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National Center for Health Care Capacity Building

Documentation and Coding

Resource Packet

Prepared by JMS Billing Solutions

PROPRIETARY INFORMATION PREPARED BY JMS BILLING SOLUTIONS, LLC FOR USE BY HEALTHHIV

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TABLE OF CONTENTS

Acronyms Used……………………………………………………………………………………….….. 3

Current Procedural Terminology Coding……………………………………………………………… 4

Evaluation and Management Services……………………………………………………….… 4

E&M Components……………………………………………………………………………..… 4

E&M Documentation Requirements…………………………………………………………… 9

Preventive Medicine Documentation Requirements………………………………………….. 10

Modifiers…………………………………………………………………………………………. 11

International Classification of Diseases, 10th Revision Clinical Modification Coding………………. 11

HIV/AIDS Diagnosis Coding…………………………………………………………………… 12

Inconclusive HIV Coding……………………………………………………………………….. 12

ICD-10-CM Code Sequencing…………………………………………………………………… 13

ICD-10-CM Code Tips………………………………………………………………………........ 13

Summary of Modifiers…………………………………………………………………………………… 14

Summary of Codes……………………………………………………………………………………….. 14

Evaluation and Management Codes…………………………………………………………… 14

HIV/AIDS ICD-10-CM Codes…………………………………………………………………… 15

AIDS Related Condition Codes………………………………………………………………… 16

HIV/AIDS Screening Codes…………………………………………………………………….. 17

Well Visit ICD-10-CM Codes……………………………………………………………………. 18

Miscellaneous Visit Codes………………………………………………………………………. 18

Supplemental Resources…………………………………………………………………………………. 19

Coding Resources………………………………………………………………………………… 19

Web Resources…………………………………………………………………………………… 20

State Medicaid Agencies………………………………………………………………………… 21


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Acronyms Used

• AMA – American Medical Association

• ARC – AIDS Related Complex

• CDC – Centers for Disease Control

• CLIA – Clinical Laboratory Improvement Amendments

• CMS – Centers for Medicare and Medicaid Services

• Dx - Diagnosis

• EIA – Enzyme Immunoassay

• ELISA – Enzyme Linked Immunosorbent Assay

• HHS – Health and Human Services

• HIV 1 – Human Immunodeficiency Virus 1

• HIV 2 - Human Immunodeficiency Virus 2

• OI – Opportunistic Infection

• WHO – World Health Organization

Coding Acronyms Used

• cc – Chief Complaint

• CPT - Current Procedural Terminology

• E&M – Evaluation and Management

• HCPCS – Healthcare Common Procedure Coding System

• HPI – History of Present Illness

• ICD-9-CM – International Classification of Diseases, 9th Revision, Clinical Modification

• ICD-10-CM – International Classification of Diseases, 10th Revision, Clinical Modification

• ICD-10-PCS – International Classification of Diseases, 10th Revision, Procedure Coding System

• MDM – Medical Decision Making

• PDx – Principal Diagnosis

• PE – Physical Examination

• PMFSH – Past Medical, Family and Social History

• ROS – Review of Systems

• SDx – Secondary Diagnosis

*Current Procedural Terminology (CPT) 2016 American Medical Association: Chicago, IL.


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Current Procedural Terminology (CPT) Coding

• Developed by AMA in 1966

• Updated annually (available January)

• CPT codes describe the procedures and services that are performed to treat medical conditions

• Reported on professional (physician) claims for services rendered on an outpatient basis

• CPT comprise of 6 sections: Evaluation & Management, Anesthesia, Surgery, Radiology,

Pathology and Laboratory, Medicine

Evaluation and Management Services E & M Codes (99201–99499)

Evaluation and Management E&M)

• Used to report medical (non-surgical) services provided by physicians

• Used by all specialties as appropriate

• Each E&M code is incremental in nature and reflects the resources necessary to provide health care

to patients

• E&M codes reflect medical care, preventive care and preventive counseling care

New vs. Established Patient Definition

• The E&M documentation guidelines provide a clear and concise definition of new vs. established

patient:

– New patient – has not received any face -to-face professional services from a physician within the

same health care entity within the last three years

• Established patient – has received face-to-face professional services from a physician within the

same health care entity within the last three years

– Commonly referred to as “follow up care”

E & M Documentation - Key Components • History

• Physical Examination

• Medical Decision Making

Component#1

History – a chronological description of the patient’s present illness related to the chief complaint

History includes:

• CC, HPI, ROS, PMFSH

• CC - a clear concise statement that describes the reason for the medical encounter typically in the

patient’s own words

• Usually the first sentence in the health record

• The medical record should clearly reflect the chief complaint

• The statement patient “here for follow up care” is insufficient as this does not clearly state the reason

for the patient seeking medical care

• Satisfactory statements include:

― Patient here for HIV test results follow up

― Patient here for antiretroviral therapy follow up

Each type of history includes documentation of some or all of the following History of Present Illness

Elements (HPI)


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HPI elements

• Location – symptomatic areas

• Quality – the quality of the symptom

• Severity – intensity of the symptom

• Duration – how long the symptoms occurred

• Timing – onset of the symptoms

• Context – what the patient was doing when symptoms began

• Modifying factors – factors that improve or worsen the patient’s symptoms

• Associated signs and symptoms – additional complaints that add to the symptoms

Review of Systems (ROS)

