Coding Corner

Anesthesia and integral services unbundling
Covers the guidelines and policies that help prevent unbundling of anesthesia and integral services, including preoperative or postoperative evaluation and management (E/M) services, procedures related to venous or airway access, and postoperative pain management.

Anesthesia upcoding and pricing modifiers
Covers the documentation elements that help prevent upcoding of time-based anesthesia services, including moderate sedation, with guidance for applying modifiers for pricing (AA, AD, QK, QX, QY, QZ), physical status (P1–P5) and altered circumstances (22, 23, 47, 59, etc.).

Complex repair upcoding
Covers the documentation elements that help prevent upcoding of surgical wound repairs, including guidelines for classifying and reporting simple (12001–12021), intermediate (12031–12057) and complex (13100–13153) repairs based on complexity, location and size.

Mohs surgery coding and unbundling
Covers documentation elements that help prevent upcoding of Mohs micrographic surgery (17311–17315), including criteria and guidance to select accurate codes for initial and subsequent stages and additional blocks. Also covers guidance to help prevent unbundling of Mohs and surgical pathology services (88300–88309, 88329–88332) reported for the same tissue specimen by the same provider.

Other repair coding and unbundling
Covers guidance that helps prevent upcoding of surgical preparation (15002–15005) or lesion excision (11400–11646) procedures and unbundling of integumentary system procedures, including transfers, grafts and flaps (14000–14302, 15050–15278, 15570–15731, 15740–15777), and services that may be inclusive if reported on the same date.

Photochemotherapy upcoding
Covers documentation elements (e.g., photosensitive chemicals, light rays, severity of dermatoses, length of direct supervision, etc.) that help prevent upcoding of photochemotherapy services (96910, 96912, 96913).

Advance care planning upcoding and unbundling
Covers documentation elements that help prevent upcoding of advance care planning (ACP) services (99497 and 99498), unbundling ACP and critical care (99291, 99292) or cognitive care (99483) services.

Critical and intensive care upcoding and unbundling
Covers guidance that helps prevent upcoding of time-based critical care services (99291, 99292) and unbundling of services considered inclusive to pediatric and neonatal critical and intensive care services (99468–99476, 99477–99480).

Hospital inpatient or observation E/M upcoding
Covers code selection criteria, including time and medical decision making (MDM) elements, for hospital inpatient or observation evaluation and management (E/M) services. This is to help prevent upcoding of initial (99221–99223), subsequent (99231–99233), same-day admit/discharge (99234–99236) and discharge (99238, 99239) codes. Also covers guidance for reporting consultations and E/M services by the same specialty physicians in group practice.

Nursing facility E/M upcoding and unbundling
Covers guidance that helps prevent upcoding of initial, subsequent and discharge nursing facility (NF) evaluation and management (E/M) services (99304–99310, 99315, 99316). Also to help prevent unbundling of nursing facility E/M services and other E/M services or procedures including continuous inhalation treatment (94644).

General lab billing guidance
Covers multiple UnitedHealthcare policies for reporting lab services, including criteria on intent to order, date of service, place of service, Clinical Laboratory Improvement Amendments (CLIA) certification and MolDx program requirements. Includes information to help avoid unbundling of lab services, including specimen validity and molecular pathology. Also reviews the appropriate use of modifiers for reporting repeat or distinct procedures (91, 59, XE, XS, etc.) and professional or technical components (26, TC).

Obstetrical services unbundling
Covers guidance that helps prevent unbundling of services that are included in the global obstetrical (OB) package (e.g., related to antepartum care, delivery and postpartum care), including evaluation and management (E/M) services, ultrasounds and labor/delivery procedures.

Allergy service and E/M unbundling
Covers guidelines for appropriately billing a separate E/M service with an allergen injection (95115, 95117) or testing service (95004–95070) to help prevent unbundling.

Injection or infusion and E/M unbundling
Covers guidance that helps prevent unbundling of an injection or infusion service (e.g., therapeutic, hydration, acupuncture, trigger-point procedures, arthrocentesis, chemotherapy, vaccinations, etc.), and an evaluation and management (E/M) service.

Multiple E/M service unbundling
Covers guidelines that help prevent unbundling of multiple evaluation and management (E/M) services (including preventive services) when reported by the same group physician (e.g., same specialty and group practice) for the same patient and same date of service.

Office E/M upcoding
Covers documentation elements that help prevent upcoding of office or other outpatient evaluation and management (E/M) services (99202–99215), including time and medical decision making (MDM) criteria for code selection.

Prolonged E/M  service upcoding and unbundling
Covers documentation elements that help prevent upcoding of time-based prolonged services without direct patient contact (99358, 99359), and guidance to help prevent unbundling of services that may be inclusive if reported on the same date. Also includes general guidance for reporting other prolonged service codes (99415–99418, G0316–G0318, G2212).

Ophthalmology procedure upcoding and unbundling
Covers documentation elements that help prevent upcoding of cataract removal (66982–66984, 66987–66989, 66991), vitrectomy (67036–67043), retinal detachment (67101–67113), and ophthalmological and visual field exams (92002, 92004, 92012, 92014). Also includes guidance to help prevent unbundling of ophthalmological services.

Speech language pathology service unbundling
Covers guidance that helps prevent unbundling of speech language pathology (SLP) and other services. Also includes elements for reporting SLP services, including qualified professionals, plan of care criteria, required modifiers and related Smart Edits.

Time-based therapy procedure upcoding
Covers documentation elements that help prevent upcoding of time-based physical therapy procedures (97110–97150, 97530–97542) and guidance on required modifiers and maximum frequency per day (MFD) limits.

Cardiovascular service upcoding and unbundling
Covers guidance that helps prevent unbundling of evaluation and management (E/M) services and cardiovascular procedures (e.g., electrocardiograms [ECGs], stress testing, catheter placement) and unbundling of myocardial perfusion imaging (MPI) procedures (78451, 78452) and related services, including 3D rendering services and cardiac blood pool imaging studies. Also covers documentation elements to help prevent upcoding of transthoracic echocardiogram (TTE) studies (93306–93308).

Global surgery package unbundling
Covers guidance for separately reporting services, including evaluation and management (E/M) visits performed during the global period of a procedure subject to the CMS Global Surgical Package concept (e.g., 000, 010, 090 global days).

Musculoskeletal procedure upcoding and unbundling
Covers criteria that help prevent upcoding of musculoskeletal system procedures (e.g., injections, implant removals, etc.) and guidance to help prevent unbundling of services or procedures that may be inclusive if reported on the same date (e.g., cast, splint or strapping procedures and other musculoskeletal procedures, vein destruction or ablation procedures, and evaluation and management [E/M] services). Also reviews modifiers (54, 55, 56) used to report a split surgical package.

Osteopathic manipulative treatment coding
Covers documentation elements that help prevent upcoding of osteopathic manipulative treatment (OMT) services (98925–98929) and guidance to help prevent unbundling of OMT and evaluation and management (E/M) services.

Procedure-to-procedure code pair unbundling
Covers guidance that helps prevent unbundling of procedure code pairs identified by National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits and circumstances for using an appropriate modifier (e.g., 59, XE, XP, etc.) to override an edit.

Radiology and E/M unbundling
Covers guidance that helps prevent unbundling of an evaluation and management (E/M) service and a radiology service (76000–77999), including computed tomography (CT), fluoroscopic guidance, ultrasound imaging services, magnetic resonance imaging (MRI), X-ray, etc. Also covers guidance to help avoid unbundling of radiology procedures that are a component of a more comprehensive service.