Coding Certification Review Blitz Day 1: 8:00 Registration 8:15 – 9:15 60 minutes Introduction - Exam Taking Tips
Medical Terminology & Anatomy Review HCPCS
1
9:15 – 10:15 45 minutes Modifiers 10:15 – 10:30 15 minutes Break 10:30 – 12:00 90 minutes ICD-9-CM 2 12:00 – 12:45 45 minutes Lunch 12:45 – 2:15 90 minutes E&M 3 2:15 – 2:25 10 minutes Quick Bio Break 2:25 – 3:25 60 minutes Anesthesia, Radiology 4 3:25 – 3:35 10 minutes Quick Bio Break 3:35 – 5:05 90 minutes Path & Lab, Medicine 5 Day 2: 8:00 Registration 8:15 – 9:45 90 minutes Intro to surgery
10,000 surgery series (Integumentary) 6
9:45 – 10:45 60 minutes 20,000 surgery series (musculoskeletal) 7 10:45 – 11:00 15 minutes Break 11:00 – 12:15 75 minutes 30,000 surgery series (respiratory and
cardiovascular) 8
12:15 – 1:00 45 minutes Lunch 1:00 – 2:30 90 minutes 40,000 surgery series (digestive)
50,000 surgery series (genitourinary) 9
2:30 – 2:45 15 minutes Break 3:00 – 5:00 120 minutes 60,000 surgery series (endocrine, nervous, eye,
ear) 10
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC Phone 609-965-8820 Email: [email protected]
Page 1 of 55
CPC EXAM – SAMPLE ANSWER GRID SECTION 1
43 Questions 31 correct / 12 wrong*
SECTION 2 60 Qustions
42 correct / 18 wrong*
SECTION 3 47 Questions
33 correct / 14 wrong* 1 ① ② ③ ④ 44 ① ② ③ ④ 104 ① ② ③ ④ 2 ① ② ③ ④ 45 ① ② ③ ④ 105 ① ② ③ ④ 3 ① ② ③ ④ 46 ① ② ③ ④ 106 ① ② ③ ④ 4 ① ② ③ ④ 47 ① ② ③ ④ 107 ① ② ③ ④ 5 ① ② ③ ④ 48 ① ② ③ ④ 108 ① ② ③ ④ 6 ① ② ③ ④ 49 ① ② ③ ④ 109 ① ② ③ ④ 7 ① ② ③ ④ 50 ① ② ③ ④ 110 ① ② ③ ④ 8 ① ② ③ ④ 51 ① ② ③ ④ 111 ① ② ③ ④ 9 ① ② ③ ④
Inte
gum
enta
ry (9
)
52 ① ② ③ ④ 112 ① ② ③ ④ 10 ① ② ③ ④ 53 ① ② ③ ④ 113 ① ② ③ ④ 11 ① ② ③ ④ 54 ① ② ③ ④ 114 ① ② ③ ④ 12 ① ② ③ ④ 55 ① ② ③ ④
E&M
(12)
115 ① ② ③ ④
Medi
cal T
erm
inol
ogy (
13)
13 ① ② ③ ④ 56 ① ② ③ ④ 116 ① ② ③ ④ 14 ① ② ③ ④ 57 ① ② ③ ④ 117 ① ② ③ ④ 15 ① ② ③ ④ 58 ① ② ③ ④ 118 ① ② ③ ④ 16 ① ② ③ ④ 59 ① ② ③ ④ 119 ① ② ③ ④ 17 ① ② ③ ④ 60 ① ② ③ ④ 120 ① ② ③ ④ 18 ① ② ③ ④ 61 ① ② ③ ④
Anes
thes
ia (6
)
121 ① ② ③ ④ 19 ① ② ③ ④
Musc
ulos
kelet
al (1
0)
62 ① ② ③ ④ 122 ① ② ③ ④ 20 ① ② ③ ④ 63 ① ② ③ ④ 123 ① ② ③ ④ 21 ① ② ③ ④ 64 ① ② ③ ④ 124 ① ② ③ ④
Anat
omy (
9)
22 ① ② ③ ④ 65 ① ② ③ ④ 125 ① ② ③ ④ 23 ① ② ③ ④ 66 ① ② ③ ④ 126 ① ② ③ ④ 24 ① ② ③ ④ 67 ① ② ③ ④ 127 ① ② ③ ④ 25 ① ② ③ ④ 68 ① ② ③ ④ 128 ① ② ③ ④ 26 ① ② ③ ④ 69 ① ② ③ ④ 129 ① ② ③ ④ 27 ① ② ③ ④ 70 ① ② ③ ④
Radi
olog
y (9)
130 ① ② ③ ④ 28 ① ② ③ ④ 71 ① ② ③ ④ 131 ① ② ③ ④ 29 ① ② ③ ④
Resp
. / Ca
rdio
(10)
72 ① ② ③ ④ 132 ① ② ③ ④ 30 ① ② ③ ④ 73 ① ② ③ ④ 133 ① ② ③ ④ 31 ① ② ③ ④ 74 ① ② ③ ④ 134 ① ② ③ ④ 32 ① ② ③ ④ 75 ① ② ③ ④ 135 ① ② ③ ④
ICD-
9 (11
)
33 ① ② ③ ④ 76 ① ② ③ ④ 136 ① ② ③ ④ 34 ① ② ③ ④ 77 ① ② ③ ④ 137 ① ② ③ ④ 35 ① ② ③ ④ 78 ① ② ③ ④ 138 ① ② ③ ④ 36 ① ② ③ ④ 79 ① ② ③ ④ 139 ① ② ③ ④ 37 ① ② ③ ④ 80 ① ② ③ ④
Path
& L
ab (1
0)
140 ① ② ③ ④ HCPC
S (5
) 38 ① ② ③ ④ 81 ① ② ③ ④ 141 ① ② ③ ④
39 ① ② ③ ④
Dige
stive
(10)
82 ① ② ③ ④ 142 ① ② ③ ④ 40 ① ② ③ ④ 83 ① ② ③ ④ 143 ① ② ③ ④ 41 ① ② ③ ④ 84 ① ② ③ ④ 144 ① ② ③ ④ 42 ① ② ③ ④ 85 ① ② ③ ④ 145 ① ② ③ ④
Codi
ng C
once
pt
43 ① ② ③ ④ 86 ① ② ③ ④ 146 ① ② ③ ④ 87 ① ② ③ ④ 147 ① ② ③ ④ 88 ① ② ③ ④ 148 ① ② ③ ④ 89 ① ② ③ ④ 149 ① ② ③ ④ 90 ① ② ③ ④ Me
dicin
e (10
)
150 ① ② ③ ④ 91 ① ② ③ ④
Geni
tour
inar