• The status of each body system

• Defines the problem

• Clarifies differential diagnoses

• Identifies the need for diagnostic tests

• Serves as baseline data for other affected body systems that may impact management and treatment

options

ROS – Body Systems

• Constitutional systems

• Eyes

• Ears, nose, mouth, throat

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Integumentary

• Neurological

• Psychiatric

• Endocrine

• Hematologic/Lymphatic

• Allergic/Immunologic

Past Medical, Family and Social History (PMFSH) Elements

PMFSH consists of a review of 3 areas:

• Past medical history – personal illnesses, injuries, major operations and medication

• Past family history – review of family medical illnesses

• Past social history – age appropriate review of past and current activities

• Documentation of all 3 areas is required for new patient encounters

Component#2

Physical Examination (PE):

• An objective assessment of organ systems or body areas pertinent to the medical complaint, illness

or injury

• The extent of the exam performed depends on the physician’s clinical judgment and the patient’s

reason for seeking medical attention


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PE Body Areas

• Head, including face

• Neck

• Chest, including breast and axillae

• Abdomen

• Genitalia, groin, buttocks

• Back

• Each extremity

PE Organ Systems

• Constitutional systems

• Eyes

• Ears, nose, mouth, throat

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Integumentary

• Neurological

• Psychiatric

• Endocrine

• Hematologic/Lymphatic

• Allergic/Immunologic

Physical Exam Documentation Tips

• Examine the body systems/body areas related to the presenting problem

• Abnormal and relevant negative exam findings of the affected or symptomatic body areas or organ

systems must be documented in detail

o A statement of “normal” is sufficient

o A statement of “abnormal” or “asymptomatic” without any explanation is not

acceptable

o Examples include:

Abnormal skin/positive for skin rashes or lesions should be documented as

“discolored skin lesions on the left arm and face”

The AMA and CMS developed a set of physical examination documentation guidelines in 1995 and

again in 1997

• The 1995 guidelines are ambiguous and somewhat subjective

• The 1997 guidelines reflect clearly defined examination elements for physicians to understand

• Physicians may choose to use either set of guidelines; but not both

Component#3

Medical Decision Making (MDM)

Complexity of establishing final diagnoses, selection of management options, and/or preparation of the

patient’s treatment plan.

MDM is determined by:

• Number of possible diagnoses and/or management options considered

• Documentation of data reviewed, amount of data and/or complexity data for review

• Risks of significant complications, morbidity and/or mortality relevant to the reason for seeking

healthcare


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Number of possible diagnoses and/or management options considered:

• Clinical impression

• Management plans and/or further evaluation

• If treatment is for an established condition, documentation should clearly reflect whether the

problem is improving, well controlled, resolving, resolved, controlled, inadequately controlled,

worsening or failing to change as expected

• The initiation of, or change in treatment or medication must be clearly documented

• Referrals to specialists must clearly reflect the type of specialist and reason for the referral

Documentation of data reviewed and/or complexity of data for review:

• Diagnostic tests such as labs, radiology or procedures which are ordered

• Review of diagnostic test results such as labs, radiology or other procedure results

• Discussions with health care professionals who performed labs, radiology or procedures

• Direct visualization and independent interpretation of image tracings or lab specimens that were

previously interpreted by other physicians

• Relevant findings from old medical records, history obtained from family members, caretakers or

other sources

Risks of significant complications, morbidity and/or mortality relevant to the reason for seeking

healthcare based on:

• The risks associated with the presenting problems, diagnostic tests, procedures and specialty referrals

• The risks related to the disease process anticipated between the present encounter and the next

encounter

• Diagnostic tests, procedures and specialty referrals based on the risks during and immediately after

diagnostic tests, procedures and specialty referrals

The E&M Table of Risk is used to help determine whether the risk of significant complications,

morbidity, and/or mortality is minimal, low, moderate, or high. Because the determination of risk is

complex and not readily quantifiable, the table includes common clinical examples rather than absolute

measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the

disease process anticipated between the present encounter and the next one. The assessment of risk of

selecting diagnostic procedures and management options is based on the risk during and immediately

following any procedures or treatment. The highest level of risk in any one category (presenting

problem(s), diagnostic procedure(s), or management options) determines the overall risk.


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E&M Table of Risk Level of Risk Presenting

Problem Diag.

Procedures Ordered

Management Options

Minimal *One self-limited or minor problem (e.g., cold, insect bite, tinea corporis)

*Lab tests – venipuncture *Chest X-ray *EKG/EEG *Urinalysis *Ultrasound *KOH Preparation

*Rest *Gargle *Elastic bandages *Superficial dressings

Low *Two/more self-limited minor prob. *One stable chronic illness *Acute uncomplicated illness or injury

*Physiologic tests not under stress (e.g., pulmonary function) *Non-cardio imaging with contrast (e.g., barium enema) *Superficial needle/skin biopsy *Clinical lab tests (i.e. arterial puncture)

*Over-the-counter drugs *Minor surgery/no risk factors *PT *OT *IV fluids w/o additive

