✅ CPT® Coding Overview (HCPCS Level I)

Used to report medical procedures and services performed by licensed providers.

 Maintained by: American Medical Association (AMA)

 Format: 5-digit numeric codes (e.g., 99213)
 Accepted by Medicare: Since 1990 (Part B)

🧠 CPT® Code Structure

I. Format Types

Categor Examp
Purpose Format
y le
Category 5-digit
Standard procedures 12002
I numeric
Category Quality performance tracking
4 digits + F 0001F
II (optional)
Category
Emerging technology/services 4 digits + T 0075T
III

✅ CPT® Symbols & Their Meanings

Symb
Meaning Purpose
ol
Telemedicine Indicates service can be delivered
⭐
Approved remotely
Must accompany a primary
➕ Add-On Code
procedure code
Pending FDA/New
⚡ Emerging or investigational service
Tech
Re-sequenced
# Placed out of sequence for clarity
Code
● New Code Added in the current CPT edition
Shares description with indented
; Semicolon
codes

➕ CPT® Add-On Code Logic

Feature Explanation
Symbol ➕ Plus sign prefix
Billing Rule Cannot be billed alone
Purpose Adds time, steps, vessels, or lesions
Example 22551 (primary) + +22552 (add-on)
Reimburseme
Paid in addition to the base code
nt
Modifier No, unless procedure-specific guidelines
Needed? require it

🗂 Refer to Appendix D in the CPT manual for complete add-on listings.

🔎 CPT® Code Selection Logic

Factor Influences Example Comparison
Skin excision (11400–11446) vs. muscle
Depth Tissue level
(21930–21933)
Amount
Extent Partial thyroidectomy (60210) vs. total (60240)
removed
Approac Surgical Open (47600) vs. laparoscopic (47562)
h technique cholecystectomy

✅ HCPCS Level II: Supplies, Equipment & Drugs

Used to report non-physician services, supplies, and products.

 Maintained by: CMS

 Format: 1 letter + 4 numbers (e.g., A0429)

Common Categories

Category Examples
DME E0143 – Walker
Ambulance A0429 – BLS
Services Ambulance
Prosthetics/
L-series codes
Bandages
Drugs/Biologics J-codes (e.g., J9201)
Emerging Services G/Q/S/T codes
V-codes (e.g.,
Vision/Dental
V2020)

💡 Quick Layering Strategy for Coding

Layer Purpose
ICD-10-
Why the patient was seen
CM
CPT What service was provided
HCPCS What materials/drugs were
II used

✳️Modifier Master Grid

🔧 CPT Modifiers (Used with CPT codes)

Modifi
Meaning Purpose
er
Separate E/M service, same E&M + procedure during same
-25
provider & day encounter
-59 Distinct procedural service Different site/session/diagnosis
-51 Multiple procedures Same session, same provider
Re-performed during same
-76 Repeat procedure (same provider)
session
Repeat procedure (different
-77 Indicates new physician
provider)
-52 Reduced services Partial service completed
-53 Discontinued procedure Terminated before completion
-58 Staged/related post-op procedure Planned follow-up surgery
Modifi
Meaning Purpose
er
Unexpected complication or
-78 Unplanned return to OR (related)
revision
Unrelated procedure during post-
-79 New issue post-procedure
op
Telehealth via real-time
-95 Preferred for synchronous visits
video/audio
-GT Telehealth (legacy modifier) Still used in some payers

📦 HCPCS Modifiers (Used with CPT or HCPCS codes)

Modifi
Meaning Common Use
er
ABN signed (Advance Beneficiary May be denied but patient
GA
Notice) notified
Not covered under Medicare
GY Statutorily excluded item/service
rules
GZ Expected denial, no ABN on file Provider did not obtain ABN
KX Medically necessary despite cap Exceeds therapy limits
Simple lab test (e.g., urine,
QW CLIA-waived test
glucose)
Paired organs (e.g., breast,
LT Left side
eyes)
RT Right side Same as above
One procedure performed on
50 Bilateral procedure
both sides
GP Physical therapy Used with therapy services
GN Speech-language pathology Used with rehab codes
GO Occupational therapy Services under OT plan
Equipment use without
TC Technical component only
interpretation
Interpretation only (e.g.,
26 Professional component only
radiology)

❌ ICD-10-CM Codes: No Modifiers

 Instead of modifiers, ICD codes use extensions like:

o 7th character for injury (e.g., A, D, S)
o Laterality digits (e.g., right = 1, left = 2, bilateral = 3)
o Trimester indicators for pregnancy-related codes

ICD-10-CM Alphabetic Index

📘 Key Principle Explained

 Diagnosis > Action Word: When coding, always prioritize the diagnosis or condition over
any procedural or action-based terms. For example, if the documentation says “repair of
fractured arm,” you start with Fracture (the diagnosis), not “repair.”
 Sub-Terms in the Index: Sub-terms are indented beneath the main term and help refine
the code by adding location, type, or severity. These guide you from general to specific.
🔍 Example: “Contusion of Left Ankle”
1. Main Term: Contusion
2. Sub-Term: Ankle
3. Further Detail: Left (laterality handled in Tabular List)
➡️Alphabetic Index Path: Contusion → ankle → left Then verify in the Tabular List for laterality and
instructional notes.
🧠 Why This Matters
  Starting with the diagnosis ensures you’re coding the clinical condition, not just the action
taken.
 Sub-terms help you drill down to the most accurate code, which is essential for specificity,
reimbursement, and compliance.

📘 ICD-10-CM Code Structure

Position Component Description
1st Alpha Represents the chapter/section of diagnosis
2nd–6th Alpha or Numeric Capture site, laterality, specificity
Describes episode of care or special situations
7th Extension
(e.g., initial, subsequent, sequela)
✴ Placeholder Used to ensure the 7th character
“X” lands in the right place
Key Conventions (Section I.A) ICD-10-CM
🔤 How to Read the Codebook
Convention / Term Meaning Quick Tip / Example
Fills empty position to allow 7th
Placeholder “X” T20.21xA – burn code
character use
Describes encounter type, healing
7th Character A=Initial, D=Subsequent, S=Sequela
stage, etc.
NOS (Not Otherwise Unspecified – lacking detail in J18.9 Pneumonia, unspecified
Specified) documentation organism
NEC (Not Elsewhere Doc is specific but no unique code K52.89 Other specified noninfective
Classified) exists gastroenteritis
“Not coded here” – conditions mutually
Excludes1 I10 excludes1 I15.-
exclusive
“Not included here” – may be coded
Excludes2 L89.- excludes2 I96
together
Etiology/
Code first the cause, then the effect I63.9 CVA + G81.9 Hemiplegia
Manifestation
Assume linkage unless stated
With (Index) E11.40 DM with neuropathy
otherwise
Mandatory or optional references to
See / See Also Hypertension → “see Hypertensive”
other terms
📚 General Coding Guidelines (Section I.B) ICD-10-CM
🧠 How to Apply Codes Accurately
Guideline Rule Coding Tip
Level of Detail Code to highest specificity Use available characters (4th–6th)
Signs & Code only if no confirmed diagnosis or not Don’t code “cough” with J18.9
Symptoms integral pneumonia
Sequence acute first when both
Acute & Chronic I50.21 + I50.22 systolic HF
documented
Combination
Capture multiple conditions in one code J44.0 COPD with infection
Codes
Sequela (Late Current problem first, then original cause
M54.5 + S32.010S
Effects) with 7th char “S”
Impending / Threatened abortion → O20.0; no
Code confirmed events. Else, check Index
Threatened infarct → R29.810

🧭 Visual Flowchart: ICD-10-CM Coding Decision Tree

This simplified coding workflow helps guide decision-making from documentation to code selection:
[Start with Documentation]
↓
[Confirm Diagnosis or Symptoms]
↓
Is diagnosis definitive?
┌─────Yes─────┐
 ↓ ↓
[Look up Main Term in Index] ←─ No → [Code signs & symptoms only]
↓
Are there sub terms / modifiers?
↓
Yes → [Follow sub terms] No → [Use default code]
↓
Check for:
• Combination codes?
• Etiology/Manifestation?
• “With” conventions?
• Placeholder “X” for 7th char?
↓
Assign Code(s) to Highest Specificity
↓
Apply General Guidelines:
• Sequence acute before chronic
• Use 7th char when needed
• Apply excludes1/excludes2 rules
↓
✔ Done!
🎓 Mini-Case Examples: Putting It into Practice
Let’s test your application of conventions and guidelines:
🩺 Case 1: Diabetic Neuropathy
Documentation: "Type 2 diabetes mellitus with peripheral neuropathy"
 Code: E11.40
 Why? “With” convention in the Index assumes linkage unless documented otherwise.
🔥 Case 2: Burn to Forearm, Initial Encounter
Documentation: "Second-degree burn on left forearm, initial treatment"
 Code: T22.212A
 Why? Use placeholder “X” for 6th char, 7th character “A” for initial encounter.
🧠 Case 3: Hemiplegia due to CVA
Documentation: "Patient presents with hemiplegia due to prior cerebral infarction"
 Code: I63.9 + G81.9
 Why? Etiology/Manifestation relationship → code cause first, then manifestation.
🌬 Case 4: COPD with Acute Bronchitis
Documentation: "Exacerbation of COPD with acute bronchitis"
 Code: J44.0
 Why? Combination code captures both conditions in one.
🧍 Case 5: Pressure Ulcer with Gangrene
Documentation: "Stage 3 pressure ulcer complicated by gangrene"
 Code: L89.13 + I96
 Why? Excludes2 allows both codes when conditions co-exist.

