (e.g. Medicare)
  • Reported in Conjunction with Vaccines, Toxoids- Immunization (90476-90749)
  • Modifier -51 should NOT be reported for the Vaccines, Toxoids
    when performed with these administration codes (90460-90474)
  • Immunization reporting Requires Two codes (x2)
    1. Administration (performing the injection) (90460-90474)
    2. Substance Administered (90476-90749)
  • Divided by
    • Method of Administration
    • Age, when Aadministered with Physician Counseling
  • Immunization Administration (90465-90468)
    • Patients through age 18 when physician counsels regarding Immunization (90460, 90461)
    • Patients 19 years of age or over (90471-90474)
      • Patients of all Ages (including under 19)
        if physician does not counsel regarding immunization
    • Percutaneous, intradermal, subcutaneous, or intramuscular injection (90471, +90472)
    • Oral or Intranasal (90473, +90474)
    • Immunization Administration codes are Divided by
      patient age and administration method
    • Make sure you code for each injection that is administered
    • Be careful when a combination Immunization (DTP) is given
      This is all combined in one injection even though there are 3 Immunizations;
      they are given in one injection so only one administration code is used
  • Methods of Administration (Administrative Methods)
    • Percutaneous
    • Intradermal
    • Subcutaneous (SC)
    • Intramuscular (IM)
    • Intranasal
    • Oral
    • Administration codes are divided according to method of administration and
      some by age of patient. Read descriptions carefully
  • Report Administration for Each DoseSingle or Combination
    • Example: Patient (over age 8) receives three separate administrations:
      • Tetanus (90471)
      • Rubella (add-on code) (+90472)
      • Diphtheria (add-on code) (+90472)
    • OR depending on payer:
      • Tetanus (90471)
      • Rubella and Diphtheria (90472 x 2)
    • Each Administered Dose Must be Reported
    • Example
      • Multiple Injections can be reported for a patient over age 8 by using
      • First injection (90471)
      • Each injection thereafter (90472)

Vaccines, Toxoids- Immunization (90476-90749)


  • Index: Vaccines
  • Products given in Immunizations
  • Many codes Age specific
    • Example:
      • Influenza virus vaccine, for ages 3 and over (90658)
        • Codes for products for Single Diseases
    • Example:
      • Tetanus Toxoid (90703)
  • Codes for Combination of Diseases
    • Example:
      • Diphtheria, Tetanus, and Whole cell pertussis (DTP) (90701)
      • Measles, Mumps, and Rubella (MMR) (90707)
  • CAUTION: There are numerous code combinations of diphtheria
  • The Vaccines/Toxoids subsection lists vaccine products given in immunizations
  • Coders must carefully review the description of the vaccine product code to determine which disease is specified
  • When is the combination code used?
    (When one code is available to describe multiple products given)
  • Be careful to select the correct code.
    For example, there are 8 combination codes for Diphtheria
  • Some vaccines given on schedule
    • Example:
      • 2-dose Hepatitis A Vaccine (90634)
        • First dose, first visit
        • Second dose, second visit
      • Reported for each visit (90634)
  • What is a Schedule based on?
    (The number of doses provided and the timing of administration)
  • Each time the vaccine is administered,
    the code is reported, along with the date the injection was given
  • Remember
    • Do NOT assign Modifier -51 with Vaccine/Toxoid codes
      • Rather, depending on payer:
        • List each code multiple times or
        • Use times (×) symbol and indicate number
    • Modifier -51 should NOT be reported for the Vaccines, Toxoids
      when performed with these administration codes (90460-90474)
  • Important Reporting Rules
    • If vaccine administered during office visit (not related to E/M)
      • Report E/M service (with modifier -25) + Vaccine + Administration
  • Depends on local carrier
    • Office visit for Vaccine Only, code only vaccine, NO E/M service
      • Depends on local carrier
    • If the office visit takes place only because of the immunization, report
      1. Immunization Administration code first
      2. Vaccine/Toxoid code second
  • Routine Vaccinations
    • Influenza
      • Administration
        • G0008 HCPCS (Medicare only)
        • Administration (90471, 90472)
      • Substance (Vaccine) (90657, 90658)
    • Pneumococcal
      • Administration
        • G0009 HCPCS (Medicare only)
        • Administration (90471, 90472)
      • Substance (Vaccine) (90732)
    • These two vaccinations are commonly provided
    • The third-party payer may require CPT codes or CPT with HCPCS codes for the service
    • For Medicare patients, the coder reports only an administration code
      for an immunization if no E/M service is reported;
      E/M office visits include the Administration of an Immunization

Psychiatry (90801-90899)