y (11
)
92 ① ② ③ ④
Page 2 of 55
93 ① ② ③ ④ 94 ① ② ③ ④ 95 ① ② ③ ④ 96 ① ② ③ ④ 97 ① ② ③ ④ 98 ① ② ③ ④ 99 ① ② ③ ④ 100 ① ② ③ ④ 101 ① ② ③ ④ 102 ① ② ③ ④
Nerv
ous/E
ye/E
ar (6
0)
103 ① ② ③ ④ * These are just estimates. The AAPC no longer states how many you can get wrong and still pass. These figures are based on 2004 guidelines from the AAPC.
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11
BLITZ!
Coding CertificationReview
BLITZ!
By Laureen Jandroep,OTR, CPC-EMS, CPC-H, RCC
CPC Exam Layout
3 sections to CPC exam5 continuous hours You must pass EACH section43 - 60 questions per sectionYou can get approximately 12 - 18 wrong per section
and still pass!**
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC2
and still pass!You have two tries to pass for the same fee
Exam Tips
The exam is NOT specialty specificTesting a GENERAL BROAD knowledgeFocus on principles of good codingThrow out your BILLING & REIMBURSEMENT
knowledge!Confidence and time management are vital
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 3
g
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22
Time Management
MethodsDot Method Hour Method
Plan on having some unanswered questions –don’t freak out!
Don’t over think or read into a question – stick to
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 4
qyour job!
Pick the BEST of the possible answers
Time Management
Compare and contrast the answersMark up your books to draw your eye to
groupings and key words that make the code different from the others
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 5
Medical Terminology
13 Questions on Medical Terminology9 Questions on AnatomyMastery of medical terminology means efficient
test taking
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 6
Page 5 of 55
33
Medical Terminology Basics
Word Parts Prefixes RootsSuffixesCombining formPut it all together = medical terminology
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 7
Know where help is in your manuals
Prefixes – Numbers
NullinonePrimi-FirstMono-, uni-One
Tri-ThreeQuad-, quadri-, tetra-FourHemi-, semi-H lf tl
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 8
OneBi-, di-Two
Half, partlyMulti-, poly-many
Prefixes – Numbers
Hyper-Excessive, more than
normalHypo-beneath or below
Macro-largeMicro-small
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 9
beneath or below normal
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44
Prefixes - Color
Alb/o, albin/oWhiteChlor/oGreenCyan/o
Erythr/oRedMelan/oBlackXantho/o
ll
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC10
Blue yellow
Prefixes – Direction or Position
Ab-Away fromAd-TowardAnte-, pre-, pro-BeforeDia
En-, endo-InsideEpi-Above, onHypo-, sub-Beneath, under
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC11
Dia-ThroughEcto-, ex-, exo-Out, without, away from
Inter-BetweenIntra-within
Prefixes – Direction or Position
Meso-MiddlePeri-AroundPost-Aft b hi d
Behind, backwardSuper-, supra-Above, beyond
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 12
After, behindRetro-
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55
Prefixes – Misc.