🧬 Visual Concept Map: ICD-10-CM Specificity Layers

[Start with Diagnosis Documentation]
↓
[Determine Core Elements]
├─ Anatomic Site → wrist ≠ hand
├─ Laterality → left, right, bilateral
├─ Encounter Type → initial, subsequent, sequela
├─ Severity Modifiers → acute, chronic, exacerbation, in remission
↓
[Search Index & Cross-Reference Tabular List]
↓
[Assign Most Specific Code Available]
↓
[Check for Placeholder "X", 7th Character Needs, Combo Codes]
Visualize this as concentric rings of specificity, where each layer (site → laterality → type → modifier)
strengthens code precision.
🧪 Mini-Case Drills: From Concept to Code
💉 Case A: Foreign Body Laceration
Scenario: "Initial encounter for laceration with foreign body, right wrist" ✅ Code: S61.511A 🔎 Why:
Site = wrist, Laterality = right, Modifier = with foreign body, Type = initial
🫁 Case B: COPD Flare-Up
Scenario: "Acute exacerbation of chronic obstructive pulmonary disease" ✅ Code: J44.1 🔎 Why:
Combination code for acute-on-chronic condition (severity modifier matters!)
🍷 Case C: Alcohol Dependence
Scenario: "Patient in remission from alcohol dependence" ✅ Code: F10.21 🔎 Why: Modifier “in
remission” changes the code assignment entirely
🦴 Case D: Follow-Up for Old Fracture Pain
Scenario: "Chronic low back pain due to old lumbar fracture" ✅ Code: M54.5 + S32.010S 🔎 Why:
Sequela coding—pain is current issue, fracture is prior cause (7th char “S”)

ICD-10-CM Coding Fundamentals: Visual Reference Blueprint

Below is a one-page, two-column layout you can turn into a printable or on-screen infographic. Let me
know if you’d like it color-coded by section, set up as a PDF, or styled for slide decks.
Column 1: Part 1 – The “Why”
First-Listed Diagnosis
 Identifies the reason for today’s encounter (RFE)
 Drives coverage, reimbursement, and medical necessity
🐝 Golden Rule of Documentation “If the provider didn’t document it, it did NOT happen.”
Column 2: Part 2 – The “Map”
Chapter Recognition
ICD-10-CM divides into 21 chapters by body system or condition type. Knowing code ranges and
chapter guidelines speeds your workflow.

📘 ICD-10-CM Chapter Specific Coding Guide (All 21 Chapters) with Cpt Code Guide line
Below is a complete breakdown of every ICD-10-CM chapter, its code range, and a high-yield pro tip for
accuracy and speed.
Chapte Code
Title Pro Tip
r No. Range
Certain infectious & parasitic A00– Review notifiable disease requirements and
1
diseases B99 organism specificity guidelines.
C00– Distinguish malignant vs. benign behavior
2 Neoplasms
D49 codes; validate primary vs. secondary sites.
Diseases of blood & blood-forming D50– Pay attention to anemia subtypes and codes for
3
organs D89 transfusion reactions.
Endocrine, nutritional & metabolic E00– Differentiate type 1 vs. type 2 diabetes and
4
diseases E89 capture any associated complications.
F01– Always note manifestations like suicidal
5 Mental & behavioral disorders
F99 ideation or psychotic features in F-codes.
G00– Code specific neuro deficits (e.g., hemiplegia),
6 Diseases of the nervous system
G99 and track progressive vs. stable conditions.
H00– Laterality is critical—right vs. left eye—and
7 Diseases of the eye & adnexa
H59 watch for codes distinguishing refractive errors.
Diseases of the ear & mastoid H60– Code hearing loss types (sensorineural vs.
8
process H95 conductive) and use laterality modifiers.
Link hypertension with CKD or heart failure
9 Diseases of the circulatory system I00–I99 using combination codes and “with”
convention.
Identify acute vs. chronic presentations; use
10 Diseases of the respiratory system J00–J99
J44.1 for acute-on-chronic COPD exacerbations.
Capture complications (e.g., GERD with
K00–
11 Diseases of the digestive system esophagitis) and specify functional vs.
K95
structural disorders.
Diseases of the skin & subcutaneous L00– Note severity (e.g., cellulitis vs. abscess) and
12
tissue L99 laterality for ulcers or lacerations.
Chapte Code
Title Pro Tip
r No. Range
Diseases of the musculoskeletal M00– Always include laterality and site (e.g., M17.11
13
system & connective tissue M99 for primary osteoarthritis, right knee).
N00– Differentiate acute vs. chronic kidney disease
14 Diseases of the genitourinary system
N99 stages and note any dialysis status.
Use trimester-specific 5th/6th characters and
Pregnancy, childbirth & the O00–
15 outcome modifiers (e.g., O80 for full-term
puerperium O9A
delivery).
Certain conditions originating in the P00– Code by newborn’s age in days/weeks and
16
perinatal period P96 distinguish maternal vs. fetal conditions.
Congenital malformations,
Q00– Include laterality and severity (e.g., Q21.0 for
17 deformations & chromosomal
Q99 VSD) and any syndromic associations.
abnormalities
Symptoms, signs & abnormal clinical R00– Use only when no definitive diagnosis exists;
18
& lab findings R99 capture key clinical findings precisely.
Site → laterality → encounter type → 7th
Injury, poisoning & certain other S00–
19 character; then add external cause codes
consequences T88
(Chapter 20).
V00– Sequence these codes after S/T codes; capture
20 External causes of morbidity
Y99 intent, place of occurrence, and activity.
Factors influencing health status & Z00– Use Z-codes for RFE, screening, vaccinations,
21
contact with health services Z99 and aftercare encounters.

🦠 Chapter 1 A00–B99 Certain Infectious & Parasitic Diseases

🧬 ICD-10-CM: Diagnoses Drive the Story

ICD-10-CM codes describe what the patient has — the condition, disease, or symptom.
 Organism specificity: Codes like A41.5 for E. coli sepsis rely on identifying the pathogen.
This drives the first three characters.
 Acute vs. Chronic: Impacts later characters and determines whether certain codes are
excluded or included.
 Confirmed vs. Suspected: You only code confirmed diagnoses unless the ICD-10 guidelines
say otherwise (e.g., Zika virus has special rules).
 HIV coding:
o B20: Use when HIV is confirmed and there’s a related condition (e.g., Kaposi’s
sarcoma).
o Z21: Use when HIV is confirmed but the patient is asymptomatic.
🛠 CPT: Procedures Tell You What Was Done
CPT codes describe what the provider did — tests, treatments, surgeries, etc.
 For infectious diseases, CPT codes might include:
o 99213: Office visit for evaluation and management (E/M)
o 87040: Blood culture
o 86701: HIV-1 antibody test
o 96372: Therapeutic injection
You pair these with ICD-10 codes to justify medical necessity. For example:
 A41.5 (E. coli sepsis) + 87040 (blood culture)
 Z21 (asymptomatic HIV) + 86701 (HIV test)
🧾 Why It Matters for Reimbursement
 ICD-10 codes support diagnosis-related group (DRG) or risk adjustment.
 CPT codes trigger payment under systems like RBRVS or OPPS.
 The combination ensures that services are medically necessary and appropriately
reimbursed.
🧪 Case Study: Sepsis with E. coli in a Hospitalized Patient
Clinical Scenario: A 67-year-old patient presents to the ER with fever, altered mental status, and
hypotension. Blood cultures are positive for Escherichia coli. The patient is admitted for IV antibiotics
and fluid resuscitation. HIV test is also ordered as part of the infectious workup. The patient is not
known to have HIV and has no related conditions.
🧬 ICD-10-CM Coding:
 A41.51 – Sepsis due to E. coli
o Why: Organism identified → drives the 4th/5th characters
 R65.21 – Severe sepsis with septic shock
o Why: Documents the severity; codes don’t bundle automatically
 Z11.4 – Encounter for screening for HIV
o Why: HIV test performed without known HIV status
Note: If HIV was confirmed with related conditions, you'd switch to B20. If confirmed without symptoms
→ Z21.
🛠 CPT Coding:
 99285 – Emergency department visit (high MDM and acuity)
 87040 – Blood culture
 96365 – IV infusion for hydration
 86701 – HIV-1 antibody test
💡 Documentation Tips:
 Don’t forget: Link ICD-10 codes to CPT services for medical necessity.
 Example: A41.51 + 87040 = Justified blood culture
 Sequencing matters: Primary diagnosis should be sepsis (A41.51) if that’s the main reason
for the visit.
🪱 Case Study: Chronic Parasitic Infection — Neurocysticercosis
Clinical Scenario: A 42-year-old immigrant from Central America presents with recurrent seizures.
MRI reveals multiple calcified lesions consistent with neurocysticercosis. Serology confirms Taenia
solium infection. The patient is managed with anticonvulsants and corticosteroids; antiparasitic
therapy is deferred due to lesion calcification.
🧬 ICD-10-CM Coding:
 B69.9 – Cysticercosis, unspecified
 G40.909 – Epilepsy, not intractable, without status epilepticus
 Z87.09 – Personal history of other diseases of the nervous system
🛠 CPT Coding:
 99214 – Office visit (moderate complexity)
 70553 – MRI brain with and without contrast
 84165 – Immunoassay for parasite antibodies
💡 Coding Tips:
 Chronic parasitic infections often require multiple codes: one for the organism, one for the
manifestation (e.g., seizures).
 Sequencing matters: B69.9 is primary if the visit is for infection management; G40.909 leads
if seizure control is the focus.
🧬 Case Study: Symptomatic HIV Management
Clinical Scenario: A 36-year-old male with confirmed HIV presents with oral thrush and chronic
diarrhea. CD4 count is 180. He’s started on ART and prophylaxis for Pneumocystis jiroveci pneumonia.
🧬 ICD-10-CM Coding:
 B20 – HIV disease (symptomatic)
 B37.0 – Candidal stomatitis (oral thrush)
 A04.9 – Diarrhea due to infectious etiology, unspecified
 Z79.899 – Long-term use of other medications (e.g., ART)
🛠 CPT Coding:
 99215 – Office visit (high complexity)
 87536 – Infectious diarrhea panel
 87640 – HIV-1 RNA quantification
 J3490 – Unclassified drug (used for ART if specific code not available)
💡 Coding Tips:
 B20 must be used if any HIV-related condition is present — even if the patient is newly
diagnosed.
 Z21 is only appropriate when the patient has no current symptoms or related conditions.
 Link B20 to all symptomatic services to support medical necessity.