Moderate *One/more chronic illnesses w/mild progression-side effect treatment *Two/more stable chronic illnesses *Undiagnosed new problem w/uncertain prognosis *Acute illness with systemic symptoms (e.g. pneumonia, colitis) *Acute uncomplicated injury

*Physiologic tests under stress *DX endoscopies w/o risk factor *Deep needle biopsy *Refer patient for consult *Cardio imaging studies w/contrast, w/o risk factors *Obtain body cavity fluid

*Minor surgery w/risk factor *Elective major surgery w/o risk factor *Prescription management *Treatment nuclear medicine *Closed fracture treatment/dislocation w/o reduction *IV fluids w/additives

High *One/more chronic illness w/severe progression – side effect of treatment *Acute/chronic illnesses/injuries threat to life *Abrupt neurologic change

*Cardio imaging studies w/contrast, w/risk factor *Cardiac electrophysiologic tests *Diag. endoscopies w/risk factor *Discography

*Elective major surgery w/risk factor *Emergency major surgery *Parenteral controlled substances *Drug treatment with intense monitoring for toxicity *Decision not to resuscitate or to de-escalate care due to poor prognosis


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Evaluation and Management Services

Documentation Requirements

There are general principles of medical record documentation that are applicable to health care services in all

settings. The following general principles help ensure that medical record documentation for all E&M

services is appropriate:

The medical record should be complete and legible

The documentation of each patient encounter should include:

o Reason for the encounter and relevant history, physical examination findings, and prior diagnostic

test results

o Assessment, clinical impression, or diagnosis

o Medical plan of care

o Date and legible identity of the observer

Past and present diagnoses should be accessible to the treating and/or consulting physician

Appropriate health risk factors should be identified

The patient’s progress, response to and changes in treatment, and revision of diagnosis should be clearly

documented

The diagnosis and treatment codes reported on the health insurance claim form should be supported by

the documentation in the medical record

The code sets used to bill for E&M services are organized into various categories and levels. In general, the

more complex the visit, the higher the level of code reported. In order to report any code, the services

furnished must meet the definition of the code. The code definition comprises of Three (3) Key

Components:

History – chief complaint, history of present illness, review of systems and past medical, family and

social history

Physical Examination – a general multi-system or single system examination of the body areas/organ

systems pertinent to the chief complaint

Medical decision making – establishing final diagnoses and management of treatment options

All new patient/initial visits require documentation of all 3 components. Established patient/subsequent

visits require clear and concise documentation of 2 of the 3 components. Medical decision making should

always be 1 of the components of an established patient visit. In order to maintain an accurate medical

record, services should be documented during the encounter or as soon as practical after the encounter.

Documentation is the key to ensuring that the level of service provided justifies the E&M visit code.

When ordering diagnostic ancillary services on your patients (i.e. lab work, radiology, physical therapy,

etc), be sure to properly document the medical condition that establishes the reason for ordering

these services in the medical record, on any requisition forms and on medical claims.


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Preventive Medicine Visits

Documentation Requirements

Preventive/well visit services are comprehensive in nature and include:

A comprehensive health and developmental history, review of systems, past family and social history

and assessment and history of pertinent risk factors

An age and gender appropriate multi-system physical examination which should include a Body

Mass Index (BMI) assessment

Anticipatory guidance, health education, risk factor reduction and/or interventions and age

appropriate counseling. Counseling should include: HIV, nutrition, exercise, depression/mental

health, tobacco, alcohol and substance abuse. The ordering of appropriate immunizations and/or the need for laboratory/diagnostic screening

exams

Management of insignificant problems or the status of previously diagnosed stable conditions (SEE

NOTE)

The comprehensive history and examination performed during a preventive medicine visit are not the same as

the comprehensive history and exam that are required for a problem-oriented Evaluation and Management

(E&M) sick visit.

If a significant amount of additional work or effort is necessary to treat an abnormality or illness which results

in a problem oriented sick visit during the preventive medicine visit encounter, both services should be

reported with the applicable CPT code. The sick visit service should be reported with a problem oriented

E&M sick visit CPT code and all of the sick visit ICD-10-CM codes should be reported. The well visit service

should be reported with the preventive medicine visit E&M CPT code and the well visit ICD-10-CM code.

Append modifier 25 to the preventive medicine visit E&M service code.

Documentation is the key to whether or not the additional work performed during the preventive medicine

visit justifies the reason for assigning an additional E&M visit code.

NOTE: The Preventive Medicine Services CPT guidelines state, “An insignificant/trivial problem or

abnormality that is encountered during a preventive medicine evaluation and management service

which does not require additional work and does not require the performance of the key components of

a problem-oriented E/M service should not be reported”.

Please refer to the Evaluation & Management Services section of the CPT code book for specific

reporting instructions.