  • Partial Hospitalization
  • Psychiatrist (Physician that specializes in psychiatry)
  • Psychologist (Not a physician)
  • Date of service
  • Time spent
  • Type of Psychotherapy
  • Place of Service
  • Comprehensive Psychiatry service (90801)
  • Psychiatric treatment at same time as E/M service, report
    • One code for therapy with E/M
    • Example: Psychotherapy and E/M (90805)
    • If psychiatric treatments are rendered on the same day as E/M service,
      both are reported with one code from the Psychiatry section
  • If these treatments are provided on a different day from the E/M service,
    a code from the E/M section is listed
  • Time major billing factor
    • Codes divided on time
    • Medical record indicates session time
  • Psychiatry section has a lengthy note under the heading that details the use of psychiatric codes in conjunction with hospital and clinic E/M services
  • Some codes reflect Evaluation or Diagnostic services,
    some reflect Therapeutic procedures, and
    some reflect Psychological testing
  • When selecting a Psychotherapy code ask these questions:
    1. Where is the service taking place?
    2. How much face-to-face time is spent with the patient?
    3. Does documentation support an evaluation & management code in addition to psychotherapy?
    4. If rendering psychotherapy, is the approximate “time” of the psychotherapy noted in the medical record?
  • Many services provided in partial hospital settings
    • Patient in hospital during day, returns to home for evenings and weekends
  • Interactive Psychotherapy is typically furnished to children
    • Uses play equipment
    • Physical aides
    • Nonverbal communications
    • Other mechanisms of communication
  • E/M Initial Hospital Care and Subsequent Hospital Care codes (99221-99233)
    • Used to Report Inpatient Stays

Biofeedback (90901-90911)


  • Index: Training, Biofeedback
  • Used to help patients gain control over body processes (self-information)
  • Example: High BP or Chronic pain
  • Medicare Coverage Issues Manual 35-27 restricts the use of biofeedback
  • Medicare doesn’t cover Biofeedback for Psychosomatic disorders
  • Patient training in Biofeedback by Professional
  • Continues on own
  • Services often part of Psychophysiologic (mind/body) therapy
  • Biofeedback is a process by which individuals can monitor and manage physiological processes that are normally out of their control
  • When Biofeedback is part of Individual Psychophysiological therapy,
    codes are listed for both the Biofeedback and the individual Psychophysiological therapy

Dialysis (90935-90999)


  • Cleanses Blood
    • Temporary (non-ESRD)
    • Permanent End Stage Renal Disease (ESRD)
  • Parts to report ESRD Dialysis Services (x2)
    1. Physician service
    2. Hemodialysis procedure
  • What is the specific purpose of dialysis?
    (It removes waste products from the blood when
    the body [the kidneys] cannot perform this function adequately.)
  • End-stage Renal Disease (ESRD) Requires Permanent, Ongoing Dialysis

Hemodialysis-Dialysis (90935-90940)


  • Hemodialysis (cleansing of blood outside the body)
    • Used for ESRD and non-ESRD
  • Billed per day for Inpatients Receiving ESRD + non-ESRD
  • Includes all Physician E/M services related to procedure
    • Modifier -25 if separate E/M service provided
  • What is the function of Hemodialysis?
    (To route blood outside of the body for filtration of waste products)
  • How long does a patient suffering from ESRD need to be on dialysis?
    (Forever or until he or she can have a kidney transplant.)

Peritoneal Dialysis-Dialysis (90945-90947)


  • Miscellaneous Dialysis Procedures (90945-90947)
    • Describes other Dialysis Procedures
      • Example:
        • Peritoneal Dialysis in which toxins are passively absorbed into dialysis fluid
    • Peritoneal dialysis uses the Peritoneal cavity as a filter
    • Peritoneal dialysis is a continuous renal replacement therapy
    • If a physician sees a patient during the dialysis session, how would this be coded?
      (If the physician sees a patient during the dialysis session for something other than what pertains to the function
      of his/her kidneys, for example the patient has a cough and is diagnosed with an upper respiratory infection,
      you would code a separate </u>E/M code with a -25 modifier attached</u>)
  • Peritoneal Dialysis
    • Services billed on per day basis for inpatient ESRD patients
    • Peritoneal dialysis is reported monthly or if less than a month, for each day the service is provided
    • How is peritoneal dialysis reported for Medicare?
      (Monthly or per day, using temporary HCPCS codes)
  • Dialysis Training
    • Patients can receive training in Self-dialysis (90989, 90993)
      • Divided by complete or partial training program
    • Where are dialysis teaching codes located?
      (Miscellaneous Dialysis Procedures)
    • Most third-party payers allow training to be billed for one time only

End Stage Renal Disease (ESRD)-Dialysis (90951-90966)