A-, an-No, not, withoutAnti-, contra-AgainstBrady-SlowDys-Bad difficult
Mal-BadPara-Near, beside, or abnormalPer-Through or by
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 13
Bad, difficultEu-Good, normalIn-not or inside (in)
Tachy-fast
Suffixes – symptoms & diagnosis
-algia, -dyniaPain-celeHernia-ectasisDilation, stretching
-emesisVomiting-ia, iasisCondition-ItisInflamation
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 14
-edemaswelling
Inflamation-lepsyseizure
Suffixes – symptoms & diagnosis
-malaciaAbnormal softness-maniaExcessive
preoccupation-oid
-osisCondition, disease-pathyDisease-ptosisProlapse, sagging
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 15
Resembling-omaTumor
p , gg g-rrhexisRupture-rrhagia
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66
Suffixes – symptoms & diagnosis
-rheaFlow, dischargeSclerosis Hardening-stasis
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 16
-stasisStopping, controlling
Suffixes – Surgery
-centesisPuncture-ectomyExcision, surgical
removal-lysis
-plastyRepair-rrhaphySuture-scopeInstrument used for
Laureen Jandroep, OTR, CPC-EMS, CPC-H, 17
Destruction-pexySurgical fixation
viewing-scopy visualy examining
Suffixes – Surgery
-stomyForming artificial
opening-tomeCutting instrument-tomy
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 18
tomyIncision-tripsycrushing
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77
Anatomy
Remember the figures in the front of CPTThere are also many pictures throughout CPTDon’t forget the ICD-9-CM Manual!
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 19
HCPCS
Three levelsLevel 1 – AMA CPTLevel 2 – National (the book)Level 3 – Regional (phased out)Some abbreviations listed in front
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 20
HCPCS
Who used HCPCSMedicare & MedicaidMany 3rd Party Payors
SymbolsModifiers
Ambulance
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 21
Page 10 of 55
88
HCPCS Layout
A – V CodesTable of DrugsAppendixWatch for measurementsRead all answers and look carefully at
differences
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC22
differences
Coding Concepts
5 questions on the CPC board examThese are general coding questionsPerhaps regarding who maintains the
manualsWhen do they come out each year etc.Most information should be available right in
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 23
Most information should be available right in your manuals
“Modifier$……It’$ All About The Money!
Page 11 of 55
“Modifiers – It’s All About the Money!” Grid © Coding & Reimbursement Network, Inc.2006 (This tool may be copied if left entirely intact with copyright notice and contact information)
Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS ~ Phone: (609)965-9585 ~ Fax: (609)965-6547 [email protected] ~ www.crn-institute.com
Part of the Coding & Reimbursement Network www.codingandriembursement.net
Type Key: GP = Global Package Modifier BUN = related to bundling or CCI E/M only = Appended to E/M codes only # = Related to number of surgeons Anes = Anesthesia Related Lab = Laboratory Related Oth = All Others
$$ Key: = $$ goes up; = $$ claim gets paid - without it claim would be denied; = $$ goes down; = $$ Stays the same (informational only)
Mod Short Description – (For Full Description see Appendix A of CPT)
Type $$
E/M Anesthesia Surgery Radiology Path & Lab
Medicine ASC & Hosp
Global Package Modifiers -24 Unrelated* E/M service by the same
physician during a postop period GP E/M E/M
-57 Decision for surgery
GP E/M E/M Medicine
-58 Staged or related procedure
GP, BUN Surgery Radiology Medicine ASC &
Hosp -76 Repeat procedure by same physician
GP ,
Surgery Radiology Medicine ASC &
Hosp
-77 Repeat procedure by another physician
GP
Surgery Radiology Medicine ASC & Hosp
-78 Return to OR for a related procedure during the postop period
GP Surgery Radiology Medicine ASC & Hosp
-79 Unrelated procedure or service by the same physician during the postop period
GP
Surgery Radiology Medicine ASC & Hosp
-54 Surgical care only
GP Surgery
-55 Postoperative management only
GP Surgery Medicine
-56 Preoperative management only
GP Surgery Medicine
© Coding & Reimbursement Network, Inc.2006 (This tool may be copied if left entirely intact with copyright notice and contact information) Bundling or CCI Modifiers
-25 Significant separately identifiable E/M service
BUN GP E/M E/M ASC &
Hosp -26 Professional component BUN Surgery Radiology P&L Medicine -58 Staged or related procedure
GP, BUN Surgery Radiology Medicine ASC &
Hosp -59 Distinct procedural service BUN Anesthesia Surgery Radiology P&L Medicine ASC &
Hosp Evaluation & Management Only Modifiers
-21 Prolonged E/M services
E/M
E/M
-24 Unrelated E/M service by the same physician during a postop period
GP E/M E/M
-25 Significant separately identifiable E/M service
GP E/M E/M ASC &
Hosp -57 Decision for surgery
GP E/M E/M Medicine
-27 Multiple outpatient hospital E/M encounters on the same date
E/M
ASC & Hosp
Page 12 of 55
“Modifiers – It’s All About the Money!” Grid © Coding & Reimbursement Network, Inc.2006 (This tool may be copied if left entirely intact with copyright notice and contact information)
Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS ~ Phone: (609)965-9585 ~ Fax: (609)965-6547 [email protected] ~ www.crn-institute.com
Part of the Coding & Reimbursement Network www.codingandriembursement.net
Number of Surgeons Modifiers -62 Two surgeons
# Surgery Radiology
-66 Surgical Team
# Surgery
-80 Assistant surgeon
# Surgery Radiology
-81 Minimum assistant surgeon
# Surgery
-82 Assistant surgeon (when a qualified resident is not available)
# Surgery
Anesthesia Related -23 Unusual anesthesia
Anes Anesthesia
-47 Anesthesia by surgeon Anes Surgery
© Coding & Reimbursement Network, Inc.2006 (This tool may be copied if left entirely intact with copyright notice and contact information) Laboratory Related
-90 Reference (outside) laboratory
Lab P&L
-91 Repeat clinical diagnostic laboratory test
Lab P&L ASC & Hosp
Other Modifiers -22 Unusual procedural services
Oth Anesthesia Surgery Radiology P&L Medicine
-32 Mandated services
Oth , E/M Anesthesia Surgery Radiology P&L Medicine
-50 Bilateral procedure
Oth Surgery Radiology Medicine ASC & Hosp
-51 Multiple procedures
Oth Anesthesia Surgery Radiology Medicine
-52 Reduced services
Oth E/M Surgery Radiology P&L Medicine ASC & Hosp
-53 Discontinued procedure
Oth Anesthesia Surgery Radiology P&L Medicine
-63 Procedure Performed on Infants less than 4 kg
Oth Surgery (not Integ.)
-73 Discontinued outpatient hospital/ASC procedure prior to anesthesia
Oth ASC & Hosp
-74 Discontinued outpatient hospital/ASC procedure after anesthesia
Oth ASC & Hosp
-99 Multiple modifiers Oth Surgery Radiology Medicine * Per CPT Assistant May 1997 “"Modifier -24 is used when a physician provides a surgical service related to one problem and then during the period of follow-up care for the surgery provides an evaluation and management service unrelated to the problem requiring the surgery." Note it does not say unrelated to the surgery itself.
Page 13 of 55
99
Two Levels
HCPCS Level I ModifiersAMA CPT Manual Appendix A
HCPCS Level II ModifiersFound in Federal Register or in HCPCS book
published by Medicode or St. Anthony etc.
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC25
What do they do?
Modify the code description without changing the core meaning
Provide additional information regarding the service provided
Tells the “story” more clearlyIntegral part of CPT and the HCPCS coding
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 26
Integral part of CPT and the HCPCS coding system
Modifier Types
GP = Global Package ModifiersBUN / CCI = Related to bundling or CCI editsE/M = Only appended to E/M procedures# = Refers to number of surgeons involvedAnes = Anesthesia Related
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 27
Lab = Laboratory RelatedOth = All other modifiers
Page 14 of 55
1010
$ Key
= $$ goes up = $$ claim gets paid - without it claim
would be denied = $$ goes down = Stays the same (informational
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC28
only)
Global Package Modifiers
-24-57-54, -55, -56-58-76, -7778 79
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC29
-78, -79
Global Package Concept
Package includes: Pre-OpOperationPost-Op
CMS definition found in the MCM at
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC30
http://www.cms.hhs.gov/transmittals/downloads/R1770B3.pdf
Page 15 of 55
1111
Pre-Op Visit
Subsequent to Decision for Surgery VisitOne related E/M on the day
immediately prior to or on the day of procedure
I I l d d i th P k
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 31
Is Included in the Package
Operation
Operation per seLocal infiltrationmetacarpal/digital blocktopical anesthesia
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 32
Postoperative follow-up care
CMS clearly states 0, 10 or 90 days see Medicare Physician Fee Schedule Database
(MPFSDB)http://cms.hhs.gov/physicians/pfs/
Or your software vendor/ service like CodeCorrect http://crn.codecorrect.com
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 33
Page 16 of 55
1212
Modifier –24 ($ )
Unrelated Evaluation and Management by the Same Physician during the postoperative period
Append to E/M codes onlyWhat it says: “I know this is during the global
period for a previous procedure but this
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 34
period for a previous procedure but this visit is unrelated – pay up”
Must know definition of your payors global period
Modifier –57 ($ )Decision for SurgeryAppend to E/M Codes only (& some
ophthalmological codes in the Medicine section)
What It Says: “I know there is going to be a claim in the next day or so for a surgery
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 35
which includes the pre-op visits – but today was the day I decided to do that surgery so it is not a pre-op visit – don’t consider this as part of the global package”
Modifier –58 ($ )Staged or Related Procedure or Service by the Same
Physician During the Postoperative PeriodAppend to CPT code when the procedure is second
and/or related to the original or first procedure.Note: A new postop period begins when the next
procedure in a staged or related procedure is provided.