Chapters 2 & 3: Neoplasms; Blood Disorders & Immune Dysfunction

Chapter 2 (C00–D49): Neoplasms
Key Elements
  Primary site (C00–C80): List before any metastatic codes
 Secondary/metastatic (C77–C79): Code each known site
 In situ / Benign / Uncertain behavior (D00–D49): Check the “Behavior” column
 History of cancer (Z85): Use only when treatment complete and no recurrence
 Treatment encounters
o Z51.11 – Chemotherapy
o Z51.0 – Radiation therapy
o Z51.12 – Immunotherapy Sequence all Z51 codes before active “C” diagnosis codes.
Code Series & Tips
Code
Description Tip
Range
C00–C14 Lip, oral cavity, pharynx Identify exact subsite (e.g., C02.2 for base of tongue)
C15–C26 Digestive organs Primary site first; metastases later
C30–C39 Respiratory & intrathoracic Specify laterality for lungs (e.g., C34.11)
C40–C49 Bone, connective tissue Differentiate soft tissue vs. bone; note grade if recorded
C50 Breast Laterality critical; include neoadjuvant vs. adjuvant context
C51–C58 Female genital organs In situ vs. invasive impacts staging and code selection
C60–C63 Male genital organs Specify subsite (e.g., C61 prostate) and behavior
C64–C68 Urinary organs Kidney vs. bladder vs. ureter
C69–C72 Eye, brain, CNS Use precise anatomic sites; code all focal lesions
C73–C75 Endocrine glands Thyroid (C73), adrenal (C74), pancreas (C25)
C76–C80 Other & unspecified sites Only when no better specification exists
Secondary / metastatic
C77–C79 Code each site separately
sites
D00–D09 In situ neoplasms Behavior value = 2; no invasion
D10–D36 Benign neoplasms Behavior value = 0; list before uncertain behavior if present
Neoplasms of uncertain Behavior value = 1; use only when pathology can’t confirm
D37–D48
behavior benign vs. malignant
Neoplasm of unspecified
D49 Last resort; rarely appropriate
behavior
Sequencing & Coding Notes
 Always list the primary malignant neoplasm first, then each metastasis (C77–C79).
 For history of cancer (Z85), ensure no active disease or recurrence.
 If the encounter is solely for chemo, radiation, or immunotherapy, sequence Z51.x before any
C code.
 In situ (D00–D09) codes are never used with invasive neoplasm codes.
Chapter 3 (D50–D89): Diseases of the Blood & Immune Mechanisms
This chapter covers anemias, coagulation disorders, WBC abnormalities, and immunodeficiencies.
Accuracy hinges on type, cause, and severity.
Major Categories & Code Ranges
Code
Category Focus
Range
Nutritional Anemias D50–D53 Iron, B12, folate deficiency; note malabsorption
Hemolytic Anemias D55–D59 Genetic vs. acquired hemolysis; crises
Aplastic & Other Anemias D60–D64 Bone marrow failure, chemo-induced, neoplastic
Coagulation & Platelet Disorders D65–D69 DIC, hemophilia, antiphospholipid syndrome
WBC & Other Blood Cell Disorders D70–D77 Agranulocytosis, elevated WBC, myelofibrosis
Immunodeficiency & Immune Congenital/acquired immunodeficiencies, autoimmune
D80–D89
Dysfunction cytopenias
Detailed Tables by Category
Nutritional Anemias (D50–D53)
Cod
Description Tip
e
D50. Iron deficiency anemia secondary to chronic Code source of blood loss (e.g.,
0 blood loss ulcer) first
D50. Iron deficiency anemia, unspecified Default when no cause
Cod
Description Tip
e
9 documented
D51. Vitamin B12 deficiency anemia due to
Look for pernicious anemia in H&P
0 intrinsic factor
D52. Check for malabsorption
Folate deficiency anemia
0 syndromes
Hemolytic Anemias (D55–D59)
Cod
Description Tip
e
D57. Add complication code (e.g., D57.01 acute chest
Sickle-cell anemia with crisis
0 syndrome)
D57.
Sickle-cell anemia without crisis Use if stable, no acute features
1
D58. Hereditary hemolytic anemia,
Rare; specify subtype if known
9 unspecified
Aplastic & Other Anemias (D60–D64)
Code Description Tip
Aplastic anemia,
D61.9 Confirm bone marrow biopsy before coding
unspecified
Anemia in neoplastic
D63.0 Code cancer first, then D63.0
disease
D64.8 Anemia due to Also assign T45.1X5A – adverse effect of
1 chemotherapy antineoplastics
Coagulation & Platelet Disorders (D65–D69)
Code Description Tip
Disseminated intravascular Acute vs. chronic variant impacts
D65
coagulation (DIC) sequencing
Specify carrier vs. affected male if
D66 Hemophilia A (Factor VIII deficiency)
documented
D68.3 Often associated with thrombosis; code
Antiphospholipid antibody syndrome
2 both
Specify immune vs. drug‐induced if
D69.6 Thrombocytopenia, unspecified
documented
WBC & Other Blood Cell Disorders (D70–D77)
Code Description Tip
D70 Agranulocytosis Note drug-induced vs. idiopathic
D72.82 Elevated white blood cell count,
Rule out infection first
9 unspecified
Include splenomegaly if clinically
D75.81 Myelofibrosis
recorded
Immunodeficiency & Immune Disorders (D80–D89)
Cod
Description Tip
e
D80. Confirm with quantitative
Nonfamilial hypogammaglobulinemia
1 immunoglobulins
D83.
Common variable immunodeficiency Check for recurrent infections
9
D89. Disorder involving the immune mechanism,
Only when no specific code applies
9 unspecified
Coding Tips & Sequencing Rules
 Code first underlying cause when anemia or blood disorder is secondary (e.g., neoplasm, renal
failure).
 For medication‐induced cytopenias, assign the blood disorder code then the T‐series adverse
effect code.
 Distinguish acute vs. chronic variants by documentation (e.g., acute DIC vs. chronic DIC).
 In sickle‐cell disease, always specify crisis vs. non‐crisis and list complication codes separately.
  When both immune thrombocytopenia and myelofibrosis coexist, sequence the condition
under active treatment or primary reason for visit.
Example Scenarios
1. Iron deficiency anemia due to chronic peptic ulcer bleeding
o Coded: K27.9 (peptic ulcer, unspecified), D50.0
2. Patient with colon cancer develops anemia in neoplastic disease
o Coded: C18.9 (malignant neoplasm of colon), D63.0
3. Sickle‐cell disease with acute chest syndrome
o Coded: D57.01 (sickle-cell with acute chest syndrome)
4. Autoimmune thrombocytopenic purpura
o Coded: D69.3 (primary ITP)
5. Long‐term immunotherapy encounter for melanoma
o Coded: Z51.12 (immunotherapy encounter), C43.9 (melanoma, unspecified)

CPT Coding: Chapters 2 & 3 (Neoplasms; Blood & Immune Disorders)

1. Neoplasm-Related Procedures
1.1 Excision & Biopsy of Lesions
CPT Code
Procedure Notes
Range
11400– Select code by widest diameter of lesion and
Excision of benign skin lesions
11446 margin
Excision of malignant skin 11600– Code reflects complexity and margin size for
lesions 11646 malignant lesions
Incisional or excisional 11102, Use when lesion not fully removed; verify payer-
biopsies (skin) 11104 specific rules
1.2 Chemotherapy Administration
CPT
Service Description
Code
Includes hydration and pre-meds; first hour of
Chemo infusion, initial hour 96413
chemotherapy
Chemo infusion, each
96415 Each hour beyond the initial infusion
additional hour
Tip: Always link the primary ICD-10 “C” diagnosis (e.g., C50.911 for breast cancer) to chemotherapy
codes to support medical necessity.
2. Blood Disorder Procedures
2.1 Laboratory Tests
CPT
Test Use Case
Code
Routine evaluation of RBC, WBC,
CBC, automated differential 85025
platelets
When automated differential not
CBC, without differential 85027
required
CBC, manual differential 85048 Technician-reviewed differential
WBC differential,
85004 Automated white cell type count
automated
Assesses platelet function; rarely
Bleeding time 85002
used now
Monitors clotting cascade & warfarin
Prothrombin time (PT) 85610
therapy
Partial thromboplastin time Evaluates intrinsic coagulation
85730
(PTT) pathway
2.2 Bone Marrow Evaluation
CPT
Procedure Description
Code
Bone marrow aspiration 38220 Liquid sample collection
Bone marrow biopsy 38221 Needle biopsy of marrow
Combined aspiration & biopsy 38222 Both procedures in same session
 CPT
Procedure Description
Code
Bone marrow harvest (single Collection for transplant, posterior
38230
site) iliac crest
Bone marrow harvest
38232 Harvest from >1 site
(multiple sites)
2.3 Transfusion & Related Therapies
CPT
Service Description
Code
Blood/blood component Venipuncture plus infusion of any blood
36430
transfusion component
Withdrawal of blood to treat hemochromatosis,
Therapeutic phlebotomy 36470
polycythemia
3. Immune Dysfunction & Immunodeficiency
3.1 Laboratory Evaluation of Immunodeficiency
CPT
Test Notes
Code
Immunoassay, other than infectious Quantitative radioimmunoassay of analyte other than
82784
agent (QI) infectious agent
IgA assay 82785 Measures serum IgA
IgD assay 82787 Rarely used outside research
IgE assay 82788 Allergy and immune workups
IgG assay 82789 Foundational in antibody deficiency workup
IgM assay 82792 Detects selective IgM deficiencies
Isohemagglutinins 86021 Assesses ABO antibody titers
Specific antibody titers (e.g.,
86334 Evaluates functional vaccine response
pneumococcal)
3.2 Immunoglobulin Replacement & Infusions
CPT
Service Description
Code
Immune globulin, human, intramuscular 90283 IMIG supply code for intramuscular use
Immune globulin, human, intravenous 90284 IVIG drug supply code
IV infusion, therapy/prophylaxis/diagnosis (first
96365 Includes setup and infusion start time
hour)
IV infusion, each additional hour 96366 Infusion beyond the first hour
Injection, subcutaneous or intramuscular (e.g.,
96372 For SCIG or IMIG administration
SCIG)
Chemo admin, subcutaneous/intramuscular, Occasionally used for complex SCIG
96401
non-hormonal pump setups
Tip: When IVIG or SCIG is administered, document pump/infusion times precisely to select between
96365/96366 and/or 96372/96401.