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HIV Testing Documentation

First visit consists of:

• The signed HIV consent form

• HIV test results

• Notation that the test results were communicated to the patient

Second visit consists of:

• Written justification for the rationale for the second or subsequent HIV test visit (i.e. risks identified

during the first visit requiring further counseling)

HIV Counseling without Testing

• Written justification that counseling was provided

• The reason why the patient declined testing

• The follow up care plan, including indications for further counseling and testing

HIV Counseling Documentation (Positive Results for Asymptomatic HIV or AIDS Infection)

Initial visit for confirmed results consists of:

• Preliminary or confirmatory positive test results

• Referrals for medical care and supportive services

• Follow up to confirm continuum of care

• Prevention/risk reduction counseling and follow up care plan

• Partner counseling and assistance including domestic violence screening

• Medical Provider HIV/AIDS Report and Partner Contact Form

Annual assessments consist of:

• Prevention/risk reduction counseling and follow up care plan

• Partner counseling and assistance including domestic violence screening

While various state Medicaid agencies suggest the use of the rapid HIV test, it is the health care provider’s

discretion to order a rapid HIV screen or the conventional HIV screening test. Contact your local Medicaid

agency for specific guidance

Rapid HIV tests – G0435, 86701, 86702 and 86703

• Orasure Technology

• Trinity Biotech Uni-Gold

• One test payable every 6 months

Venipuncture – blood sample or urine sample collection

• CPT 36415 – routine venipuncture

• If HIV blood screening performed, must also report code 36415

Modifiers What are Modifiers? Modifiers are two-digit (numeric or alpha numeric) codes that indicate that a procedure or service has been

altered by a specific circumstance, but has not changed the code’s definition

• There are CPT modifiers and HCPCS modifiers

• Some modifiers impact reimbursement

• Modifiers are never reported alone

• Each state Medicaid agency determines the approved modifiers

• Contact your local Medicaid agency for specific guidance


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Modifiers commonly reported with HIV Services

Modifier 25 - Significant, Separately, Identifiable E&M Service by Same MD on the Same Day of a

Procedure, Service or Other E&M Service

• Only report with E&M service codes (99201-99499)

• Do NOT report with lab codes

• Do NOT report with HCPCS codes


Modifier 92 - Alternative Laboratory Platform Testing

With current CDC recommendations on routine testing and the move toward HIV testing as a routine part of

care, more providers may use rapid test kits. Several of these are CLIA-waived and suitable for use in

physician offices. The following is the CPT guidance for use of this modifier:

“When laboratory testing is being performed using a kit or transportable instrument that wholly or in part

consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92

to the usual laboratory procedure code (HIV testing 86701-86703).”

• Only report with Path/Lab test codes (86701-86703)

• Do NOT report on E&M codes


Modifier QW - CLIA waived test

In accordance with the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), a laboratory

provider must have: a Certificate of Compliance, a Certificate of Accreditation or a Certificate of

Registration in order to perform clinical diagnostic laboratory procedures of high or moderate complexity.

Waived tests include test systems cleared by the FDA designated as simple, have a low risk for error and are

approved for waiver under the CLIA criteria.

• Only report with Path/Lab test codes (86701-86703)

• Do NOT report on E&M codes

• If a combination of waived and non-waived tests are performed, modifier QW should not be used.


International Classification of Diseases

• ICD-9 codes developed by the World Health Organization in 1948

• ICD-9-CM revised and published for use in 1979

• CMS mandated the use of ICD-9-CM codes on all claims since October 1988

• CMS revised these mandates to reflect “mandatory” correct reporting of ICD-9-CM codes on all claims

• ICD-9-CM codes describe medical conditions, (diseases) and injuries and poisoning

• Updated annually

• Reported on all claim types (physician, institutional, pharmacy, DME, etc)

The ICD-9 Coding System was phased out October 1, 2015 and replaced with two new Coding Systems:

ICD-10-CM & ICD-10-PCS


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• The ICD-10 Coding System is consistent with changes in health care and provides more codes that reflect

emerging technology

• ICD-10-CM codes are used to report medical conditions

• ICD-10-PCS codes are reported on inpatient hospital (institutional) claims only to reflect the facility bill

• Continue reporting CPT & HCPCS codes for services rendered by physicians

• Continue reporting ICD-9-CM codes for services rendered through September 30, 2015

• Claims submitted with ICD-10 codes for services rendered now through September 30, 2015 will be denied

• Begin reporting ICD-10-CM codes for services rendered on or after October 1, 2015

• Claims submitted with ICD-9-CM codes for services rendered on or after October 1, 2015 will be denied

HIV/AIDS Diagnosis Coding

According to the ICD-10-CM coding guidelines, ICD-10-CM code B20 includes the following terms:

• Acquired immune deficiency syndrome;

• Acquired immunodeficiency syndrome;

• AIDS;

• AIDS-like syndrome;

• AIDS-related complex; and

• HIV infection, symptomatic

• HIV 1

Use additional code(s) to identify all manifestations of HIV

Use additional code to identify HIV-2 infection (B97.35)

EXCLUDES:

– asymptomatic HIV infection status (Z21)

– exposure to HIV virus (Z20.6)

– nonspecific serologic evidence of HIV (R75)

Report code B97.35 for Human immunodeficiency virus, type 2 [HIV-2]

“ICD-10-CM Official Coding Guidelines” Code Book Excerpts:

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) a. Human Immunodeficiency Virus (HIV)

Infections

2) Selection and sequencing of HIV codes

(d) Asymptomatic human immunodeficiency virus Z21, Asymptomatic human immunodeficiency

virus [HIV] infection status, is to be applied when the patient without any documentation of

symptoms is listed as being “HIV positive,” “known HIV,” “HIV test positive,” or similar

terminology. Do not use this code if the term “AIDS” is used or if the patient is treated for any

HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive

status; use B20 in these cases.