  • Type of Dialysis
  • Complexity of Service
  • Number of Visits
  • Include
    • Establishment of Dialyzing Cycle
    • Physician Services
    • E/M Outpatient Dialysis Visits
    • Patient Management During Dialysis
  • Reported for month: (90951-90966)
    • Less than full month of service (per day) (90967-90970)
    • Divided on Age and Number of Visits
  • Dialysis services are usually billed as a monthly fee and are performed on an outpatient basis
  • How are physician services for dialysis reported?
    (By the type of dialysis the patient is receiving, the number of doctor visits)
  • Code descriptions describe physician service only to dialysis patient (NO modifier -26)

Gastroenterology (91010-91299)


  • For Tests and Treatment of
    • Esophagus
    • Stomach
    • Intestine
  • Usually Reported with E/M or Consultation Service code
  • Caution: Many bundled services
  • Several Intubation codes
    must carefully review the code descriptions to determine which services are bundled into the code
  • Bernstein Test
  • GI Tract Intraluminal Imaging

Ophthalmology (92002-92499)


  • New Patient
  • Established Patient (within 3 years)
  • Complexity
  • Bilateral codes (modifier -52 if not)
  • General Ophthalmology service (Routine Eye Exams)
  • Intermediate Ophthalmology service (92002, 92012)
  • Comprehensive Ophthalmology service (92004, 92014)
  • Contains E/M codes
    • NOT E/M codes from Front of CPT
  • Definitions for New and Established patients same as for E/M section
  • Most codes are for Bilateral Services
    • If Only One (1) Eye, use <u>Modifier -52 (reduced service)
  • Read the definitions of intermediate and comprehensive services in the CPT!
  • Extensive subsection notes explain levels of service and present examples to clarify the codes
  • Codes are based on whether the patient is New or Established, and on the complexity of service received
  • For coding purposes, what is the definition of a new patient?
    (One who has not received any professional service within the past 3 years from the physician
    or another physician of the same specialty in the same group practice)
  • Example
    • Intermediate (92002, 92012)
      • Review of history
      • External examination
      • Ophthalmoscopy
      • Biomicroscopy for an acute complicated condition
        (e.g., iritis) not requiring comprehensive ophthalmological services
    • Intermediate and Comprehensive:
      • Comprehensive (92004, 92014)
      • Integrated services in which medical decision making cannot be separated from the examining techniques used
  • Examination under general anesthesia with manipulation of the globe (92018)
  • Spectacle Services Report
  • Eye Testing
    • External (Ophthalmoscopy, Biomicroscopy)
    • Visual Acuity
    • Basic Sensorimotor Examination (sensory, motor coordination)
    • Confrontation Visual Fields (peripheral vision)
    • Tonometry (intraocular pressure)
    • Complete Visual System evaluation
    • Mydriasis (excess pupil dilation) - Ophthalmoscopy
  • Electro-oculography
    • Electro-oculogram (EOG)
  • Gonioscopy (scope, angles of eye)
  • Nystagmus (rapid involuntary eye movements)
    • Nystagmus test
  • Optokinetic (movement of eyes to objects in visual field)
  • Angioscopy (study eye capillaries)
  • Electroretinography (measures electrical response of various retina cell types)

Special Otorhinolaryngologic Services (92502-92700)


  • For Special Evaluations of Audiologic system
  • Modifier -52 for 1 Ear
  • Audiology (Hearing) Testing
  • Tests and Studies of
    • Ears
    • Nose
    • Larynx
  • Go beyond those usually provided in evaluation
  • May be reported in addition to basic Audiologic service
  • The services in this subsection deal with special testing or studies for the ears, nose, and larynx
  • Who can perform an audiology test?
    (Physician or Trained Audiologist)
  • Otorhinolaryngologic Diagnostic and Treatment Services
    • Surgery section
    • Nasopharyngoscopy with Endoscopy (92511-25)
    • Otorhinolaryngologic diagnostic and treatment services are usually reported using
      codes from the Surgery section; only special services are reported using codes from the Medicine section
  • Special treatments and diagnostic services
    • Example:
    • Nasal Function Tests (Rhinomanometry) or Audiometric Tests
  • All hearing tests bilateral unless indicated one ear in description
  • Use Modifier -52 for 1 Ear
  • How would a test be coded if the procedure was only performed on one ear and the description did not state one ear or unilateral?
    (With a -52 modifier)
  • Nasopharyngoscopy
  • Tympanometry (Evaluation of Middle Ear disorders)
  • Electrocochleography

Cardiovascular Therapeutic Services


Therapeutic Services-Cardiovascular (92950-92998)