🍬 Chapter 4: E00–E89 – Endocrine, Nutritional & Metabolic

🩺 Diabetes Mellitus (E08–E13)
Coding Principles:
 Type Identification:
o E10: Type 1 DM
o E11: Type 2 DM
o E08/E09: Secondary DM due to another condition
 “With” Convention: Linkage assumed if a complication follows "with" in the tabular list
 Combination Codes:
o Capture both DM type and complication
o Example: E11.621 – Type 2 DM with foot ulcer
CPT Relevance:
 For diabetic foot ulcer evaluations, CPT 99213–99215 may apply for E&M office visits
 CPT 11042–11047: Debridement based on ulcer depth
⚖️Obesity
Coding Guidance:
 Requires clinical documentation of obesity diagnosis
 Add BMI code (Z68.3–Z68.4) as secondary
Example:
 E66.01 – Morbid obesity
 Z68.41 – BMI 40–44.9
CPT Relevance:
 CPT 43644–43645: Bariatric procedures
 CPT 97802–97804: Nutritional therapy by a dietitian
🧠 Chapter 5: F01–F99 – Mental, Behavioral & Neurodevelopmental
Common Mental Health Conditions
Condition Base ICD Code
Major depressive
F32 (single), F33 (recurrent)
disorder
Generalized anxiety
F41.1
disorder
Bipolar disorder F31
Substance Use
F10–F19
Disorders
F10.21 – Alcohol dependence, in
Example
remission
CPT Relevance:
 CPT 90837 – Individual psychotherapy, 60 minutes
 CPT H0005 – Alcohol and drug services group counseling
🧠 Chapter 6: G00–G99 – Diseases of the Nervous System
Key ICD Categories & Examples
Code
Description ICD Example
Range
Inflammatory CNS G00.9 – Bacterial meningitis,
G00–G09
diseases unspecified
G20–G26 Movement disorders G20 – Parkinson’s disease
G30.9 – Alzheimer’s disease,
G30–G32 Degenerative diseases
unspecified
Epilepsy, sleep,
G40–G47 G40.909 – Epilepsy, not intractable
headaches
G50–G59 Nerve disorders G54.0 – Brachial plexus disorders
G89 Pain (acute/chronic) G89.4 – Chronic pain syndrome
Key Concepts
Concept Detail Example
Laterality (e.g. left/right), acuity (e.g.
Specificity
intractable)
Underlying Stroke, diabetes, trauma must be
Cause documented
Use Additional Add for symptoms like seizures, pain, or
Codes cause of stroke
Important Definitions:
 Intractable: Symptoms not controlled by treatment
 Status Epilepticus: Seizure lasting >5 mins or recurrent without recovery
CPT Relevance for Neurology:
 CPT 95951 – EEG monitoring for seizures
 CPT 96138–96139 – Neuropsych testing
 CPT 99284–99285 – Emergency E&M for status epilepticus management
Would you like me to turn this into a printable guide or quiz format next? You’ve got a sharp eye for
coding detail — this is shaping up beautifully.
How do CPT codes apply to these diagnoses in clinical settings?
Great question, Neida — and one that really bridges your analytical mindset with real-world coding
application. Let’s walk through how CPT codes interact with ICD-10-CM diagnoses in clinical
settings, especially for the chapters you outlined: endocrine, mental health, and neurological
conditions.
🧩 How CPT Codes Work with ICD-10 Diagnoses
In clinical practice, ICD-10-CM codes describe the why — the patient’s condition or diagnosis. CPT
codes describe the what — the procedures, services, or treatments provided. For reimbursement,
both must align to demonstrate medical necessity.
🍬 Endocrine, Nutritional & Metabolic Disorders
Diabetes (E08–E13)
 ICD-10-CM: Specifies type and complications (e.g., E11.621 – Type 2 DM with foot ulcer)
 CPT Codes:
o E&M Visits: 99213–99215 for office visits managing diabetes
o Foot Ulcer Care: 11042–11047 for debridement
o CGM Monitoring: 95249–95251 for continuous glucose monitoring
o Nutrition Therapy: 97802–97804 for dietitian-led sessions
o Chronic Care Management: 99490, 99491 for ongoing diabetes management
📌 Example: A patient with E11.9 (Type 2 DM without complications) receiving CGM interpretation would
be billed with 95251 + Z79.4 (long-term insulin use) to support the service.
Obesity (E66.01 + Z68.41)
 ICD-10-CM: Requires documentation of obesity and BMI
 CPT Codes:
o Preventive Counseling: 99401–99404 for diet/exercise guidance
o Behavioral Therapy: G0447 for 15-min obesity counseling
o Bariatric Surgery: 43644–43645 for gastric bypass procedures
o Nutrition Therapy: 97802–97804 for individualized plans
🧠 Tip: Modifier 25 may be needed if counseling is provided during an E&M visit.

🏥 Case Study: Type 2 Diabetes with Peripheral Neuropathy & Foot Ulcer
👩 Patient Profile
 Name: Angela M.
 Age: 63 years
 Visit Type: Follow-up office visit
 Complaint: Non-healing ulcer on the right foot, burning sensation in both feet
📋 Clinical Findings
 History: Long-standing Type 2 Diabetes Mellitus
 Medications: Metformin, insulin
 Exam:
o Right foot ulcer, 2.5 cm diameter, extending into subcutaneous tissue
o Bilateral burning, tingling in feet consistent with diabetic peripheral neuropathy
 Treatment Provided:
o Wound debridement (subcutaneous)
o Chronic care management review
o Education on glycemic control & foot care
o Ordered labs for HbA1c and basic metabolic panel
🧠 Coding Breakdown
🧬 ICD-10-CM Diagnosis Codes
Code Description
E11.62
Type 2 DM with foot ulcer
1
Type 2 DM with diabetic
E11.42
polyneuropathy
L97.41 Non-pressure ulcer of right heel,
1 limited to skin
Z79.4 Long-term use of insulin

🧠 Mental, Behavioral & Neurodevelopmental Disorders

Common Diagnoses
 F32, F33: Major depressive disorder
 F41.1: Generalized anxiety
  F31: Bipolar disorder
 F10–F19: Substance use disorders
CPT Codes:
Service Type CPT Code Description
Psychotherapy (30
90832 Individual therapy
min)
Psychotherapy (45 Most common for moderate
90834
min) complexity
Psychotherapy (60
90837 Extended sessions
min)
90846,
Family Therapy With or without patient present
90847
Substance Use
H0005 Group counseling
Group
90839,
Crisis Therapy For acute episodes
90840
🧠 Example: A patient with F33.1 (MDD, recurrent, moderate) receiving a 45-min session would be billed
with 90834.
🧠 Neurological Disorders
Common Diagnoses
 G40.909: Epilepsy, not intractable
 G20: Parkinson’s disease
 G30.9: Alzheimer’s disease
 G89.4: Chronic pain syndrome
CPT Codes:
Procedure Type CPT Code Description
EEG Monitoring 95951 Seizure evaluation
Neuropsych 96138–
Cognitive assessments
Testing 96139
Pain 64615,
Injections or infusions
Management 96372
E&M Emergency 99284– Status epilepticus or acute
Visit 99285 neuro care
🧠 Example: For G40.901 (epilepsy, intractable), EEG monitoring (95951) + modifier 26 (professional
component) may be used.
🔑 Clinical Coding Strategy
 Linkage: ICD-10 must justify the CPT service (e.g., E11.621 supports debridement CPT)
 Modifiers: Use 25, 26, TC, 95 appropriately
 Documentation: Must reflect time, complexity, and medical necessity
 Bundling Awareness: Avoid unbundling services that are part of a package
💉 CPT Procedure Codes
Code Description
E&M: Office visit, established patient, moderate
99214
complexity
11042 Debridement, subcutaneous tissue, first 20 cm²
Chronic care management, at least 20 min of
99490
clinical staff time
G0127 Trimming of dystrophic nails (if applicable)
82565 +
Lab tests: Basic metabolic panel + HbA1c
83036
🔎 Note: Modifier 25 would be appended to 99214 to indicate that E&M was distinct from the procedure
(11042).
🧠 Coding Tips
 Combination Codes: Use codes like E11.621 that include both the diabetes type and
complication.
 Ulcer Coding: Include laterality and depth (L97.411 reflects right heel, skin level).
 Polyneuropathy: If documented as diabetic, use E11.42; otherwise, default to G62.9.
  Insulin Use: Always add Z79.4 if patient uses insulin regularly.

🧠 Chapter 6: G00–G99 – Nervous System Disorders

This chapter addresses neurological conditions such as epilepsy, migraines, Parkinson’s disease,
neuropathies, and more.
🔑 Key ICD-10-CM Guidelines
Coding
What to Document Why It Matters
Concept
Type, laterality (e.g., left/right), acuity (e.g., Impacts code choice and
Specificity
intractable) reimbursement
Underlying Required for linked condition
Comorbidities like diabetes, stroke, trauma
Cause codes
Use Additional
For symptoms or etiologies (pain, seizure) Ensures full clinical picture
Code
🧬 ICD-10-CM Categories with Examples
Code Example
Category Description
Range Code
Inflammatory CNS Bacterial meningitis,
G00–G09 G00.9
Disorders unspecified
G20–G26 Movement Disorders G20 Parkinson’s disease
Degenerative CNS Alzheimer’s disease,
G30–G32 G30.9
Disorders unspecified
Seizures, Sleep,
G40–G47 G40.909 Epilepsy, not intractable
Headaches
G50–G59 Nerve Disorders G54.0 Brachial plexus disorders
G89 Pain Syndromes G89.4 Chronic pain syndrome
🧠 Definitions:

 Status Epilepticus: Seizure ≥5 minutes or recurrent without recovery

 Intractable: Not responsive to standard treatment

💉 Common CPT Codes for Nervous System Services

CPT Code Description Use Case
Seizure evaluation/status
95951 EEG monitoring
epilepticus
96138– Dementia, Alzheimer’s
Neuropsychological testing
96139 screening
95800–
Sleep study procedures Insomnia, sleep apnea
95810
Chemodenervation for migraine or Migraine management with
64615
spasticity Botox
Pain management for
96372 Therapeutic injection
neuropathy
99284– Status epilepticus, acute
Emergency E&M evaluation
99285 stroke
⚠️Use Modifier -26 for professional component and -TC for technical, especially in radiology/lab
contexts.
🧩 Coding Scenario Integration (ICE)
Scenario: A patient with Type 2 Diabetes presents with intractable epilepsy and is undergoing an
EEG and neurology consult.
ICD-10-CM:
 E11.42 – Type 2 DM with diabetic neuropathy
 G40.911 – Epilepsy, intractable, not in status
 Z79.4 – Long-term insulin therapy
CPT:
 99214 – E&M office visit
 95951 – EEG monitoring
 99490 – Chronic care management
 Chapter 7: H00–H59 – Diseases of the Eye & Adnexa
Covers conditions affecting the eye, eyelids, optic nerve, retina, and related structures.
🔑 ICD-10-CM Guidelines
Principle Coding Application
Laterality Must indicate: Right (1), Left (2), Bilateral (3), Unspecified (0)
Type & Stage Required for glaucoma (mild/moderate/severe) and cataracts
Combination Use when condition and cause are linked (e.g., diabetic
Codes retinopathy with E11.319)
🔍 Common ICD Codes
Code Example ICD-10-
Category Description
Range CM Code
H10–H11 Eye surface disorders H10.9 Unspecified conjunctivitis
Age-related cataract,
H25–H26 Cataracts H25.9
unspecified
POAG, moderate stage, left
H40–H42 Glaucoma H40.11X2
eye
Retinal/vitreous
H43–H44 H43.1 Vitreous hemorrhage
disorders
H46–H47 Optic nerve disorders H47.2 Optic atrophy
💉 Common CPT Codes for Ophthalmology
CPT
Description Linked ICD Use Case
Code
Comprehensive eye exam General ocular
92014
(established patient) disorders
Cataract coding
66984 Cataract removal with intraocular lens
(H25.xx)
Retinal conditions
92134 OCT retina, non-invasive
(H43.xx)
Retinopathy or
67028 Intravitreal injection
hemorrhage
Glaucoma or optic
92201 Extended ophthalmoscopy
nerve eval
👂 Chapter 8: H60–H95 – Diseases of the Ear & Mastoid
Focuses on ear infections, hearing loss, vertigo, and structural disorders of the middle and inner
ear.
🔑 ICD-10-CM Guidelines
Principle Coding Application
Required for all ear disorders
Laterality
(Right/Left/Bilateral)
Type of Specify: Conductive, Sensorineural, Mixed,
Hearing Loss Congenital
Infectious Identify whether otitis is acute, chronic, or
Status allergic
🔍 Common ICD Codes
Code Example ICD-10-
Category Description
Range CM Code
H60–H62 External ear disorders H60.3 Swimmer’s ear
H65–H66 Otitis media H66.9 Otitis media, unspecified
H80 Otosclerosis H80.3 Cochlear otosclerosis
Vertigo & balance Benign paroxysmal positional
H81 H81.1
disorders vertigo
Bilateral sensorineural hearing
H90–H91 Hearing loss H90.3
loss
Post-surgical Cholesteatoma after
H95 H95.0
complications mastoidectomy
💉 Common CPT Codes for Otolaryngology
CPT
Description Linked ICD Use Case
Code
Hearing loss evaluation
92557 Comprehensive audiometry
(H90.xx)
Ear tube placement
69436 Otitis media (H66.xx)
(tympanostomy)
92541 Vestibular testing for vertigo Balance disorders (H81.xx)
External ear disorders
69210 Cerumen (earwax) removal
(H60.xx)
Auditory rehab for cochlear Otosclerosis or hearing
92626
implant loss