(f) Previously diagnosed HIV-related illness Patients with any known prior diagnosis of

an HIV-related illness should be coded to B20. Once a patient has developed an HIV-

related illness, the patient should always be assigned code B20 on every subsequent

admission/encounter. Patients previously diagnosed with any HIV illness (B20) should

never be assigned to R75 or Z21, Asymptomatic human immunodeficiency virus [HIV]

infection status.


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Inconclusive HIV Diagnosis Coding

• Newborn babies born to HIV+ mothers often have a diagnosis of HIV+ as a result of the mother’s antibody

status instead of the newborn

• The diagnosis of HIV+ in newborns lasts up to 18 months after without the newborn ever becoming infected.

This is known as a “False Positive” result

• Another term for “False Positive” is inconclusive HIV test results

• Inconclusive test results are reported with ICD-10-CM code R75

• People with healthy immune systems can be exposed to four (4) types of infections with no reaction: viral,

bacterial, fungal and parasitic

• People living with HIV/AIDS are not as fortunate

• HIV/AIDS related “opportunistic infections” take advantage of the weakened immune system resulting in

life threatening illnesses

• The most severe OI’s occur when the CD4 count is below 200 cells/mm3

• Patients diagnosed with any OI’s are no longer considered to be HIV+

The CDC has a comprehensive list of OI’s located on their web page.

Most common OI’s:

• Candidiasis (Thrush)

• Cytomegalovirus (CMV)

• Herpes simplex viruses (chronic)

• Kaposi Sarcoma

• Pneumocystis pneumonia (PCP)

• Mycobacterium avium complex (MAC or MAI)

• Toxoplasmosis (Toxo)

• Tuberculosis (TB)

• Recurrent severe bacterial pneumonia

• Wasting Syndrome

• Malaria

ICD-10-CM Code Tips

• Only confirmed cases of AIDS or HIV infection should be coded

• Chart documentation that states “possible”, “probably”, “rule out”, “suspected” or “suspicion of” are

never reported as AIDS (Dx B20)

• A diagnosis of HIV+ and asymptomatic HIV (Z21) is not the same as a diagnosis of HIV infection,

symptomatic HIV/AIDS and AIDS (B20)

• Patients may test positive for HIV but may not become sick for many years

• Once a diagnosis of HIV infection, symptomatic HIV/AIDS or AIDS is documented in the health record,

report ICD-9-CM code B20

• Symptomatic HIV (code Z21) and inconclusive HIV (code R75) are never reported once a patient has a

confirmed diagnosis of AIDS (code B20)

• Health record documentation which states that the patient has:

– HIV+, has not been diagnosed with an HIV-related illness (past or present), they are considered to be

asymptomatic; assign code is Z21

– HIV asymptomatic but is currently being treated for any HIV-related illness or is described as having

any condition(s) resulting from HIV+ status; assign code B20

– HIV 2 infection; assign code B20 and code B97.35


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– Inconclusive or nonspecific HIV test results; assign code R75

– Exposure to or contact with someone who has HIV/AIDS; assign code Z20.6 (note that this code is

reported as an SDX; never as the PDx)

– Engaged in unsafe sex practices that increases their risk; assign code Z72.89

– Present for a well visit encounter that includes HIV testing and counseling; assign codes Z00.00/Z00.01

and Z71.7

• Present for HIV testing and counseling; assign codes Z11.4 and Z71.7

• Once medical record documentation states any of the common OI’s, assign ICD-9-CM code B20 as the

principal diagnosis and the OI condition as the secondary diagnosis.

• Some opportunistic infections (OI’s), are inherent to HIV, such as pneumocystis carinii pneumonia (B59)

and Kaposi’s sarcoma (C46.-)

ICD-10-CM Code Sequencing

• When it is necessary to report multiple diagnoses codes, accurate interpretation of coding guidelines

ensures proper code sequencing

• Coding guidelines that denote “principle diagnosis” vs “secondary diagnosis” only, must be adhered to

• OI infections codes are always assigned as the secondary diagnoses (when reported)

• The HIV-2 code is always assigned as the secondary diagnosis code (when reported)


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Modifiers

E&M

MODIFIER

NARRATIVE DESCRIPTION

25 Significant, separately, identifiable E&M service by same MD on same day as another

procedure/service

MODIFIERS NARRATIVE DESCRIPTION QW CLIA waived test

92 Alternative laboratory platform testing

E&M CPT Codes

E&M CPT

CODES

NARRATIVE DESCRIPTION

99201-99205 OFFICE/OUTPATIENT VISITS - NEW PATIENT: 99201 – Level 1

99202 – Level 2

99203 – Level 3

99204 – Level 4

99205 – Level 5

99211-99215 OFFICE/OUTPATIENT VISITS - ESTABLISHED PATIENT: 99211 – Level 1

99212 – Level 2

99213 – Level 3

99214 – Level 4

99215 – Level 5

99381-99387 INITIAL PREVENTIVE/WELL VISITS - NEW PATIENT: 99381 - Age Younger Than 1 Year