  • CPR
  • Cardioversion (changing, converting an abnormal heart rhythm to normal)
  • PTCA (Percutaneous transluminal coronary angioplasty) (92982-92984)
    • Access through the Femoral or Brachial Artery
    • Catheter with Balloon Tip Threaded Up to Heart
      • Balloon is Expanded and Widens Vessel
    • Codes are found under the Therapeutic Services and Procedures category
  • Coronary Atherectomies
  • Heart Valvuloplasties
  • Angioplasty and Artherectomy are performed during the same session,
    only the Athrectomy is billed
  • If a stent is placed in a Coronary Vessel,
    the stent placement takes hierarchy over both the Angioplasty and Artherectomy
  • Main Vessels that can be coded (x3)
    1. Left Anterior Descending (-LD)
    2. Right Coronary Artery (-RC)
    3. Left Circumflex (-LC)
  • Angioplasty (open up a vessel of the heart that is blocked with plaque [ASHD])
    • Cardiography (93000-93278)
    • Implantable and Wearable Cardiac Device Evaluations (93279-93299)
    • Echocardiography (93303-93352)
    • Echocardiograms are Ultrasounds of the heart that aid in diagnosing Valvular disorders
      • Doppler Echocardiography
  • Ultrasonic Documentation, Velocity Mapping, Imaging
    • The echocardiograms are selected by either complete exam or follow-up (limited) study
    • Full echocardiogram by a physician (93306)
      • Shows the complete echo

+Cardiography (93000-93042)

+Cardiovascular Monitoring Services (93224-93278)

Implantable and Wearable Cardiac Device Evaluations (93279-93299)


  • Implantable Cardiovascular Monitor (ICM)
  • Implantable Ccardioverter-Defibrillator (ICD)
  • Implantable Loop Recorder (ILR)

+Echocardiography (93303-93352)

Cardiac Catheterization-Cardiovascular (93451-93568)


  • Diagnostic Medical Procedure
  • Veins and Arteries
  • Cardiac Catheterization Components (Cardiac Cath Components) (x3)
    1. Catheterization (Positioning catheter)
    2. Injection
    3. Imaging
  • Congenital Cardiac Catheterization codes (93530-93533)
    • Do NOT include Injection or Imaging
    • Cardiac Catheterization is a Diagnostic Procedure that includes
      (Catheter to aid in diagnoses of the heart)
      • Introduction
      • Positioning
      • Repositioning
      • Also included is
        • Recording of pressures
        • Obtaining blood samples
        • Cardiac output measures
  • Components (x3)
    1. Positioning of the Catheter
      • Code selection is made based on where the catheter will be placed
        • LHC
        • RHC
        • BHC
    2. Injections
      • Coded by what vessel is being injected
    3. Imaging
      • Only 2 codes. Read the description carefully
  • Right Heart Access
    • Right femoral vein, Inferior vena cava
    • Basilic vein (arm), Superior vena cava
    • Measure and record
      • Right Atrial
      • Right Ventricular
      • Pulmonary Artery
      • Pulmonary Capillary Wedges pressures
    • Right-sided pressure measurements help diagnose
      • Congestive heart failure
      • Right-sided valve disease
  • Left Heart Access
    • Arterial system
      • Right femoral artery, Ascending Aorta, Aortic Valve, Left Ventricle
    • Left heart catheterization helps diagnose
      • Coronary artery disease
      • Left ventricular dysfunction
      • Valve disease

Noninvasive Vascular Diagnostic Studies-Cardiovascular (93880-93990)


  • Vascular codes for Procedures on Noncoronary Veins and Arteries
  • Veins and Arteries Other Than Heart and Great Vessels
  • Includes
    • Patient care
    • Supervision and Interpretation (S&I)
    • Copy of Results
  • These procedures use the same devices as those used in
    Heart and Great Vessel Echocardiography
  • What distinguishes these procedures from coronary procedures?
    (The divisions are based on the location of the Vein or Artery that is being studied.)

Pulmonary (94002-94799)


  • Ventilation Management, Therapies, and Diagnostic tests
  • Index: Pulmonology, Diagnostic
  • Report Therapies
    • Nebulizer treatments
    • Incentive Spirometry
    • Diagnostic tests
      • Pulmonary Function tests
  • Includes Procedure and Interpretation of Test Results
    • Additional E/M Service Reported Separately
  • Ventilator Management codes
    • Further divided by place of service
    • Facility is billed per day
    • Home billed by time once per month
  • Physician Interpretation of test (Modifier -26)
  • What pulmonary therapy might be used?
    (Nebulizer treatments, Incentive spirometry)
  • Several tests might be administered to help the physician form a diagnosis. Each test should be reported separately unless otherwise indicated in the code description

Allergy and Clinical Immunology (95004-95199)