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 36
provided. Don’t use for return to OR see –78Don’t use for unrelated procedures in the global
period – see -79
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1313
Modifier –76 ($ )
Repeat Procedure by Same PhysicianAppended to CPT codes to indicate when the
same physician repeats the same service, sometimes on the same day
Same CPT code as done previouslyWhat it says: “I know this is the same CPT
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 37
What it says: I know this is the same CPT code as above (or reported earlier) but it is a repeat not a duplicate”
Modifier –77 ($ )
Repeat Procedure by Another PhysicianSame as –76 but repeated by a different
physicianSame CPT code as previously done by first
physician
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 38
DG: An explanation of the medical necessity for the repeat service is necessary.
Modifier –78 ($ )
Return to the Operating Room for a Related Procedure During the Postoperative Period
Global package modifier that does not reset global days from previous surgery
Used when treatment for complications requires a return to the OR
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 39
qDifferent CPT code from original surgeryUsually paid at 70 to 80%
Page 18 of 55
1414
Modifier –79 ($ )
Unrelated Procedure or Service by the Same Physician During the Postoperative Period
Appended to surgical codes to indicate that an unrelated procedure was performed by the same physician during the postoperative period of the original procedure
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 40
procedure.Otherwise payer’s computer system would
kick it out as being part of the follow period for the previous surgery.
Modifier –54, -55, -56 ($ )Surgical Care Only; Postoperative
Management; Preoperative ManagementTo use correctly there must be an agreement
for the transfer of care between physicians.
Use box 19 to indicate date of transfer of responsibility
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 41
espo s b tyWithout transfer then the services of the
non-surgeon are reported with regular E/M codes
Append to surgical codes only
CCI or Bundling Modifiers
-25-26-59
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 42
Page 19 of 55
1515
Modifier –25 ($ )
Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
Append to E/M codes only to indicate it was separate from that required for the procedure
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 43
and a clearly documented, distinct and significantly identifiable service was rendered
Many 3rd party payers will not accept when billed with a minor procedure on the same day
Modifier –26 ($ )
Professional ComponentTotal fee split between professional and
technical componentUse only on global service codes not on codes
that are only for professional component by definition. (I.e.. 94014 is a total and 94016
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 44
(is a PC)
Use when a physician is providing the interpretation of the diagnostic test/study performed
Modifier –59 ($ )
Distinct Procedural ServiceIndicates procedure was distinct or
separate from other services provided on same date
Alert!: The “unbundling” modifier – allows bypassing of payor edits (CCI) – be
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 45
yp g p y ( )careful!
Modifier of last resortDG: Need good supportive documentation
to use this modifier.
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1616
E/M Only Modifiers
-21-24 (already discussed with Global Package Modifiers)
-25 (already discussed in BUN group)-27 (out-patient only)-57 (already discussed with Global Package
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 46
Modifiers)
Modifier –21 ($ )Prolonged Evaluation and Management
ServicesWhat it says: “I have met the description
for the highest level of care but I still spent more than the usual time.”
Only use on the highest level E/M in any given category
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 47
given categoryDon’t use on prolonged services, critical
care or neonatal care codes
Modifier –24 ($ )Unrelated Evaluation and Management by the
Same Physician during the postoperative period
Append to E/M codes onlyWhat it says: “I know this is during the global
period for a previous procedure but this visit
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 48
is unrelated – pay up”Must know definition of your payors global
period
Page 21 of 55
1717
Modifier –25 ($ )Significant, Separately Identifiable
Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
Append to E/M codes only to indicate it was separate from that required for the
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 49
was separate from that required for the procedure and a clearly documented, distinct and significantly identifiable service was rendered
# - Number of Surgeon Modifiers
-62-66-80-81-82
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 50
Modifier –62 ($ )Two SurgeonsSame CPT code is used for each surgeon,
each appends –62For different specialties – many payors will
deny if used by surgeons of the same specialty
Only applicable to certain codes (see MFSDB
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 51
Only applicable to certain codes (see MFSDB etc.)