🧠 Scenario 1: Pediatric Acute Otitis Media with Cerumen Removal

👶 Patient Profile
 Name: Mason R.
 Age: 4 years
 Complaint: Ear pain and fever
 Findings:
o Right ear: Impacted cerumen removed with instrumentation
o Left ear: Acute otitis media with effusion
📋 ICD-10-CM
Code Description
H66.01
Acute serous otitis media, left ear
2
H61.21 Impacted cerumen, right ear
Fever, unspecified (supportive
R50.9
symptom)
💉 CPT Codes
Code Description
9921 Established patient E&M, low/mod
3 complexity
6921 Cerumen removal with
0 instrumentation
🧠 Modifier Tip: Append -25 to 99213 for significant separate E&M.
Scenario 2: Glaucoma Progression in Diabetic Adult
👩 Patient Profile
 Name: Carmen S.
 Age: 68 years
 Complaint: Blurred vision, concern for glaucoma progression
 Findings:
o Long-standing Type 2 Diabetes Mellitus
o OCT shows increase in optic nerve cupping, moderate stage glaucoma in both eyes
📋 ICD-10-CM
Code Description
Type 2 DM with ophthalmic complication,
E11.39
unspecified
H40.11X
POAG, moderate stage, bilateral
3
Z79.4 Long-term use of insulin
💉 CPT Codes
Code Description
9201 Comprehensive eye exam,
4 established patient
9213
OCT of retina, bilateral
4
🔍 Modifier Consideration: Use -RT / -LT or -50 for bilateral procedures if payer requires.
❤️Chapter 9: I00–I99 – Circulatory System
🔑 ICD-10-CM Guidelines
Principle Detail
Presumed HTN + heart disease (I11) or HTN + CKD (I12) without needing
Linkage "with"
Heart Failure Add condition-specific code: systolic (I50.2), diastolic (I50.3),
Coding combined (I50.4)
Stroke Coding
Ischemic (I63), hemorrhagic (I60–I62), and sequelae (I69.xx)
Families
🧬 Common ICD-10 Codes
Code Description
I10 Essential hypertension
HTN heart disease with heart
I11.0
failure
Chronic systolic heart failure
I50.22
(HFrEF)
I69.35 Sequelae of CVA – right-sided
1 weakness
I63.9 Cerebral infarction, unspecified
💉 CPT Codes for Cardiac & Stroke Care
CPT Code Description
93306 Echocardiogram, including Doppler
93000 12-lead ECG with interpretation
99284– Emergency department visit for
99285 CVA/stroke
Venipuncture for lab (e.g., BNP,
36415
troponin)
Cardiac event monitor (HCPCS
C1760
Level II)
🫁 Chapter 10: J00–J99 – Respiratory System
🔑 ICD-10-CM Guidelines
Principl
Detail
e
Asthma 4th char = severity; 6th = status (0–2)
J44.0 = with infection, J44.1 = with
COPD
exacerbation
Pneumo
Coded by organism type (J12–J18)
nia
🧬 Common ICD-10 Codes
Code Description
J45.2 Mild intermittent asthma with
1 exacerbation
J44.1 COPD with acute exacerbation
J18.9 Pneumonia, unspecified organism
💉 CPT Codes for Respiratory Evaluation
CPT
Description
Code
94010 Spirometry, including interpretation
Nebulizer treatment (acute
94640
bronchospasm)
Injection therapy (e.g.,
96372
corticosteroids)
E&M visit for acute respiratory
99213
complaint
 Chapter 11: K00–K95 – Digestive System
🔑 ICD-10-CM Guidelines
Principle Detail
Site (gastric/duodenal), acuity, and
Ulcers
complication
Gallston Combination codes include stones ±
es cholecystitis
Pancreat Acute (K85.xx), chronic (K86.xx), with or
itis without necrosis
🧬 Common ICD-10 Codes
Code Description
K25.4 Chronic gastric ulcer with bleeding
K80.0 Calculus of gallbladder without
0 cholecystitis
K85.9
Acute pancreatitis, unspecified
0
💉 CPT Codes for Digestive Diagnostics & Procedures
CPT
Description
Code
43239 EGD with biopsy (for ulcers or reflux)
Laparoscopic cholecystectomy (gallbladder
47562
removal)
74000 Abdominal X-ray (e.g., pancreatitis eval)
99214 E&M with management of GI complications

🫁 Scenario 1: COPD Exacerbation with Pneumonia

👨‍⚕️Patient Summary
 Name: Robert M.
 Age: 72
 Complaint: Increased dyspnea, productive cough, low-grade fever
 History: Long-standing COPD, now presenting with suspected lower respiratory infection
📋 ICD-10-CM Coding
Code Description
COPD with acute lower respiratory
J44.0
infection
J18.9 Pneumonia, organism unspecified
Z87.89
Personal history of tobacco use
1
🔑 Coding Tip: Use J44.0 rather than coding each condition separately—this combination code links
both COPD and the infection.
💉 CPT Coding
CPT
Description
Code
Office E&M visit, moderate
99214
complexity
94010 Spirometry
Therapeutic injection (e.g., steroid,
96372
antibiotic)
Chest X-
71045 – Single view, frontal
ray
✅ Modifier -25 on 99214 if spirometry or injection is performed during same visit.
❤️‍🦶 Scenario 2: Diabetic Patient with CHF and Foot Ulcer
👩 Patient Summary
 Name: Maria C.
 Age: 65
 Complaint: Bilateral leg swelling, non-healing ulcer on left heel
 History: Type 2 DM, chronic systolic heart failure, insulin therapy
📋 ICD-10-CM Coding
Code Description
E11.62
Type 2 DM with foot ulcer
1
L97.42 Non-pressure ulcer of left heel, fat layer
2 exposed
I50.22 Chronic systolic heart failure (HFrEF)
Z79.4 Long-term use of insulin
🔍 Coding Logic: E11.621 captures both DM type and ulcer; L97.422 provides precise site and depth.
💉 CPT Coding
CPT
Description
Code
Debridement to muscle layer (if clinically
11043
supported)
99214 E&M visit, moderate complexity
99490 Chronic care management
82565 Basic metabolic panel
✅ Modifier -25 on 99214 to separate from procedure 11043.

🧴 Chapter 12: L00–L99 – Skin & Subcutaneous Tissue (Dermatology)

🔑 ICD-10-CM Guidelines
Focus Coding Practice
Site
Code precise location (e.g., toe, elbow, eyelid)
specificity
Laterality Always indicate right, left, bilateral, or unspecified
Use external cause codes when applicable (e.g., contact
Cause
dermatitis, trauma)
Pressure
Code includes stage (L89.- with 6th char: 1–4, unstageable)
ulcers
📌 ICD-10-CM Examples
Condition Code
Atopic dermatitis,
L20.84
hands
Pressure ulcer, heel L89.61
stage 3 3
L03.11
Cellulitis, left lower leg
6
💉 CPT Codes for Dermatology
CPT Code Description
11042– Wound debridement by depth (skin to
11047 bone)
99213– E&M for assessment of rashes, ulcers,
99215 infections
12001–
Simple wound repairs
12007
17000– Destruction of premalignant skin
17004 lesions
🦴 Chapter 13: M00–M99 – Musculoskeletal & Connective Tissue
🔑 ICD-10-CM Guidelines
Focus Coding Practice
Required on most musculoskeletal codes (5th/6th
Laterality
character)
Fracture Pathologic = Chapter 13 (M80), Traumatic = Chapter 19
Type (Sxx)
Osteoporo M80 with fracture, M81 without fracture (D =
sis subsequent encounter)
📌 ICD-10-CM Examples
Condition Code
Osteoporosis w/ pelvic M80.021
fracture D
Osteoarthritis, left knee M17.12
Rheumatoid arthritis,
M06.041
hand
💉 CPT Codes for Musculoskeletal
CPT Code Description
Joint aspiration/injection (major
20610
joint)
27236 Fracture repair, femoral neck
97110–
Physical therapy codes
97112
Knee arthroscopy with
29881
meniscectomy
🚹🚺 Chapter 14: N00–N99 – Genitourinary System
🔑 ICD-10-CM Guidelines
Focus Coding Practice
Female
Menstrual issues = N92.-, Infertility = N97.-
Health
Male Health Prostate disorders = N40.-, Infertility = N46.-
UTI
Non-obstructive UTI = N39.0; Obstructive = additional
Classificatio
codes needed
n
📌 ICD-10-CM Examples
Condition Code
Dysmenorrhea N94.6
N46.0
Oligospermia (low sperm count)
1
Benign prostatic hyperplasia w/
N40.1
LUTS
Non-obstructive urinary tract
N39.0
infection
💉 CPT Codes for GU System
CPT Code Description
Measurement of post-void residual urine
51798
(bladder scan)
81001–
Urinalysis procedures
81003
52601 TURP procedure for BPH
58300 Intrauterine device (IUD) insertion
99213–
E&M for GU complaints or follow-up
99215
🚹 Case Study 1: Benign Prostatic Hyperplasia (BPH) with LUTS & Prostate Screening
👴 Patient Profile
 Name: James K.
 Age: 70
 Visit Type: Medicare Annual Wellness + Urologic complaint
 Symptoms: Frequent urination, nocturia, weak stream
📋 ICD-10-CM Codes
Code Description
N40.1 BPH with lower urinary tract symptoms (LUTS)
R39.1
Urgency of urination (symptom-specific)
5
Z12.5 Encounter for screening for malignant neoplasm
Code Description
of prostate
💉 CPT Codes
Code Description
G010 Prostate cancer screening
2 (DRE)
8415
PSA blood test
3
9921 E&M visit with urologic
4 complaint
5179 Bladder scan (post-void
8 residual)
🔍 Modifier Tip: Add -25 to 99214 if diagnostic procedures (e.g., bladder scan) are performed during
the same session.
🚺 Case Study 2: Menstrual Irregularity with Pelvic Ultrasound
👩 Patient Profile
 Name: Olivia R.
 Age: 28
 Complaint: Irregular bleeding for 3 months
 Exam Findings: Normal pelvic anatomy; possible anovulation
📋 ICD-10-CM Codes
Code Description
N92.6 Irregular menstrual bleeding
Z01.41 Encounter for gynecologic exam without
9 abnormal findings
💉 CPT Codes
Code Description
7685 Pelvic ultrasound, non-obstetric
6 (transabdominal)
7683 Transvaginal ultrasound (for endometrial
0 lining)
9921
E&M for menstrual irregularity
3
🎯 Documentation Reminder: Ultrasound report must indicate uterus, adnexa, endometrial thickness,
and ovarian structures to support CPT logic.