  • Subheadings (x2)
    1. Allergy Testing (95004-95075)
    2. Allergen Immunotherapy (95115-95199)
    • Should NOT report both together
  • Immunotherapy—
    indicated for patients with allergic rhinitis due to seasonal pollinosis caused by trees, grasses, weeds, etc.
  • Allergy Testing (95004-95075)
    • Consists of performance, evaluation, and interpretation of allergens placed under the skin
    • Sensitivity testing using various types of test methods (Methods of Tests)
      • Percutaneous
      • Intracutaneous
      • Inhalation
    • Tests use numerous substances (Types of tests, Testing Types)
      • Allergenic Extracts
      • Venoms
      • Biologics
      • Foods
    • Type and number of tests based on physician’s judgment
    • Allergy Testing describes testing by various methods and defines the types of tests
    • Why must the number of tests always be specified for billing purposes?
      (Because payment is made per test for most of these codes)
    • Medical record will indicate the
      • Number of tests
      • Type of test
      • Method of testing
    • What are some types of allergy testing?
      (Allergenic extracts, Venoms, Biologicals, Food)
    • What are some methods of allergy testing?
      (Percutaneous, Intracutaneous, Inhalation)
  • Allergen Immunotherapy (95115-95199)
    • Divided into three Types of Services (x3)
      1. Injection only
      2. Prescription and Injection
      3. Provision antigen (substance) only (Substance only)
    • Immunotherapy (Hyposensitization)
    • Payable in an office setting (95115 & 95117)
    • Professional service bundled into code
    • All codes for allergen immunotherapy have specific notes that describe the service
    • How are these codes divided out?
      (Injection only, Prescription and Injection, and Substance only)
    • Physician service bundled into immunotherapy codes
    • If separate E/M service provided, report separately with modifier -25
    • An office visit code is not usually reported. When is it reported?
      (When the physician provided another identifiable service at the time of immunotherapy)

Endocrinology (95250, 95251)


  • Glucose Monitoring

Neurology and Neuromuscular Procedures (95800-96020)


  • Sleep Studies (95800-95811)
    • Physician performs Professional Component (Modifier -26)
    • Electroencephalogram (EEG)
    • Polysomnography (brain wave measurement during sleep)
  • Electromyography, Electromyographic (EMG) (Muscle testing)
  • Range of Motion Measurements (ROM)
  • Cerebral Seizure Monitoring
  • Neurologic Function Tests
  • Neurologist
  • Pediatric Pulmonologist
  • Parameters
  • Nerve Conduction Tests (95900-95905)
    • F-wave studies (access motor nerve function)
    • Appendix J (Specific nerves tested)
    • Modifier -59
  • H-reflex Studies (95934-95936)
    • Assessment of Tibial Motor Nerve and Gastrocnemius-soleus muscle complex
  • Contains codes to report tests, such as:
    • Sleep testing
    • Muscle and range of motion testing
    • Electroencephalography (EEG)
    • Neurostimulator procedures
    • Functional brain mapping
  • Many bundled services
  • Services usually provided in addition to E/M service
  • Often consultative services (e.g., 99241-99242)
  • These codes are usually used by Neurologists
  • To code sleep tests accurately, the coder must know the parameters
    (what is being measured during the sleep test) and the stages of testing.
    In addition, many codes include a time component.
  • What is polysomnography?
    (Measurement of the brain waves during sleep with the added feature of recording the various stages of sleep, i.e.,
    excited, relaxed, drowsy, asleep, or deep sleep)

Central Nervous System (CNS) Assessments/Tests (96101-96125)


  • Used to report:
    • Psychological tests
    • Speech/Language (Aphasia) Assessments
    • Developmental Progress Assessments
    • Thinking/Reasoning Status Examinations
  • Codes from this section are used for Psychological Tests, Speech/Language Assessments, Developmental Progress Assessments, and Thinking and Reasoning Examinations
  • Codes based on per hour basis
    • Except for basic Developmental Testing
  • Includes written report of results

Health and Behavior Assessment/Intervention (96150-96155)


  • Assessment, Intervention for Behavioral, Emotional, Social, Psychological, Knowledge Factors
  • NOT performed by Physician
  • If performed by Physician, then…E/M code
  • Assessment
    • Clinical Interview
    • Behavioral Observation
    • Questionnaires
  • Intervention
    • Individual
    • Group
    • Family
  • 15 minute increments

Hydration- Health/Behavior (96360, 96361)