99382 - Early Childhood (Age 1 to 4 Years)

99383 - Late Childhood (Age 5 to 11 Years)

99384 - Adolescent (Age 12 to 17 Years)

99385 - Early Adult (Age 18 to 39 Years)

99386 - Adult (Age 40 to 64 Years)

99387 - Late Adult (65 Years of age and older)

99391-99397 FOLLOW UP PREVENTIVE/WELL VISITS - ESTABLISHED PATIENT: 99391 - Age Younger Than 1 Year

99392 - Early Childhood (Age 1 to 4 Years)

99393 - Late Childhood (Age 5 to 11 Years)

99394 - Adolescent (Age 12 to 17 Years)

99395 - Early Adult (Age 18 to 39 Years)

99396 - Adult (Age 40 to 64 Years)

99397- Late Adult (65 Years of age and older)

99401-99404

PREVENTIVE MEDICINE COUNSELING AND/OR RISK FACTOR

REDUCTION (WITHOUT HISTORY AND PHYSICAL EXAM) PROVIDED TO

AN INDIVIDUAL: Approximately 15 minutes

Approximately 30 minutes



NOTE: Well/preventive visit services are comprehensive in nature and include counseling and anticipatory

guidance. These services can be reported by physicians and other qualified physician practitioners (i.e. Nurse

Practitioners, Physician Assistants). Refer to page#10 for preventive services documentation requirements.


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HIV/AIDS ICD-10-CM CODES

ICD-9-CM

CODES

NARRATIVE DESCRIPTION ICD-10-CM

CODES

V08 Asymptomatic HIV

Includes:

HIV+

HIV+ status

Z21

V01.79

Exposure to HIV/AIDS

Includes:

Pre-exposure to HIV/AIDS

Z20.6

V69.2 High risk sexual behavior Z72.51-Z72.53

V65.44 HIV Counseling Z71.7

042 HIV Disease

Includes:

AIDS

AIDS like syndrome

AIDS related complex (ARC)

Symptomatic HIV infection

HIV 1

B20

079.53 HIV 2

Report as secondary diagnosis code ONLY (when

applicable)

B97.35

795.71 Nonspecific Evidence of HIV

Includes:

Inconclusive HIV test

False positive results

False +

R75

V69.8

Other Problems Related to Lifestyle

Includes:

Asymptomatic high risk

Report as secondary diagnosis code (when applicable)

Z72.89

V73.89 Special Screening for Other Specified Viral Diseases

Includes:

HIV/AIDS

Z11.4


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AIDS RELATED CONDITION ICD-10-CM CODES

ICD-9-CM

CODES


CODES

112.84 Candidiasis - Esophageal B37.81

112.4 Candidiasis – Lungs, Bronchi & Trachea (Pulmonary) B37.1

112.0 Candidiasis – Oral

Thrush B37.0

078.5 Cytomeglavirus B25.0-B25.9

054.9 Herpes Simplex Virus – Chronic

HSV B00.9

176.0-176.9 Kaposi Sarcoma C46.0-C46.9

031.2 Mycobacterium avium complex or M. kansasii, disseminated or

Extrapulmonary

DMAC, MAC, MAI

A31.2

136.3 Pneumocystis pneumonia

PCP B59

130.0 Toxoplasmosis of brain B58.2

011.90 Pulmonary TB A15.0

482.9 Bacterial Pneumonia

Bacterial PNA J15.9

348.30 HIV related Encephalopathy G93.40-G93.49

799.40 Wasting Syndrome

Cachexia R64

NEW ICD-10-CM CODE CHANGES

Some codes now require the following 7th character values:

Injury, Poisoning and Certain Other Consequences of External Causes

Diseases of the musculoskeletal system (pathological fractures)

7th Digit Description Coding Guidelines

A Initial Encounter (for active treatment) Patient receiving active treatment i.e. surgery, ED,

Physician clinic/Office visit

D Subsequent encounter (routine follow up

once active treatment completed)

Patient completes active treatment and presents for

routine follow

S Sequela (new condition develops as a

result of previous injury or condition) Patient follow up for sequale or residual effect

ACCIDENTAL FINGERSTICK ICD-10-CM CODES

ICD-9-CM

CODES

ICD-10 NARRATIVE DESCRIPTION

(Report as secondary diagnosis code ONLY)

ICD-10-CM

CODES

E920.5 –

accident caused

by hypodermic

needle

(needlestick)

Contact with hypodermic needle, initial encounter W46.0xxA Contact with hypodermic needle, subsequent encounter W46.0xxD Contact with hypodermic needle, sequela W46.0xxS Contact with contaminated hypodermic needle, initial encounter W46.1xxA Contact with contaminated hypodermic needle, subsequent

encounter W46.1xxD

Contact with contaminated hypodermic needle, sequela W46.1xxS


19

HIV/AIDS SCREENING SERVICE CODES

CPT CODES NARRATIVE DESCRIPTION

36415 Venipuncture

Includes:

Includes collection of blood by venipuncture

Routine venipuncture

Phlebotomy

CPT/HCPCS CODES NARRATIVE DESCRIPTION (ANTIBODY)

