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CMS to revise E&M Documentation Guidelines

Most physicians and other practitioners bill patient visits to the PFS under a relatively generic set of codes that distinguish level of complexity, site of care, and in some cases whether or not the patient is new or established. These codes are called Evaluation and Management (E/M) visit codes. Billing practitioners must maintain information in the medical record that documents that they have reported the appropriate level of E/M visit code. CMS maintains guidelines that specify the kind of information that is required to support Medicare payment for each level. There are three key components to selecting the appropriate level:
  • History of Present Illness (History)
  • Physical Examination (Exam) and
  • Medical Decision Making (MDM). 
CMS agreed with continued feedback from stakeholders that these guidelines are potentially outdated and need to be revised, especially the history and exam components.

CMS is seeking comment from stakeholders on specific changes they should undertake to update the guidelines, to reduce the associated burden, and to better align E/M coding and documentation with the current practice of medicine.

Comments on the CMS proposal to revise the E/M documentation guidelines are due no later than Sept. 11, and can be submitted by one of four methods:

1. Submit electronic comments on this regulation to www.regulations.gov. Follow the instructions for “submitting a comment.”

2. Mail written comments to:

CMS-1676-P 2
Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
P.O. Box 8016
Baltimore, MD 21244-8013.

3. By express or overnight mail. You may send written comments to:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850.

4. Deliver (by hand or courier) written comments before the close of the comment period to:

Centers for Medicare & Medicaid Services, Department of Health and Human Services,
Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW., Washington, DC 20201

ICD 11 To Be Implemented in 2018

Following the ICD-11 Revision Conference in Tokyo, the WHO team has been focusing on a cross-cutting view of the classification. The horizontal work is done to ensure the chapters work together and are consistent in their approach to classifying entities, such as post procedural conditions, or conditions seen principally in Primary Care that appear in multiple chapters. There has also been work done on the index to confirm that terms point to the correct location, and are correctly written in natural language. The mapping of concepts between ICD-10 and ICD-11 is also in the process of being reviewed. Movements of entities between chapters are verified and corrected where necessary.

Below is an example for ICD 11 codes for Hypertension
Hypertensive diseases
BA00 Essential hypertension  
BA00.1 Combined diastolic and systolic hypertension  
BA00.2 Isolated diastolic hypertension  
BA00.3 Isolated systolic hypertension  
BA00.Y Other specified essential hypertension  
BA00.Z Essential hypertension, unspecified  
BA01 Hypertensive heart disease  
BA02 Hypertensive renal disease  
BA03 Hypertensive crisis  
BA04 Secondary hypertension  
MD90.11 White coat hypertension  
BA0Y Other specified hypertensive diseases  
BA0Z Hypertensive diseases, unspecified

Coding guidelines for Intervertebral Disc Aspiration

Intervertebral disc aspiration involves placement of a needle into the disc space with aspiration, and washings, in an attempt to gain enough sample to evaluate for the possibility of disc infection.

CPT 62267 - Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes.

For imaging, use 77003 - Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid).

Procedure Description:

The physician positions the patient on his side or lying face down and after prepping and draping the patient, administers a local anesthetic at the proposed puncture site. Using fluoroscopy or computed tomography imaging guidance, the physician then introduces a hollow needle into the spinal column at the puncture site. then advances the needle until she positions it in the disc or in the surrounding tissue. Then he verifies the needle placement using CT or fluoroscopic imaging then uses the needle to aspirate fluid and or cells, moving the needle and taking samples as necessary. he sends samples to the laboratory for diagnostic testing. Finally, he withdraws the needle and applies a sterile dressing.

CPT 62287 - Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injections at the treated levels, when performed, single or multiple levels, lumbar

Procedure Description:

Patient is appropriately prepped and anesthetized, the physician uses one of several methods to decompress or remove disc material from a disc that is protruding through two or more vertebrae in the lumbar portion of the spine. In any method, using fluoroscopy, the physician injects contrast into the gel like center, or nucleus, of the suspect spinal disc to better visualize the disc and protruding material, known as discography. The physician also uses an endoscope and fluoroscopy guidance, along with a local epidural anesthetic injection, to perform a lumbar decompression. In this procedure, the physician places the patient on a radiolucent table and inserts a needle through a stab wound in the flank, or side of the patient and guides the needle into the disc interspace, being careful not to puncture the dura. After puncturing the disc, he confirms the proper positioning of the needle using fluoroscopic images. Next, he either manually, or using an automated device, radiofrequency, or laser energy, aspirates disc tissue, removing as much material as he safely can until he decompresses the nerve.


If deep bone biopsy of the vertebral body end plate and percutaneous disc aspiration are performed at the same level, use code 20225 to describe the procedure. Do not use code 62267 in this case.