DG – good medical necessity documentation needed
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1818
Modifier –66 ($ )
Surgical TeamFor highly complex proceduresUsed by each participating surgeon on the
same CPT codeDG: This is a “by report” modifier so be
prepared to submit documentation with
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 52
prepared to submit documentation with claims and have good medical necessity to warrant team surgery
Modifier –80 ($ )
Assistant SurgeonSame CPT code as primary surgeonCan be used with other modifiers such as –50
and –51Check for coverage guidelines such as MFSDB
to see if payor will pay for an assist at
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 53
to see if payor will pay for an assist at surgery
DG: Medical necessity documentation is key
Modifier –81 ($ )Minimum Assistant SurgeonUsed when the services of a second or third
assistant surgeon are requiredDG: Medical necessity is keyRarely recognized by Medicare – doesn’t
even show on the MFSDB
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 54
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1919
Modifier –82 ($ )
Assistant Surgeon (when qualified resident surgeon not available)
Same as modifier –80 but for teaching hospitals that have residency programs
Must have documentation on file that a qualified resident was not available
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 55
q
Anesthesia Related
-23-47
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 56
Modifier –23 ($ )
Unusual AnesthesiaRestricted to anesthesiologistsDon’t append to surgical codesUsed for procedures that would normally not
need anesthesia or would only need local anesthesia
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 57
anesthesiaDo not use for local anesthesia
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2020
Modifier –47 ($ )
Anesthesia by SurgeonDo not attach to anesthesia codesFor use of regional or general anesthesia. Not covered by Medicare and many
M di id
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 58
Medicaid programs
Lab Modifiers
-90-91
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 59
Modifier –90 ($ )
Reference (Outside) LaboratoryUsed on lab procedures that are performed
by a party other than the treating or reporting physician but billed by the physician’s office
Not allowed by Medicare
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 60
Not allowed by Medicare
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2121
Modifier –91 ($ )Repeat Clinical Diagnostic Laboratory TestAppend to lab procedures to indicate repeat lab
tests or studies performed on the same day on the same patient
Only use when additional test results are obtained subsequent to the administration or performance of the same test(s) on the same
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 61
performance of the same test(s) on the same day.
Don’t use if CPT descriptor itself indicates it is a repeat or series of tests as in 82951, glucose; tolerance test (GTT), three specimens.
Other Modifiers-22-32-50-51-5253
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 62
-53-99
Modifier –22 ($ )
Unusual Procedural Services“I did extra work or spent an unusual amount
of time due to _________, pay me more”DG: Document in detail the circumstances that
make the case unusual.
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 63
Tip: Send in documentation with claim.Alert: Overuse can trigger an audit.
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2222
Modifier –32 ($ )
Mandated ServicesUse when the physician is aware of third-party
involvement regarding mandated servicesWho and why must be clearly documentedConsidered informational and when used,
many insurers allow 100% reimbursement i h d d ibl
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 64
without a deductible or copay.No effect on Medicare payment
Modifier –50 ($ )
Bilateral ProcedureOnly use when the code description does not
already state it is bilateralUse only when the exact same service/code is
reported for each bilateral anatomical siteFor Medicare enter as one line-item with a unit
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 65
of one. Payment is 150%“One or both” - no need for -50
Modifier –51 ($ )
Multiple ProceduresUse to indicate that more than one surgical
service was performed by the same physician on the same session.
Usually some shared component to the workW t h f b l th t i di t th d i
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 66
Watch for symbols that indicate the code is –51 exempt + and
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Modifier –52 ($ )
Reduced ServicesWhat it says: “I did this procedure but did not
complete it fully as described in CPT.”Intended for procedures that accomplished some
result, but less than expected for the procedure
Performed at a lesser levelBil t l d l d id
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 67
Bilateral procedure was only done on one sideDG: – Send with documentation that supports a
reduction of procedure code description to prevent payment delays
Modifier –53 ($ )Discontinued ProcedureWhat it says: “Due to extenuating circumstances I
elected to terminate procedure due to patient risk”
The procedure was actually started but was discontinued before completion due to the patient’s condition
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 68
patient s conditionDG: – Send with documentation that supports a
reduction of procedure code description to prevent payment delays
-52 vs. -53
Decision Matrix -52Reduced
-53Discontinued
Anesthesia Stopped Before Usually Stopped After
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 69
Cancelation Elective by patient or physician
Physician decision due to patient risk
Result Some benefit No benefit
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Modifier –63 ($ )Procedure Performed on Infants less than 4
kgNew to 2003Unless otherwise designated, this modifier
may only be appended to procedures/services listed in the 20000-
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 70
69999 code series.Smaller bodies mean more complex surgeries
and should be paid at a higher rate – this modifier tells that story.
Modifier –99
Multiple ModifiersOnly use if payors computer system does not
accept multiple modifiers on the same lineEnter modifiers in box 19 on HCFA 1500 form1=22, 2=51 The 1 and 2 indicate which line
item the modifiers refer to
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 71
item the modifiers refer toRarely used
Questions?