*86701 HIV 1; single result

*G0435 HIV 1 and/or HIV 2; single result

*86702 HIV 2, single result

*86703 HIV 1 & HIV 2; single result

86689 HIV confirmatory (Western Blot)

CPT/HCPCS CODES NARRATIVE DESCRIPTION (ANTIGEN)

87389 EIA HIV 1 antibody with HIV 1 & HIV2 antigens; qualitative or semi-

quantitative; single step

G0432 EIA; HIV 1 and/or HIV 2

87390 EIA HIV 1; qualitative or semi-quantitative; multi-step

87391 EIA HIV 2; qualitative or semi-quantitative; multi-step

G0433 ELISA; HIV 1 and/or HIV 2

87534 DNA/RNA; HIV 1; direct probe

87535 DNA/RNA; HIV 1; amplified probe

87536 DNA/RNA; HIV 1; quantification

87537 DNA/RNA; HIV 2; direct probe

87538 DNA/RNA; HIV 2; amplified probe

87539 DNA/RNA; HIV 2 quantification

NOTE: * Describes Quick /Rapid HIV Test performed in an office or clinic setting. Must possess a valid CLIA Certificate of

Waiver issued by CMS and you must append modifier QW to CPT code 87880. Please go to CMS’ website for a list of CLIA

waived tests that require a CLIA Certificate.

All other codes can only be reported by an Internist, Family Practitioner, etc if you possess a valid CLIA license.


20

WELL VISIT ICD-10-CM CODES

ICD-9-CM

CODES


CODES V20.2 Routine infant, child or adolescent checkup/exam – Ages 29 days to – 17 years old Z00.121,

Z00.129

V20.31 Routine newborn checkup/exam – Newborn 0 to 7 days old Z00.110

V20.32 Routine newborn checkup/exam – Newborn 8 days to 28 days old Z00.111

V70.0 Routine adolescent or adult checkup/exam – Ages 18 years and older Z00.00-Z00.01

V70.3 General medical exam for:

Camp

School admission

Sports competition

Z02.0, Z02.2,

Z02.4-Z02.6,

Z02.82, Z02.89

V70.5 General exam for pre-school age children

V70.6 Health examination in population surveys Z00.6, Z00.8

V70.8 Other specified general medical examinations Z00.8

V70.9 Unspecified general medical examination Z02.9

NOTE: When assigning any ICD-10-CM codes from category Z00.- as the principal diagnosis code, an

additional code may be required (as a secondary diagnosis code) to identify special screening examinations for:

Viral and chlamydial diseases

Bacterial and spirochetal diseases

Other specified infectious diseases

Malignant neoplasms/cancer conditions

Endocrine, nutritional, metabolic & immunity disorders

Blood & blood forming organs

Mental disorders and developmental handicaps

Neurologic, eye and ear diseases

Cardiovascular, respiratory, and genitourinary diseases

Other conditions

MISCELLANEOUS VISIT CODES

ICD-9-CM

CODES

NARRATIVE DESCRIPTION ICD-10-CM CODES

V15.81 Noncompliance with medical treatment

Against medical advice

Z91.11, Z91.120- Z91.128,

Z91.130- Z91.138, Z91.14, Z91.19

V58.61-V58.67 Long term (current) use of medication Z79.01-Z79.899

V58.69 Long term (current) use of other specified medication such as:

High risk medication

Methadone

Opiate analgesic

Z79.891

*V68.1 Prescription refill Z76.0

NOTE:

Disclaimer: Please refer to the latest coding reference books to verify all codes contained in this packet. Where applicable,

some ICD-10-CM codes must be assigned to the highest level of specificity (7th character designation). CPT codes and some

HCPCS codes may require add-on codes to accurately report services rendered. Reporting services with invalid codes could

result in payment denial or delay in payment.


21

Coding Resources

• CPT® 2016 Professional Edition. Publisher: American Medical Association.

• Pocket Guide to E&M Coding and Documentation. Publisher: Healthcare Quality

Consultants.

• HCPCS Level II 2016. Publisher: Ingenix Optum.

• ICD-9-CM, Volumes 1 & 2, Professional. Publisher: Ingenix Optum.

• ICD-10-CM and ICD-10-PCS Coding Handbook 2016, Nelly Leon-Chisen, RHIA.

Publisher: American Hospital Association.

• ICD-10-CM Fast Finder Sheets. Publisher: Ingenix Optum.

Note: Coding resources are updated annually. Please be sure to update coding resources each year.


22

WEB RESOURCES

• Centers for Medicare and Medicaid Services (CMS) –

http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html

http://www.cms.gov/center/coverage.asp

• Food and Drug Administration (FDA) –

http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDRegulatoryAssista

nce/default.htm

• American Medical Association (AMA) –

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-

practice/coding-billing-insurance/cpt.page

• National Center for Health Statistics (NCHS)


• Centers for Disease Control (CDC)

http://www.cdc.gov/mmwr/index.html

• American Academy of Professional Coders (AAPC)

http://www.aapc.com/resources/index.aspx

• American Health Information Management Association (AHIMA)

http://www.ahima.org/resources/default.aspx

• The American Academy of Family Physicians (AAFP) -

www.aafp.org/online/en/home/practicemgt/codingresources.html

• American Hospital Association (AHA)

http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml


http://www.cms.gov/center/coverage.asp

http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDRegulatoryAssistance/default.htm

http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDRegulatoryAssistance/default.htm

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-%20%20%20%20%20%20%20%20%20%20practice/coding-billing-insurance/cpt.page

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-%20%20%20%20%20%20%20%20%20%20practice/coding-billing-insurance/cpt.page


http://www.cdc.gov/mmwr/index.html

http://www.aapc.com/resources/index.aspx

http://www.ahima.org/resources/default.aspx

http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml


23

State Medicaid Agencies

The following is a list of Medicaid Agencies for the United States and the surrounding territories.