Do not use code 62267 with codes for Fine needle aspiration (10022), deep bone biopsy (20225), therapeutic disc decompression (62287), or discography (62290, 62291).

Use code 62287 when the physician is performing a therapeutic removal of disc material percutaneously to ease symptoms of disc compression of adjacent nerves. Code 62287 is used only once, regardless of the number of levels treated at one session.

Do not report 62287 in conjunction with 62267, 62290, 62311, 77003, 77012, 72295, when performed at same level.

Obstetrics and Gynaecology Coding & Billing Guidelines

Obstetrics and Gynaecology / Maternity care services; 

1. Antepartum care
2. Delivery services
3. Postpartum care

The 2 types of OB coding/billing guidelines are given below,

1. Global OB Care
2. Non-global OB care or partial services

Global OB Care

The total obstetric care package includes the provision of antepartum care, delivery services and postpartum care. When the same group physician and/or other health care professional provides all components of the OB package, report the Global OB package code. 

The CPT for Global OB codes are,

59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 

59510 – Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 

59610 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery 

59618 – Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery 

Billing Guidelines 

The global maternity allowance is a complete, one-time billing which includes all professional services for routine antepartum care, delivery services, and postpartum care. 

The fee is reimbursed for all of the member’s obstetric care to one provider. 

If the member is seen four or more times prior to delivery for prenatal care and the provider performs the delivery, and performs the postpartum care then the provider must bill the Global OB code. 

Global maternity billing ends with release of care within 42 days after delivery. Global OB care should be billed after the delivery date/on delivery date. 

Services Included In Global Obstetrical Package, 
  • Routine prenatal visits until delivery, after the first three antepartum visits 
  • Recording of weight, blood pressures and fetal heart tones 
  • Admission to the hospital including history and physical 
  • Inpatient Evaluation and Management (E/M) service provided within 24 hours of delivery 
  • Management of uncomplicated labor 
  • Vaginal or cesarean section delivery 
  • Delivery of placenta (CPT code 59414)
  • Administration/induction of intravenous oxytocin (CPT code 96365-96367)
  • Insertion of cervical dilator on same date as delivery (CPT code 59200)
  • Repair of first or second degree lacerations 
  • Simple removal of cerclage (not under anesthesia) 
  • Uncomplicated inpatient visits following delivery
  • Routine outpatient E/M services provided within 42 days following delivery
  • Postpartum care after vaginal or cesarean section delivery (CPT code 59430)
The above mentioned services are not separately reimbursed when reported separately from the global OB code. 

As per ACOG (American College of Obstetricians and Gynecologists) coding guidelines, reporting of third and fourth degree lacerations should be identified by appending modifier 22 to the global OB code (CPT codes 59400 and 59610) or delivery only code (CPT codes 59409, 59410, 59612 and 59614). Claims submitted with modifier 22 must include medical record documentation that supports the use of modifier. 

Services Excluded from the Global Obstetrical Package

The following services are excluded from the global OB package (CPT codes 59400, 59510, 59610, 59618) and may be reported separately. 
  • First three antepartum E&M visits
  • Laboratory tests
  • Maternal or fetal echography procedures (CPT codes 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76820, 76821, 76825, 76826, 76827 and 76828)
  • Amniocentesis, any method (CPT codes 59000 or 59001)
  • Amniofusion (CPT code 59070)
  • Chorionic villus sampling (CPT code 59015)
  • Fetal contraction stress test (CPT code 59020)
  • Fetal non-stress test (CPT code 59025)
  • External cephalic version (CPT code 59412)
  • Insertion of cervical dilator (CPT code 59200) more than 24 hr before delivery
  • E&M services which is unrelated to the pregnancy (e.g. UTI, Asthma) during antepartum or postpartum care.
  • Additional E/M visits for complications or high risk monitoring resulting in greater than the typical 13 antepartum visits. However these E/M services should not be reported until after the patient delivers. Append modifier 25 to identify these visits as separately identifiable from routine antepartum visits.
  • Inpatient E/M services provided more than 24 hrs before delivery
  • Management of surgical problems arising during pregnancy (e.g. Cholecystectomy, appendicitis, ruptured uterus)
Non-global OB care, or partial services 

Non-global OB care, or partial services, refers to maternity care not managed by a single provider or group practice. Billing for non-global OB or Partial care may occur if, 
  • A patient transfers into or out of a physician or group practice
  • A patient is referred to another physician during her pregnancy
  • A patient has the delivery performed by another physician or other health care professional not associated with her physician or group practice
  • A patient terminates or miscarries her pregnancy 
  • A patient changes insurers during her pregnancy
The physician provide only partial services instead of global OB care, To bill for that portion of maternity care only. Use the codes below for billing antepartum-only, postpartum-only, delivery-only, or delivery and postpartum only services. 