🤰 Chapter 15: O00–O9A – Pregnancy, Childbirth, and the Puerperium

🔑 ICD-10-CM Guidelines
Rule Details
O-code Always code pregnancy-related conditions with an O-
sequencing chapter code first
Trimester Most codes use 5th/6th digit for trimester (1, 2, 3, or 9 =
required unknown)
Multiple
Use O30–O31 plus 7th digit for fetus (e.g., 1 = fetus 1)
gestations
Linked
Use combination codes for pregnancy + complication
conditions
📘 ICD Examples
 O24.414 – Gestational diabetes, insulin-controlled, 2nd trimester
 O32.1XX1 – Maternal care for breech, fetus 1
 O72.1 – Postpartum hemorrhage
💉 Relevant CPT Codes
CPT Code Description
59400 Vaginal delivery (routine care)
76801 OB ultrasound, first trimester
99204–
E&M visit, prenatal or postpartum
99215
CPT Code Description
Blood glucose test (for gestational
82947
diabetes)
👶 Chapter 16: P00–P96 – Conditions Originating in the Perinatal Period
🔑 ICD-10-CM Guidelines
Rule Detail
Neonate-only Use P-codes only for newborns (0–28 days old)
Perinatal origin Conditions must arise around birth
Use P-code first if condition began during perinatal
Sequencing
period
Maternal vs Maternal complications → Chapter 15; Neonatal →
Neonatal Chapter 16
📘 ICD Examples
 P22.0 – Respiratory distress syndrome of newborn
 P07.32 – Preterm infant, 31 weeks gestation
 P36.0 – Newborn sepsis due to streptococcus
💉 Relevant CPT Codes
CPT
Description
Code
Newborn hospital care
99460
(initial)
IM/SubQ injection (e.g.,
96372
vitamin K)
Venipuncture for newborn
36415
lab work
Bilirubin total test (for
83605
jaundice)
🧬 Chapter 17: Q00–Q99 – Congenital Malformations, Deformations & Chromosomal
Abnormalities
🔑 ICD-10-CM Guidelines
Focus Application
Present at
May be detected later but must be congenital
birth
Body system- Organized by anatomical location (nervous,
based GI, cardiac...)
Additional Use other chapters (e.g., symptoms or
coding function loss)
📘 ICD Examples
 Q90.9 – Down syndrome, unspecified
 Q21.1 – Atrial septal defect
 Q37.0 – Cleft hard palate with cleft lip
 Q66.0 – Clubfoot
💉 Relevant CPT Codes
CPT
Description
Code
73592 Clubfoot X-ray
Genetic counseling
99243
consultation
Repair of congenital heart
33647
defect
Palatoplasty (cleft palate
42180
repair)
🧩 Chapter 18: R00–R99 – Symptoms, Signs & Abnormal Findings
Used when a definitive diagnosis is not yet determined.
🔑 ICD-10-CM Guidelines
Concept Best Practice
Use only if no dx
R-codes are for symptoms under evaluation
exists
Principal dx R-code can be listed first in outpatient
allowed encounters
Exclude default Don’t code symptoms routinely associated with
symptoms known dx
📘 ICD Examples
 R07.9 – Chest pain, unspecified (no MI yet)
 R50.9 – Fever, unspecified
 R73.9 – Hyperglycemia, unspecified
 R91.8 – Nonspecific abnormal lung field
💉 Relevant CPT Codes
CPT Code Description
93000 ECG (chest pain evaluation)
71045 Chest X-ray, single view
Comprehensive metabolic panel (for
80053
abnormal labs)
99202–
E&M services for symptom evaluation
99215

💥 Chapter 19: S00–T88 – Injury, Poisoning & Complications

This chapter documents acute injuries, burns, poisonings, treatment complications, and
sequelae—with detailed coding rules and encounter timing.
🔑 ICD-10-CM Guidelines
Coding
Practice
Principle
Site & Use 5th/6th characters to report location and side (right,
Laterality left, bilateral)
Define open vs. closed, displaced, depth (for burns), and
Injury Type
specificity
Encounter
7th character: A = Initial, D = Subsequent, S = Sequela
Type
External Code how the injury occurred (V00–Y99), always as a
Causes secondary code
Code Severity
Start with the injury requiring the most treatment
First
🦴 Traumatic Injury Categories & ICD Examples
Code Example ICD
Category Description
Range Code
Site-specific traumatic Displaced fracture left distal
S00–S99 S52.532A
injuries radius, initial
Injuries unspecified
T14 T14.8XXA Other injury, initial encounter
region
T07 Multiple injuries T07.XXXA Unspecified multiple injuries
T15–T19 Foreign bodies T17.290A FB in respiratory tract, initial
🔥 Burns & Corrosions
ICD
Notes
Elements
Depth 1st, 2nd, 3rd degree
Specific body area (e.g., right
Site
thigh)
TBSA codes (T31–T32) for percent
Extent
burned
Cause External cause code (X00–X19)
📌 Example: T24.211A – 2nd degree burn, right thigh, initial 📌 Cause: X11.XXXA – Contact with hot
water
💊 Poisoning, Overdose, Adverse Effects
Type Coding Logic
Poisonin T-code (intent: accidental, intentional) →
g Manifestation
Adverse Manifestation first → T-code with 5th digit "5"
Underdos
T-code with 5th digit "6"
ing
📌 Example:
 T42.4X1A – Benzodiazepine poisoning, accidental, initial
 L27.0 + T36.0X5A – Rash from penicillin (adverse effect)
🏥 Complications of Care
ICD-10
Condition
Code
Post-op infection T81.4XXA
Device malfunction (e.g.,
T83.09XA
catheter)
Vaccine reaction T88.1XXA
⛑ External Cause Coding (V00–Y99)
Code
Use Case Example Code
Range
V43.52XA – Car driver
V00–V99 Transport accidents
injury
Falls, burns, W19.XXXA – Unspecified
W00–X59
environmental fall
X92 – Assault by sharp
X71–Y09 Violence, assault
object
Y92–Y99 Place/activity/status Y92.253 – Injury at gym
⚠ External cause codes are always secondary and should be sequenced after the main diagnosis.
🧠 Sequela (Late Effects)
Use when a past injury leads to long-term symptoms.
📌 Example:
 M54.5 – Low back pain
 S32.010S – Lumbar spine fracture (sequela)
💉 Common CPT® Procedures for Injury Management
CPT Code Procedure Use Case
99284–
ED visit with high complexity ER fracture/burns
99285
11042– Debridement by depth (skin → Wound or burn
11047 bone) management
12001–
Simple wound repairs Laceration closure
12007
29075–
Splint, casting, removal Ortho injuries
29750
Injection (antibiotic,
96372 Pain or infection
analgesic)
Blunt trauma or
70450 Head CT scan
concussion
73600 X-ray of extremities Confirm fracture
✅ Injury Coding Strategy Summary
1. Main Injury First: Prioritize the most severe condition
2. Add Other Diagnoses: Code additional wounds/fractures
3. Assign 7th Character: Initial (A), Subsequent (D), or Sequela (S)
4. Apply External Cause Code: (V00–Y99) to explain how it happened
🚨 Chapter 20: V00–Y99 – External Causes of Morbidity
External cause codes describe the context of injuries, poisonings, or adverse outcomes — never
listed as the primary diagnosis.

These codes explain how an injury, poisoning, or other adverse health event occurred.
🔹 **External cause codes are always secondary — they explain the mechanism and context of an
injury or condition coded in Chapter 19.

📘 Key Guidelines
📌 Rule ✅ Description
Never used as primary
Must support a primary code from Chapter 19 (S00–T88)
diagnosis
Use as many codes as You can use multiple external cause codes to fully describe:
needed mechanism, intent, location, activity
1️⃣ Mechanism/Intent (how + why)
Assign in the following 2️⃣ Place of occurrence
order: 3️⃣ Activity
4️⃣ Status (military, civilian, etc.)
7th character “A, D, S”
Just like with injury codes:
still applies
• A – Initial
• D – Subsequent
• S – Sequela