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2525
BREAK
ICD-9-CM
Know the layout of the book2 Volumes
Volume 1 Tabular17 Chapters Appendix A-E
Volume 2 Index (usually in front)Index to DiseasesTable of Drugs & Chemicals
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 74
Table of Drugs & ChemicalsIndex to E Codes
ICD-9-CM Conventions
NotesIncludesExcludesCode First Underlying DiseaseUse Additional Code
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 75
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2626
ICD-9-CM Conventions
[ ] Brackets[ ] Slanted Brackets( ) Parentheses: Colon{ } Braces
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 76
ICD-9-CM Conventions
NEC – “Not Elsewhere Classifiable”Books Fault
NOS – “Not Otherwise Specified”Doctors Fault
SEESee Also
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 77
See Also
ICD-9-CM = MN
Medical Necessity IS ICD-9-CM codingSpecificity is keyPrimary Dx Code is the chief reason for the
encounter (there are a few exceptions)Other codes are supporting codes –
they “round out the story”
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 78
they “round out the story”
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ICD-9-CM Linkage
Each procedure code should be matched with an appropriate diagnosis code
HCFA 1500 has 4 spaces for Dx codes6 lines for procedures codesThis linkage show the medical necessity linkageL t f dit
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 79
Largest source of payor edits
Coding Diagnosis Codes
Find key term(s)Use indexFollow Cross ReferencesVERIFY in tabularFollow instructions in tabular
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 80
Tabular Instructions
ChapterSection
Category (3-digit)Sub-category (4th digit)
Sub-Classifiction (5th digit)
Instructions are found at all of these levels
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 81
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ICD-9-CM Special Areas
Late EffectsE-CodesV-Codes
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 82
ICD-9-CM Chapter Specific
InfectionNeoplasmsMyocardial InfarctionsMentalInjuries & Trauma
WoundInjury
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 83
InjuryFractureBurn
ICD-9-CM Special Areas
ObstetricalPerinatalMental Disorders
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 84
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Section 3
47 Questions33 Needed to Pass14 Can be wrong
E&M – 12 QuestionsAnesthesia – 6 Questions
di l 9 Q i
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 86
Radiology – 9 QuestionsPathology – 10 QuestionsMedicine – 10 Questions
E&M
Three Main StepsDetermine Location/CategoryDetermine HEM or Time (if dominant)Determine Overall Level (2 of 3 vs. 3 of 3)For the exam it will be spelled out most of the
ti
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 87
time
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E/M Leveling Exercise Remember, When it’s 3 of 3 code to the lowest and when its 2 of 3 drop the lowest
HEM (history, exam, MDM)
Office New Patient Level 3 of 3
(just use 1,2,3,4,or 5)
Office Established Patient 2 of 3
Level (just use 1,2,3,4, or 5) PEL CCM CCS CDM CEH DPH EDM EPH EDS EDL CDM PEM DEL CES PDL DDH EEM CDL DDL EDH CPH CPS CEM EES DDM PEH CDH PPL PPM PPH EPS EPL ECS EPM ECL ECM EEH
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E&M Location
Start with the table of Categories and Subcategories (page 5 of pro. Version)
Write the page numbers next to each subcategory
Be mindful of “status” vs. location
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 88
E&M Categories
Office or Other OutpatientHospital ObservationHospital InpatientConsultsEmergency Department
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 89
Critical Care Services
E&M Categories
Neonatal Intensive CareNursing Facility ServicesDomiciliary, Rest Home or Custodial CareHome ServicesProlonged ServicesC M t
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 90
Case Management
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3131
E&M Categories
Case Management ServicesCare Plan Oversight Preventive Medicine ServicesNewborn CareSpecial E&M
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 91
Other E&M
E&M Determine the HEM3 Key AreasHistoryExamMedical Decision MakingContributory AreasCounseling
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 92
Coordination of CareNature of presenting problem
E&M History
History Levels(P) Problem Focused(E) Expanded Problem Focused(D) Detailed(C)Comprehensive
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 93
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E&M Exam
Exam Levels(P) Problem Focused(E) Expanded Problem Focused(D) Detailed(C)Comprehensive
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 94
E&M Medical Decision Making
Medical Decision Making (MDM) Levels(S) Straightforward(L) Low Complexity(M) Moderate Complexity(H) High Complexity
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 95
E&M Leveling
Mark your margins3 of 3
“Code to the lowest”
2 of 3“Drop the lowest”
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 96
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3333
BREAK
Anesthesia
PackageTime ReportingModifiersPhysical StatusQualifying CircumstancesCPT Appendix A Modifiers
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 98
CPT Appendix A ModifiersHCPCS ModifiersCrosswalk
Anesthesia
TypesGeneral
InhalationIntravenous
RegionalPeripheral Nerve Blocks
Other TypesLocal (Included in
surgical package)Conscious Sedation
(in medicine section)
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 99
Peripheral Nerve BlocksSpinalEpidural
section)
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Anesthesia
UnbundlingSpecialized Services – Bill SeparateSwan-Ganz catheter placement and monitoring
(93503)Arterial (ART) lines (36620-36625)MAC – Monitored Anesthesia Care
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 100
All but the “knock out”-QS modifier
Radiology
Global ServiceProfessional ComponentTechnical Component
PlanesPositioning TermsAdministration of Contrast
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 101
Administration of ContrastOral and rectal don’t count
Supervision & Administration
Radiology
Four Main SectionsDiagnostic Radiology
ViewsX-ray vs. MRI etc.