  • Chemotherapy Services
  • Infusion (Therapeutic procedure to introduce fluid into body over a long time)
    • Example:
      • Fluid into vein for patient rehydration
        • Infusion Service and Pre-packaged fluid and electrolytes
    • Other than pre-packaged…Report separately
  • Physician must
    • Administer OR
    • Supervise Administration of the Infusion
  • Based on Time it takes for the infusion to be completed
  • Drug that is infused would be reported using an HCPCS code or CPT (99070)
  • Infusion lasts 90 minutes (first hour) (90765)
  • Additional over 60 mins needs to be 31 mins or greater to count for an additional hour (90766)
  • Hydration, Therapeutic Infusions, IV Pushes
    • Only one initial service per encounter
    • Patient presents for Hydration (Initial service)
      • Has drug therapy while being hydrated
      • Drug therapy is subsequent
        • Add-on code (+)
      • Example: 3 hours hydration with antiemetic by IV push for 15 minutes
        • Hydration, 1 hr (96360)
        • Hydration, hr 2 and 3 (96361 × 2)
        • Antiemetic IV Push (96375)
    • Key to billing for Hydration, Therapeutic Infusions, IV Push
      • Only one initial service is billable per encounter
      • All others must be coded with an Add-on code listed as each additional hour or sequential push.
    • Remember
      • Subsequent infusions or pushes are add-on codes
      • DO NOT REQUIRE modifier -51
    • Watch the notes carefully as they are a good indicator of what can be billed together and what is bundled

Therapeutic, Prophylactic, and Diagnostic Injections and Infusions- Health/Behavior (96365-96379)


  • Chemotherapy Services
  • Intravenous infusions (96365-96368)
    • Time
    • Type of Infusion
    • Sequential Infusion (96367, add-on(+))
      • Second Drug given is After the First
    • Concurrent infusion (96368)
      • Additional drug is given
        at the same time as the first drug
  • Subcutaneous Infusions (96369-96371)
  • Therapeutic, Prophylactic, and Diagnostic Injections (96372-96376)
    • Physician MUST Be Present
    • Add-on code only when service is in a facility
    • Method used for Administration
  • Subcutaneous and Intramuscular Injections (96372)
    • In addition to Substance Injected
    • Example
      • Subcutaneous Human Rabies Immune Globulin
        90375 (substance), 96372 (administration)
  • Vaccine/Toxoid Administration (90460, 90461, 90471-90474)
  • Intra-Arterial (96373)
  • Intravenous Push (96374, 96375, 96376)
  • Types of Drug Administration (Drug Administration Type)
    • Therapeutic
    • Prophylactic
    • Diagnostic
  • Codes divided by Administration Method (Administration Method)
    • Subcutaneous (SC)
    • Intramuscular (IM)
    • IV Push (Intravenous Push)
    • Intra-arterial
    • Injections are divided based on the method of injection
      Physician must be present for these injections
  • Push takes 15 minutes or less
  • Over 15 minutes is an Infusion
    • Infusions are based on time. The second hour must be 31 minutes or more
  • Also report the Substance Administered (J code)

Chemotherapy Administration (96401-96549)


  • Injection and Intravenous Infusion Chemotherapy (96401-96417)
    • Subcutaneous/Intramuscular
    • Intravlesional
    • Intravenous
  • Intra-Arterial Chemotherapy (96420-96425)
    • Administered via Arteries
  • Other Injection and Infusion Services (96440-96549)
    • Pleural (96440)
    • Peritoneal, Indwelling Port (96446)
    • Central Nervous System (CNS) (96450)
    • Portable, Implantable Pump, Reservoir
      Refilling, Maintenance (96521, 96522)
  • Preparation and Administration of Chemotherapy only
    • If separate E/M service provided, report E/M code and Modifier -25
  • Chemical can be Administered (injected into)
    • Lesion
    • Vein
    • Tissue
    • Muscle
    • Artery
    • Cavity
    • Nerve
  • Chemotherapy may be provided by several Modalities
  • Coders should read the patient record carefully before coding to ensure that the correct modality is identified
  • Intravenously Injected Chemicals:
  • Methods of Delivery of Chemical (x2)
    1. IV Push quickly puts into vein (15 minutes or less)
    2. IV Infusion delivers over longer period time (15 minutes or more)
  • Chemotherapy Administration codes are Covered
    only when drug being used is an Antineoplastic and Diagnosis is cancer
  • Why should a coder be familiar with the coding requirements of third-party payers for chemotherapy?
    (Some third-party payers will pay for both an IV push and an infusion on the same day; others will not.
    Knowing this helps to assure the correct reimbursement.)
  • Often divided on Time of Infusion/Injection procedure
    • Example:
      • Chemotherapy administration, intravenous infusion, up to 1 hour, single or initial substance/drug (96413)
  • When multiple drugs are given by different routes of administration,
    a separate fee will be paid for each route of administration
  • What determines the code to be used?
    (The method of treatment and the length of time taken to complete the treatment)
  • Some codes include several hours of treatment time, and others specify each hour of treatment time
  • Unit billing or multiple coding may be necessary to accurately reflect the services provided
  • Chemical Agent (substance) reported separately
  • Special supplies (e.g., special needles) reported separately; Level II HCPCS code or (99070)
  • When are codes from the Chemotherapy Administration subsection used?
    (In a clinical setting)
  • Are both the drug and the administration billable? (Yes)
  • Where would you find the codes for the drugs? (HCPCS book, J codes)
  • Intra-arterial Catheter Placement (Cutdown) (36640)
  • Intra-arterial route has coverage restrictions for Medicare
    (e.g., coverage is for patients with liver cancer, diagnosis codes 155.0-155.2 and 197.7) and colon cancer
    that is metastatic to the liver
  • Intra-arterial placement (injection is made into the artery)
  • Injections with Chemotherapy
    • Report separately any Analgesic or Antiemetic (for vomiting)
      • Before or after chemotherapy
      • Report both the administration and J-code
    • If the patient is given an additional medication before or after chemotherapy, such as an analgesic or antiemetic, administration of this medication is reported separately
    • Only one initial code can be billed per session so if a patient had chemotherapy infusion, 1 hour (96413) and an IV push of an antiemetic you would not use the code 90774 for the push as you have already used an initial code 96413. The correct codes to use would be 96413 for the chemotherapy agent administration and 90775 for the IV push of the antiemetic. The drugs would also be billed with the proper J codes.
    • The drugs given are also coded separately
  • Hydration provided prior to or following Chemotherapy (modifier -59)
  • Medication mixed, One Infusion, less than 15 mins (96375 X 1) + J codes
  • Office Visit in addition to Chemotherapy Administration (E/M + modifier -25)