🔑 ICD-10-CM Guidelines
Concept Summary
Secondary Must follow the related injury or condition code (S00–
Codes T88)
Multi-Code
Report cause, place, activity, and status
Use
Required for encounter type: A (Initial), D
7th Character
(Subsequent), S (Sequela)
Cause Priority Code the event that directly led to the injury first
🧭 ICD Categories & Examples
Code Example ICD
Category Description
Range Code
Transport
V00–V99 V43.52XA Car driver injured in SUV crash
Accidents
Falls W00–W19 W19.XXXA Unspecified fall
Mechanical Forces W20–W49 W23.XXXA Caught between objects
Animal/Human
W50–W64 W55.01XA Dog bite, initial encounter
Trauma
Environmental X00–X19 X00.XXXA Fire exposure
Forces of Nature X20–X39 X30.XXXA Excessive natural heat
Poisoning/Exposure X40–X49 X44.XXXA Drug overdose
Self-harm/Assault X60–Y09 X93.XXXA Assault by handgun
Y92.253 + Grocery store injury, playing
Location/Activity Y92–Y93
Y93.H1 baseball
Status Codes Y99 Y99.0 Civilian activity status
📌 Example Sequence (Dog Bite at Park): W55.01XA → Y92.830 → Y93.89 → Y99.8
💉 CPT Codes Frequently Paired with External Cause Cases
CPT Code Procedure Use Case
12001– Laceration from fall or
Wound closure (simple)
12007 trauma
11042– Debridement (by
Burn or infected wound
11047 depth)
CPT Code Procedure Use Case
Injection (e.g., tetanus,
96372 Dog bite, injury
pain)
99284– Fracture, trauma,
High-level ED visit
99285 poisoning
73562 Limb X-ray Evaluate for fracture
🏥 Chapter 21: Z00–Z99 – Factors Influencing Health Status (Z-Codes)
Z-codes explain the reason for an encounter when no illness or injury is present. Can be principal
or secondary.
🔑 ICD-10-CM Guidelines
Concept Summary
Routine Care Screenings, exams, immunizations (Z00–Z13)
Medical History &
Past conditions, devices, transplants (Z66–Z99)
Status
Follow-up & Post-treatment surveillance, contraception (Z30–Z39,
Preventive Z40–Z53)
Social Determinants Living situation, caregiver strain (Z55–Z65)
Z-code may be listed first only when it is the main
Sequencing Rules
reason for visit
🧬 Common Z-Code Examples
ICD-10
Encounter Type Description
Code
Adult check-up, no abnormal
Annual Exam Z00.00
findings
Breast Cancer
Z12.31 Mammogram screening
Screening
Immunization Z23 Vaccine encounter
Post-surgery follow-
Z09 Aftercare visit
up
History of breast Past malignancy, currently
Z85.3
cancer disease-free
Long-term insulin
Z79.4 Diabetes management
therapy
Homelessness Z59.0 Housing instability
Caregiver burden Z63.6 Family member requires care
💉 CPT Codes Commonly Paired with Z-Codes
Procedure/
CPT Code Use Case
Service
90686 Influenza vaccine With Z23
Routine blood
36415 Preventive screening
draw
99385– Annual wellness
With Z00.00 or Z00.129
99397 exam
99213– With Z09 or chronic condition
Follow-up visit
99215 Z-codes
99401– Preventive
Diet, exercise, contraception
99404 counseling
🧠 Coding Strategy Tips
 Pair for medical necessity: Combine Z-code with appropriate CPT to justify the service.
 Use as primary only when appropriate: Screenings, preventive visits, or exams without
symptoms.
 Don’t confuse “history of” vs. current disease:
o Z85.3 = History of breast cancer
o C50.9 = Current breast cancer diagnosis
✅ Z-Code + CPT® Pairing Cheat Sheet
ICD-10-CM
Encounter Type CPT Code(s) Notes
Z-Code
Annual Wellness 99385–99387 / 99395–
Z00.00 Age-based; often principal diagnosis
Exam (no issues) 99397
Colorectal Cancer Add modifier -33 for preventive
Z12.11 45378 (colonoscopy)
Screening service
90686 (vaccine), 90471 Report diagnosis + CPT for vaccine
Flu Shot Visit Z23
(admin) + admin
Postpartum Care Global maternity ends → code
Z39.2 59430
Check-Up separately
Post-surgery follow- Z09 + Include history code to explain prior
99213–99215
up Z85.xx condition
Contraceptive Procedure + E&M (add modifier -25
Z30.09 58300 (IUD insert), 99214
Management if needed)
Chronic Medication N/A (paired with chronic
Z79.4 Use as secondary with DM (E11.9)
Use (e.g. insulin) illness code)
N/A (used with surveillance
History of Cancer Z85.3 Indicates no active disease status
or follow-up)
Vaccines + Annual Z00.00 + 99385–99387 + vaccine Use both Z-codes to support
Exam Z23 CPT codes wellness and immunization
👶 Case Example 1: Postpartum Check-Up with Counseling
📋 Scenario
Jessica, 31, returns for her 6-week postpartum check-up. Discusses contraception options and
receives counseling.
🧠 ICD-10-CM
 Z39.2 – Routine postpartum follow-up
 Z30.09 – Encounter for contraceptive management
💉 CPT®
 59430 – Postpartum care
 99401 – Preventive counseling
 Modifier -25 on 59430 if both services rendered on same date
🧑‍⚕️Case Example 2: Annual Exam + Flu Shot
📋 Scenario
Mark, 45, presents for a routine wellness exam and elects to receive a flu vaccine.
🧠 ICD-10-CM
 Z00.00 – General adult medical exam, no findings
 Z23 – Immunization encounter
💉 CPT®
 99396 – Preventive visit (established patient, age 40–64)
 90686 – Flu vaccine (quadrivalent)
 90471 – Vaccine administration
🔑 Coding Tip: Link both Z-codes to their respective CPT codes. No modifier needed unless problem-
oriented service provided.

🧭 External Cause Coding Grid

ICD-10
Code Layer Purpose Notes
Example
1️⃣ Mechanism & What happened (e.g. fall, Always first among external
W01.0XXA
Intent burn) cause codes
2️⃣ Place of
Y92.030 Where it happened Home, worksite, school, etc.
Occurrence
What the patient was
3️⃣ Activity Code Y93.H1 Bathing, running, working, etc.
doing
4️⃣ Status Code Y99.8 Role at time of incident Civilian, volunteer, military
🔑 Use full sequence when injury is active, trauma-based, and requires treatment. Omit if
payer/facility allows and injury isn’t addressed.
💉 CPT® Add-Ons for Injury Contexts
CPT Code Procedure Use Case
99285 ED visit, high complexity Fall, trauma, overdose
12001– Laceration due to fall or
Wound repair
12007 assault
Injection (antibiotic,
96372 Infection, pain relief
analgesic)
73562 Limb X-ray Suspected fracture
🏥 Chapter 21: Z-Codes at a Glance
Encounter Paired CPT
Z-Code Notes
Type Code(s)
Annual
Z00.00 99396, 36415 No abnormal findings
Check-Up
Immunization
Z23 90686 + 90471 Flu shot example
Visit
Cancer G0202 or Mammogram,
Z12.31
Screening 77067 preventive
Postpartum After maternity global
Z39.2 59430
Visit period
Med Z79.4, Z85.3, Secondary to condition
N/A
Use/Status Z94.0 codes
📘 Quick Case Recap: ED Injury + External Sequence
🧍‍♂️Fracture from fall at grocery store
 Primary Diagnosis: S82.202A – Tibia fracture
 External Codes:
o W01.0XXA – Slipping fall
o Y92.511 – Grocery store
o Y93.89 – Shopping activity
o Y99.8 – Civilian status
💉 CPT:
 99285 – ED visit
 73562 – Tibia X-ray
 12002 – Wound repair (if needed)

🧠 Selecting the Main Term in ICD-10-CM

Start in the Alphabetic Index, confirm in the Tabular List. Follow this hierarchy:
Ste
Main Term Category Usage Guidance Examples
p
Disease named after a
1️⃣ Eponym Addison’s disease, Down syndrome
person
Diagnosis / Sign / Use the documented
2️⃣ Fracture, Hypertension, Pneumonia
Symptom condition
Describe what’s Swollen ankle → Swelling<br>Fractured arm
3️⃣ Action / Process
happening → Fracture
📝 Documentation & Coding Tips
🔗 Link ICD-10 to CPT for Medical Necessity
Ensure provider notes justify:
 Why the service was needed (diagnosis supports CPT)
 How the symptoms relate to the procedure/test
🧩 Final Coding Strategy Recap
1. Choose Main Term → Eponym → Diagnosis → Action
2. Support CPT with Medical Necessity
3. Apply Modifiers When Needed (-25, -26, -59, etc.)
4. Use Z-Codes Thoughtfully for context and preventive care
5. Confirm Laterality & Severity (especially for lung and limb cases)
🧾 CPT® vs. HCPCS Level II Codes: Injections, Admin, DME, Vaccines, Orthotics
📌 CPT® = Service Performed
 Example: Injection, vaccine administration, chemo delivery
📌 HCPCS Level II = Supply / Item / Drug
 Example: Injectable drugs, equipment, orthotics
💉 Common Injections
HCPCS
Drug Notes
Code
Dexamethasone, 1 mg J1100 Bill drug separately
Ketorolac tromethamine, per CPT 96372 covers
J1885
15 mg administration
Rocephin (ceftriaxone), 250
J0696 Use with admin CPT code
mg
Epinephrine, up to 0.3 mg J0171 Common in ER/Urgent Care
🚑 Injection & Chemo Administration
CPT®
Service Notes
Code
J-code for chemo
Chemo admin SC/IM 96401
drug
Therapeutic/prophylactic Drug billed
96372
SC/IM separately
💉 Vaccines
Code
Service/Drug Code(s) Notes
Type
Flu shot admin (non-
CPT 90471 Medicare uses G0008
Medicare)
Q2037–Q2039, Q-codes specific to
Flu vaccine (drug only) HCPCS
90686 Medicare
🩼 DME & Orthotics
HCPCS
Item Modifiers/Notes
Code
Standard wheelchair E1130 Requires medical necessity
Crutches, underarm,
E0114 Code includes both crutches
pair
NU (new), RR (rental), RA
Folding walker E0143
(replacement)
CPAP device E0601 Check LCD (Medicare)
Nebulizer machine E0570 Often used in lung disease
Wrist-hand orthosis L3908 L-codes for orthotics
Knee brace, hinged L1812 RT/LT, KX, NU if needed
⚠️Modifiers & Medicare Tips
 Modifiers: RT, LT, NU, RR, KX
 Coverage Rules: Confirm LCD/NCD for Medicare items
 Medicare Special Codes:
o G0008 = Flu shot admin
o Q203X = Flu vaccine brand

Drug Example
🧪 Injection + Drug Example
Scenario: Patient receives a ketorolac injection for pain relief.
 CPT® Code: 96372 (Therapeutic injection administration)
 HCPCS Code: J1885 (Ketorolac tromethamine, per 15 mg)
 Tip: Always bill the drug separately from the administration.
💉 Flu Vaccine – Medicare vs. Commercial
Scenario: Patient receives a flu shot.
 Commercial Insurance:
 o CPT® Code: 90471 (Admin)
o HCPCS/CPT Code: 90686 (Flu vaccine)
 Medicare:
o HCPCS Code: G0008 (Admin)
o HCPCS Code: Q2039 (Flu vaccine, NOS)
 Tip: Use Q-codes and G0008 for Medicare claims.
🩺 Chemo Injection
Scenario: Patient receives a subcutaneous chemotherapy injection.
 CPT® Code: 96401 (Chemo admin, SC/IM)
 HCPCS Code: J9190 (Fluorouracil, 500 mg)
 Tip: Pair CPT admin code with appropriate J-code for the drug.
🦽 DME Example
Scenario: Patient is prescribed a CPAP machine.
 HCPCS Code: E0601 (CPAP device)
 Modifiers: NU (new), KX (meets coverage criteria)
 Tip: Check LCD/NCD for Medicare coverage requirements.
🦵 Orthotic Example
Scenario: Patient receives a hinged knee brace.
 HCPCS Code: L1812
 Modifiers: RT/LT (side), NU (new), KX (coverage justification)
 Tip: Modifier use is critical for reimbursement.
🧾 E/M + Procedure Example
Scenario: Patient presents with acute pharyngitis and receives a Rocephin injection.
 CPT® Code: 99213 (E/M visit, low complexity)
 CPT® Code: 96372 (Injection admin)
 HCPCS Code: J0696 (Rocephin, 250 mg)
 Modifier: -25 on 99213 to indicate separate E/M service
 Tip: Modifier -25 supports separate reimbursement for E/M and procedure.