Only one of the following options should be used, not a combination. 

A. Antepartum care only 
  • For 1 to 3 visits: Use E/M office visit codes. 
  • For 4 to 6 visits: Use CPT 59425, This code must not be billed by the same provider in conjunction with one to three office visits, or in conjunction with code 59426. 
  • For 7 or more visits: Use CPT 59426 – Complete antepartum care is limited to one beneficiary pregnancy per provider.
Billing Guidelines 

If the patient is treated for antepartum services only, the physician should use CPT code 59426 if 7 or more visits are provided, CPT code 59427 if 4-6 visits are provided, or each E/M visit if only providing 1-3 visits. 

As per ACOG and AMA guidelines, The antepartum care only codes 59425 or 59426 should be reported as described below, 
  • A single claim submission of CPT code 59425 or 59426 for the antepartum care only, excluding the confirmatory visit that may be reported and separately reimbursed when the antepartum record has not been initiated. 
  • The units reported should be one.
  • The dates reported should be the range of time covered, 
  • E.g. If the patient had a total of 4-6 antepartum visits then the physician should report CPT code 59425 with the from and to dates for which the services occurred. 
  • CPT 59425 and 59426 – These codes must not be billed together by the same provider for the same beneficiary, during the same pregnancy. 
  • Pregnancy related E/M office visits must not be billed in conjunction with code 59425 or 59426 by the same provider for the same beneficiary, during the same pregnancy.
B. Delivery services only

The following are the CPT codes for delivery services only, 

59409 – Vaginal delivery only (with or without episiotomy and/or forceps) 

59514 – Cesarean delivery only 

59612 – Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 

59620 – Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery

The delivery only codes should be reported by the same group physician for a single gestation when, 
  • The total OB package is not provided to the patient by the same physician or group practice. 
  • Only the delivery component of the maternity care is provided and the postpartum care is performed by another physician or group of physicians. 
Services included in the delivery services

As CPT and ACOG guidelines the following services are included in the delivery services codes and shouldn’t be reported separately. 
  • Admission to the hospital, 
  • The admission history and physical examination, 
  • Management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery, external and internal fetal monitoring provided by the attending physician
  • Intravenous induction of labor via oxytocin (CPT code 96365-96367)
  • Delivery of the placenta, any method
  • Repair of first or second degree lacerations
  • Insertion of cervical dilator (CPT 59200) to be included if performed on the same date of delivery. 
Reporting of third and fourth degree lacerations should be identified by appending modifier 22 to the global OB code (CPT codes 59400 and 59610) or delivery only code (CPT codes 59409, 59410, 59612 and 59614)

Claims submitted with modifier 22 must include medical record documentation which supports the use of modifier.

C. Delivery only including postpartum care

If the same individual or Same group physician provided the delivery care and postpartum care, in these instances few CPT code has encompass both of these services, The following are CPT defined delivery and postpartum care. 

59410 – Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 

59515 – Cesarean delivery only; including postpartum care  

59614 – Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 

59622 – Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care 

Services included in the delivery only including postpartum care services
  • Hospital visits related to the delivery during the delivery confinement 
  • Uncomplicated outpatient visits related to the pregnancy
  • Discussion of contraception
D. Postpartum Care Only

The following is the CPT defined postpartum care only, 

59430 – Postpartum care only (separate procedure) 

Services included in the postpartum care
  • Uncomplicated outpatient visits related to the pregnancy 
  • Discussion of contraception
Services Excluded in the postpartum care
  • E/M of problems or complications related to the pregnancy
Billing Guidelines 

The postpartum care only should be reported by the same group physician provides the patient with services of postpartum care only. 

If a physician provides any component of antepartum along with postpartum care, but does not perform the delivery, then the services should be itemized by using the appropriate counterpart care code and postpartum care code. 






New Influenza Vaccine code CPT 90682

Effective for dates of service on and after July 1, 2017, influenza virus code 90682 will be payable by Medicare. Annual Part B deductible and coinsurance amounts do not apply to this code. 

New CPT code Effective from July 2017 - 0474T

The American Medical Association (AMA) releases Category III Current Procedural Terminology (CPT) codes twice per year: in January, for implementation beginning the following July, and in July, for implementation beginning the following January. For the July 2017 update, the Centers for Medicare & Medicaid Services (CMS) is implementing one (1) Category III CPT code that AMA released in January 2017 for implementation on July 1, 2017. 

0474T - Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space.

Average reimbursement will be $1200, please contact your respective MACs on the exact reimbursement for this procedure.

What's the Social Security Number Removal Initiative (SSNRI)?

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status. Refer CMS Newsroom for more information.. 

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