Photodynamic Therapy (96570-96571)


  • Add on codes for Bronchoscopy, Endoscopy, Gastrointestinal codes
  • Injected agent remains in cancerous cells longer than normal cells
    • After agent dissipates from normal cells, lesion is exposed to laser light
    • Agent Absorbs Light
    • Photosensitizing agent produces oxygen and cancer cells are destroyed
  • How are codes for endoscopic application divided?
    (On the basis of time—the first 30 minutes and then each additional 15 minutes)
  • External application is based on each exposure session

Special Dermatological Procedures (96900-96999)


  • Usually Specialized Procedures Provided on Consultation Basis
    • Separate E/M consultation code then appropriate
  • Treatment of Skin Conditions:
    • Actinotherapy (with ultraviolet light)
    • Photochemotherapy (with light-sensitive chemicals and light rays)
  • What common dermatological condition is treated with Actinotherapy? (Acne)
  • Contact third-party payers regarding reimbursement as
    some of these procedures may be deemed cosmetic and not reimbursable

Physical Medicine and Rehabilitation (97001-97799)


  • Treatments and Patient Training
  • Used by Physicians and Therapists to report services for variety of treatments
    (Modalities of Treatments)
    • Traction
    • Electrical Stimulation (used to help heal fractures)
    • Therapeutic exercise
    • Whirlpool
  • Patient training:
    • Gait training
    • Functional activities
    • Massage
  • Often have Time Components
    • Example: Prosthetic training, per 15 minutes (97761)
  • Divided by Type of Therapy
    • Example: Physical or Occupational
  • Modalities Divided by
    • Supervised
    • Constant Attendance
  • Codes are reported on the basis of time or treatment area, as stated in the code description
  • When is Unit Coding necessary?
    (When the time spent administering the treatment exceeds the time listed in the code)
  • How are test and measurement codes listed?
    (By type of testing and by time the testing takes)
  • Physical Medicine and Rehabilitation Subsections
    • Modalities (Physical agent, Thermal, Acoustic, Light, Mechanical, Electrical)
      • Supervised
      • Constant Attendance
    • Therapeutic Procedures
    • Active Wound Care Management
    • Tests and Measurements
    • Orthotic Management and Prosthetic Management
    • Other Procedures

Active Wound Care Management (97597-97606)


  • Allied health professionals perform these procedures — NOT Physicians
  • Debridement Services
    • High pressure waterjets
    • Scissors
    • Scalpels
    • Forceps
    • First 20 sq cm or less (97597)
    • Each additional 20 sq cm (97598)
  • Based on Nonselective or Negative Pressure procedures
  • Nonselective debridement
  • Debridement
    • Nonselective healthy tissue removed along with necrotic tissue (97602)
    • Removal of necrotic tissue without anesthesia (97597, 97598)
    • Negative pressure wound therapy (NPWT) is
      controlled application of subatmospheric pressure to a wound (97605, 97606)
  • Each code for ongoing care reported on per session basis
  • NOT Used With, or to Replace, the Surgical Debridement codes 11042-11047
    What determines the codes that can be used?
    (The area [number of square centimeters] treated)

• :

  • Must document debridement was performed, level of tissue debrided, method of debridement
  • Document the size and character of wound before and after debridement
  • Document a treatment plan and patient education
  • Direct (One-to-One) Patient Contact