Complete mailing address, telephone number, fax number, email address and web page information is

available for your convenience. To access the web page, click on Contact the STATE NAME HERE

Department of Health hyperlink. To narrow your search, type any of the following to:

Medicaid Billing

Provider Billing

HIV Coding Guidelines

State Health Departments

Alabama Kentucky North Dakota

Alaska Louisiana Ohio

Arizona Maine Oklahoma

Arkansas Maryland Oregon

California Massachusetts Pennsylvania

Colorado Michigan Rhode Island

Connecticut Minnesota South Carolina

Delaware Mississippi South Dakota

District of Columbia Missouri Tennessee

Florida Montana Texas

Georgia Nebraska Utah

Hawaii Nevada Vermont

Idaho New Hampshire Virginia

Illinois New Jersey Washington

Indiana New Mexico West Virginia

Iowa New York Wisconsin

Kansas North Carolina Wyoming

Territorial Health Departments

American Samoa Northern Mariana Islands U.S. Virgin Islands

Guam Puerto Rico

REVISED 02/11/2016

http://www.medicaid.alabama.gov/

http://chfs.ky.gov/dms

http://www.nd.gov/dhs/services/medicalserv/medicaid

http://dhss.alaska.gov/dpa/pages/medicaid/default.aspx

http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

http://medicaid.ohio.gov/

http://www.azdhs.gov/

http://www.maine.gov/dhhs/oms

https://www.okhca.org/

https://www.medicaid.state.ar.us/

https://www.marylandhealthconnection.gov/medicaid-basics-benefits

http://www.oregon.gov/oha/healthplan/pages/stateplan.aspx

http://www.dhcs.ca.gov/Pages/default.aspx

http://www.mass.gov/eohhs/gov/departments/masshealth

http://www.dhs.pa.gov/citizens/healthcaremedicalassistance/#.VuhZQUvZWhM

https://www.colorado.gov/pacific/hcpf/colorado-medicaid

http://www.michigan.gov/mdhhs/0,5885,7-339-71547_4860---,00.html

http://www.dhs.ri.gov/Programs/index.php

http://www.ct.gov/dss/cwp/view.asp?a=2353&q=305218

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=Health_Care

https://www.scdhhs.gov/site-page/medicaid

http://www.dhss.delaware.gov/dmma/

https://www.medicaid.ms.gov/

https://dss.sd.gov/medicaid/generalinfo/medicalprograms.aspx

https://www.dc-medicaid.com/dcwebportal/home

http://dss.mo.gov/fsd/msmed.htm

https://www.tn.gov/tenncare

http://www.myflfamilies.com/service-programs/access-florida-food-medical-assistance-cash/medicaid

http://dphhs.mt.gov/montanahealthcareprograms/welcome/memberservices

https://www.hhsc.state.tx.us/medicaid

https://dch.georgia.gov/medicaid

http://dhhs.ne.gov/medicaid/Pages/medicaid_index.aspx

https://medicaid.utah.gov/

http://humanservices.hawaii.gov/mqd

https://www.medicaid.nv.gov/

http://dvha.vermont.gov/

http://healthandwelfare.idaho.gov/Default.aspx?TabId=123

http://www.dhhs.nh.gov/ombp/medicaid

http://www.dss.virginia.gov/benefit/medical_assistance

http://www.illinois.gov/hfs/Pages/default.aspx

http://www.state.nj.us/humanservices/dmahs/clients/medicaid

http://www.hca.wa.gov/medicaid/Pages/index.aspx

http://www.in.gov/fssa/2408.htm

http://www.hsd.state.nm.us/

http://www.dhhr.wv.gov/bms/Pages/default.aspx

http://dhs.iowa.gov/ime/about

http://www.health.ny.gov/health_care/medicaid

https://www.dhs.wisconsin.gov/medicaid/index.htm

http://www.kdheks.gov/hcf/Medicaid

https://dma.ncdhhs.gov/medicaid

http://www.health.wyo.gov/healthcarefin/medicaid/home.html

http://medicaid.as.gov/

http://chcc.gov.mp/

http://www.dhs.gov.vi/financial_programs/medical_assistance.html

http://dphss.guam.gov/article/2013/04/11/guam-medicaid-program

http://www.salud.gov.pr/Servicios-al-Ciudadano/Pages/Programa-de-Asistencia-Medica-Tarjeta-de-Salud.aspx

@HealthHIV

www.Facebook.com/HealthHIV

http://www.YouTube.com/HealthHIV

http://tinyurl.com/HealthHIVLinked

E-mail: [email protected]

Telephone: 202.232.6749

Fax: 202.232.6750

Website: www.HealthHIV.org

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