Diagnostic UltrasoundRadiation Oncology
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 102
gyTreatment Sessions
Nuclear Medicine
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BREAK
Pathology & Laboratory
PanelsDrug TestingEvocative/Suppression TestingPath ConsultChemistry Tests
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 104
Anatomic PathologySurgical Pathology
Medicine
Stick & StuffPsychiatryDialysisOphthalmologyENTC di l t t t
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 105
Cardiovascular treatmentCardiac CatheterizationPulmonaryAllergy & Clinical Immunology
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Medicine
NeurologyChemoPM&ROsteo Manipulative & Chiropractic TxSpecial Services, Procedures, and ReportsConscious SedationOth
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC 106
Other
Questions?
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11
BLITZ!
Coding Certification Review
BLITZ!
By Laureen Jandroep,OTR, CPC-EMS, CPC-H, RCC
Day Two
Section Two
Surgery & Modifiers60 questions42 needed to passCan get 18 wrong
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC2
General Surgery Guidelines
Format
Separate Procedures / BundlingSurgical Package
Scope Procedures
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC3
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Surgery Section Format
18 Subsections (green headings in 2005)General (10021 – 10022)Integumentary (10040 – 19499)Musculoskeletal (20000 – 29909)Respiratory (30000 – 32999)Cardiovascular (33010 – 39599)
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC4
Cardiovascular (33010 39599)Hemic & Lymphatic (38100 – 38999)Mediastinum & Diaphragm (39000 – 39561)
Surgery Section Format
Digestive (40490 – 49999)Urinary (50010 – 53899)Male Genital System (54000 – 55899)Intersex Surgery (55970 – 55980)Female Genital (56405 – 58999)M t it C & D li (59000 59899)
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC5
Maternity Care & Delivery (59000 – 59899)Endocrine (60000 – 60699)
Surgery Section Format
Nervous (61000 – 64999)
Eye & Ocular Adnexa (65091 – 69990)Auditory (60900 – 69979)
Operating Microscope (69990)
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC6
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Guidelines
Colored guideline pages (beginning of surgery)
Subsection guidelines
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC7
Key Concepts
Separate ProceduresRelated to bundlingSay’s “Be careful I am usually part of other
procedures”OK to report when that is all that was doneOK to report if done at a separate time etc. (-59)
Complications
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC8
ComplicationsCode separately Not included in package
Key Concepts – Scopes
If a code is NOT listed under a scope heading then it is an “open” procedure
“Portal” refers to poke holes for scopeDiagnostic scopes
CAN report on their own
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC9
CAN report on their ownCAN report with open proceduresCANNOT report with “surgical” scopes
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10k – Integumentary
Lesion Excision / DestructionLaceration RepairTissue TransferSkin Grafts & FlapsBurns
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC10
Breast Procedures
BREAK
20k – Musculoskeletal
Organized by body areaFracture CareSpineCasts & StrappingScopes
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC12
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30K – Respiratory & Cardio
Respiratory SystemPay attention to anatomyBubble & highlight
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC13
30K – Respiratory & Cardio
Cardiovascular SystemPacing cardioverter –pacemaker or defibrilatorCABGAngioplasty – TransluminalAtherectomy – TransluminalComposite grafts
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC14
Vascular injection proceduresEndoscopy
BREAK
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40k – Digestive
Code organized from “in to out”Endoscopy – through natural or existing
openingScopes dominate in this section
Upper GI – Mouth down
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC16
Lower GI – anus up-52 for incomplete colonoscopy
50k – Urinary, Genital System & Maternity
Urinary SystemBe careful of Urethra vs. UreterUrodynamicsEndoscopyUreter and Pelvis
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC17
Ureter and Pelvis
50k – Urinary, Genital System & Maternity
Genital SystemMaleIntersexFemale
Vulvectomy definitions
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC18
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50k Urinary Genital System & Maternity50k – Urinary, Genital System & MaternityMaternity & Delivery Coding
PackageVaginalC-SectionVBAC
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC19
BREAK
60k – Endocrine, Nervous, Eye, Ear
Endocrine SystemNervous
Sx of skull baseSpine & Spinal Cord
Eye (Occular)Cataract Removal Coding
Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC21
gEarOperating Microscope
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Homework
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E/M Leveling Exercise Remember, When it’s 3 of 3 the code to the lowest and when its 2 of 3 drop the lowest
HEM (history, exam, MDM)
Office New Patient Level 3 of 3
(just use 1,2,3,4,or 5)
Office Established Patient 2 of 3
Level (just use 1,2,3,4, or 5) PEL 1 3 CCM 4 5 CCS 2 5 CDM 3 4 CEH 2 5 DPH 1 4 EDM 2 4 EPH 1 3 EDS 2 3 EDL 2 3 CDM 3 4 PEM 1 3 DEL 2 CES 2 3 PDL 1 3 DDH 3 4 EEM 2 3 CDL 3 4 DDL 3 4 EDH 2 4 CPH 1 5 CPS 1 2 CEM 2 4 EES 2 3 DDM 3 4 PEH 1 3 CDH 3 5 PPL 1 2 PPM 1 2 PPH 1 2 EPS 1 2 EPL 1 3 ECS 2 3 EPM 1 3 ECL 2 3 ECM 2 4 EEH 2 3
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