Medical Nutrition Therapy (97802-978804)


  • Nonphysician for Medical Nutritional Therapy Assessment (NTA) or Intervention
  • If Physician Provides Service (E/M code or Preventive Medicine code)
  • Fact to Face
    • Initial, Reassessment (15 mins)
    • Group (30 mins)

+Acupuncture (97810-97811)

Osteopathic Manipulative Treatment (OMT) (98925-98929)


  • Both Inpatient (IP) and Outpatient (OP) settings
  • Physician Manual Treatment
    • Eliminate or Alleviate Somatic (Body) Dysfunction and Related Disorders
  • Physician Services Bundled into Codes
  • Divided by Number of Body Regions Involved
    • Head region
    • Cervical region
    • Thoracic region
    • Lumbar region
    • Sacral region
    • Pelvic region
    • Lower extremities
    • Upper extremities
    • Rib cage region
    • Abdomen and Viscera region
  • Based on number of regions treated
  • Doctors of Osteopathy (DO)
  • What is osteopathic manipulative treatment?
    (A form of manual treatment applied by a physician to
    eliminate bodily dysfunction and related disorders)
  • Categorized on the basis of the number of body regions treated
  • What is chiropractic manipulation?
    (Manipulation of the spinal column and other structures)
  • Chiropractic Manipulative Treatment subsection is
    broken down according to the number of regions manipulated
  • If a separate identifiable service is provided (E/M code, Modifier -25)
  • Nonphysicians (98966-98969)

Chiropractic Manipulative Treatment (CMT) (98940-98943)


  • Divided by Number of Regions Manipulated
  • Professional Assessment Bundled
  • Spine Regions (x5)
    1. Cervical
    2. Thoracic
    3. Lumbar
    4. Sacral
    5. Pelvic
  • Extraspinal Regions (x5)
    1. Head
    2. Lower extremities
    3. Upper extremities
    4. Rib cage
    5. Abdomen

Non-Face-To-Face Nonphysician Services (98966-98968, 98969)


  • Divided into
    • Telephone Services (98966-98968)
      • Documented time
    • On-Line Medical Evaluation (98969)
      • Per incident
        • Qualified Health Care Professional
        • Cannot originate from a related assessment provided within previous 7 days OR
          • Result in an appointment within 24 hours or soonest available
  • Non-Face-to-Face Nonphysician Services (98966-98969) Report
    Telephone and Online E/M Services by Nonphysicians

Special Services, Procedures, and Reports (99000-99091)


  • Index: Special Services
  • Unusual Hours, Holidays
  • Adjunct Codes
  • Postoperative follow-up, Office Visit provided during Global Period (99024)
  • Supplies and Materials (99070)
    • HPCS code (more specific)
  • Hospital Mandated On-call Services (99026, 99027)
  • Medication Therapy Management Services (99605-99607)
    • Pharmacist’s Services in Medication Management
  • Other Codes Include
    • Medical Testimony
    • Completion of Complicated Reports
    • Education Services
    • Unusual Travel
    • Supplies
  • Handling and Conveyance Laboratory Specimens (99000-99002)
  • Postoperative Follow-up Visits Included in Surgical Package (99024)
  • Office Visits After Posted Hours or in Locations Other than Office (99053) (24-hour facility)
  • Medicare bundles most of the Special Services procedures
  • This is a miscellaneous section that includes codes that do not fit into other sections
  • Includes Postoperative Follow-up Visits
    When a patient comes in for a routine post-op E/M visit and is in a global period,
    99024 would be the correct code to use if there were no complications or other complaints.
    This has no reimbursement value. It just states that the patient was there and was seen

Qualifying Circumstances for Anesthesia (99100-99140)

Moderate Sedation (99143-99150)

Other Services and Procedures (99170-99199)


  • Anogenital Examination with Colposcope of Child, Suspected Trauma
  • Visual Function Screening
  • Pumping Poison from Stomach (Stomach Pumping)
  • Therapeutic Phlebotomy Treatment

Home Health Procedures/Services (99500-99602)


  • Nonphysician Services, Patient’s Residence
    • Assisted Living Apartment
    • Custodial Care Facility
    • Group Home
    • Other Nontraditional Residence
    • Divided based on Reason for Service

Home Infusion Procedures Services (99601, 99602)

  • Administration of Therapies
    • Nutrition
    • Chemotherapy
    • Pain Management
  • Nonphysician Allied Health Professionals
  • Divided Based on Time

Medication Therapy Management Services (99605-99607)

  • New or Established and Time
  • Pharmacist Patient Assessments and Interventions by Request
  • Assist in Management of Treatment Related Medication Complications and Interactions


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