E/M Families

🚑 🏢 SNF / 🏡 Home 💬
🩺 Office / 🏥 Inpatient / Preventive
Emergency Nursing Health / Consultatio
Outpatient Observation Medicine
Dept Facility Hospice ns

99281– 99241–
99202–99215 99221–99239 99304–99318 99341–99350 99381–99397
99285 99255
📝 Select Level by…

📋 Medical Decision Making

⏱ Total Time
(MDM)

Meet ≥ 2 of 3 elements at the Document “Total time = __ minutes” +

same level tasks

Use CPT® MDM grid (Problems,

Thresholds drive 99202–99215
Data, Risk)
Pick only one method per encounter
💎 High-Yield Pearls & Memory Aids
• ▶️Use one method—MDM or Time—per visit

• ➕ Modifier 25 for same-day procedure

• 👥 Split/Shared: use greater of time or MDM (2024 CMS rule)

• ⏰ Prolonged services: +99417 (commercial) / +G2212 (Medicare)

Memory Aids | “2 of 3 = MDM” | Need any 2 MDM elements to level up | | “Time = Today” | Count
only provider’s work on DOS | | “ED = MDM Only” | Emergency codes ignore Time thresholds | | “99211
= Nurse” | Minimal nursing visit—no physician face time |
🔍 Specialty Spotlights

Choose up to 3; duplicate blocks as needed

🩺 Primary Care / Family Medicine

 Scenario: Hypertension follow-up → 99213 (20 min EST)

 Common Levels: 99212–99214

🚑 Emergency Medicine

 ED MDM Grid Call-out: Straightforward → High

 Badge: “MDM Only”

🏥 Inpatient Services

 Flowchart:
1. Admit (99221–99223)
2. Subsequent (99231–99233)
3. Discharge (99238–99239)
 Highlight: ICU decisions ()

🏢 SNF / Nursing Facility

 Initial (99304–99306) vs. Subsequent (99307–99310)
 Motif: Nursing home silhouette
🏡 Home Health / Hospice
 Includes travel time call-out

💓 Specialty Clinics (e.g., Cardiology)

1. High-risk arrhythmia MDM example → Level 4
2. Typical Time: 45–59 min (New), 30–39 min (Est

🩺 E/M Documentation & Practical Application Cheat Sheet

1️⃣ SOAP Note Structure → Why It Matters for E/M
Lett Compon
What to Include
er ent
Subjectiv Chief Complaint + HPI + Review of
S
e Systems
O Objective Vitals, Physical Exam Findings, Test Results
Assessme
A Diagnoses / Clinical Impressions
nt
Medications, Tests, Referrals, Follow-Up
P Plan
Instructions
• Coding link: A well-crafted SOAP note either proves the MDM elements you select or documents the
total minutes you bill.

2️⃣ Real-World Coding Walk-Throughs

1. Established Patient with Uncontrolled Diabetes
A patient who’s been coming to the clinic for a while has blood sugar that’s still too high. To sort it out,
the doctor:
 Looks over recent lab tests
 Reads notes from their endocrinologist
 Starts a new medication
Because the visit involved managing a long-term illness that’s gotten worse, reviewing outside
records, and changing treatment, it counts as a “moderate complexity” visit. In billing terms, that’s
code 99214.
2. New Patient with Extended Counseling
Someone comes in for their very first appointment and spends 35 minutes talking through several
chronic health issues. The doctor covers diet advice, medication teaching, and helps the patient make
a plan.
Since this visit is driven by the total time spent—more than half an hour—it’s billed based on time, not
decision-making. That puts it in the 30–44-minute bracket, which is code 99203.
3. Emergency Department Chest Pain Work-Up
A person arrives at the ER complaining of chest pain. The team:
 Rules out a heart attack (possible ACS)
 Orders and reviews lots of tests (ECG, blood work, maybe imaging)
 Makes critical, high-risk decisions quickly
Because this is an urgent, life-threatening scenario with extensive data review and serious decisions,
it’s billed at the highest ER level, 99285.

3️⃣ Quick E/M Coding Checklist

1. Place of Service → Select correct code family (Office, ED, Inpatient, etc.)
2. Patient Status → New vs. Established (office); Initial vs. Subsequent (inpatient)
3. Choose Method → MDM or Total Time (ED = MDM only)
4. Match Level → Use the MDM grid or the Time thresholds table
5. Prolonged Services? → +99417 (commercial) / +G2212 (Medicare) for each extra 15 min
beyond 99205/99215
6. Audit Your Note → • For MDM: Ensure SOAP documents the Problems, Data, and Risk
elements you selected • For Time: Include “Total time today: __ min (review, exam, counseling,
orders, documentation).”

CPT and ICD-10-CM Coding Guidelines: Global Surgical Packages

1 CPT Coding Guidelines

1.1 Global Surgical Package Structure

Surgeries are assigned a global period that bundles pre-, intra-, and post-operative services into one
CPT code.

Global periods fall into three phases: pre-op evaluation, the procedure itself, and routine post-op care.

Only when documentation supports a distinct service can you unbundle with the appropriate modifier.

1.2 Included vs. Separately Billable Services

 Pre-Op E/M on day of or day before surgery → bundled (use -25 only if significant, separately
documented E/M)
 Intra-Op procedure, local anesthesia by surgeon, simple wound closure → bundled
  Post-Op visits, dressing and suture removal, routine orders/scripts → bundled

Separately billable items (with correct modifiers or distinct diagnoses):

 Anesthesia services (CPT 00100–01999)

 Intermediate/complex wound repairs (CPT 12031–13153)
 Unrelated E/Ms on date of surgery (modifier -25)
 Services beyond global period (modifier -79)

1.3 Global Period Durations

Global Procedure
Examples
Days Type
0 Minor Biopsy, lesion removal
Cyst excision,
10 Intermediate
hemorrhoidectomy
Cholecystectomy,
90 Major
hysterectomy

Always verify the CPT code’s assigned global days in the CPT manual.

1.4 Key Bundling Rules

1. Local Anesthesia by Surgeon

o Bundled into the surgical CPT; not billable separately.
2. Surgeon-Performed Wound Repair
o Simple closure → bundled
o Intermediate/complex closure → bill with 12031–12057 or 13100–13153
3. Anesthesia Services
o Report CPT 00100–01999 separately; surgeon’s local infiltration remains bundled.

1.5 Modifier Spotlight

Modifi
Use When…
er
Significant, separately documented E/M on same day as
-25
surgery
Unrelated procedure/service by the same provider during
-79
global period
-57 Decision for surgery (pre-op E/M the day before)
Staged or related procedure planned before the original
-58
surgery
-59 Distinct procedural service not normally billed together

Do not use modifier -25 for routine preoperative history/exam visits.

1.6 Documentation Best Practices

 Include start/end times, ASA status, and qualifying circumstances for anesthesia claims.
 Clearly describe wound type, length, layers closed, and technique.
 For E/Ms billed with -25, document history, exam, and medical decision-making distinct from
the surgical procedure.
 Maintain a table or EHR prompt for each CPT’s global period, bundled services, and applicable
modifiers.
2 ICD-10-CM Coding Guidelines

2.1 Principal vs. Additional Diagnoses

Principal diagnosis: the condition chiefly responsible for the procedure.

Additional diagnoses: comorbidities or factors influencing management (e.g., diabetes,

anticoagulation).

2.2 Sequencing & Specificity

 Sequence codes in order of clinical importance.

 Code to the highest level of specificity: include laterality, encounter type, and severity.
 Use Z-codes for preoperative evaluations (Z01.81) only if they drive extra services beyond the
global package.

2.3 Linking Diagnoses to CPT

 On CMS-1500, assign diagnosis pointers 1–4 to each line item.

 Ensure that the principal diagnosis pointer links to the surgical CPT.
 Secondary pointers capture comorbidities affecting peri-operative care (e.g., G47.33 for sleep
apnea).

2.4 Post-Op Conditions & Complications

 Code complications requiring separate management (e.g., T81.4XXA – infection following a

procedure).
 Distinguish expected post-op care (bundled) from complications triggering additional billable
services.

2.5 Documentation Essentials

 Link each service to an ICD-10 code in the operative report.

 Capture any unexpected findings or complications in detail.
 For modifier-59 scenarios, document why the service was distinct from the primary surgery.

3 CPT–ICD-10-CM Pairing Examples

CPT ICD-10-CM Global

Procedure Diagnosis Description
Code Code Period
Unilateral primary osteoarthritis of
27447 Total knee arthroplasty M17.11 90 days
knee
Intermediate repair, 2.6–7.5 cm Laceration of right knee, initial
12032 S81.112A 10 days
laceration encounter
19325 Breast augmentation N62 Hypertrophy of breast 90 days
42320 Tonsillectomy & adenoidectomy J35.3 Hypertrophy of tonsils with adenoids 90 days
Congenital hypospadias (rounded to
54150 Circumcision (age < 28 days) Q55.0 10 days
nearest code)

CPT and ICD-10-CM Guideline Rules for Anesthesia Coding

1. Medicare CPT Anesthesia Guidelines

Every anesthesia claim to Medicare must follow the CPT Anesthesia Section (00100–01999) and
Medicare’s own billing policies:

 Documentation of Time Record exact “wheels-in” to “wheels-out” (or room entry to exit)
times. Calculate time units by dividing total minutes by 15 (fractions round up).
 Base & Time Units Pull base units from the ASA Relative Value Guide. Add time units,
physical status modifiers (P1–P6), and qualifying circumstance codes (+99100, +99140, etc.)
exactly as allowed.
 Medical Direction vs. Personal Service Apply modifiers:
o AA for anesthesiologist personally performing
o QY/QK/AD/QX for various MD-CRNA arrangements
o QZ for CRNA solo
o GC for resident with teaching physician
o QS for Monitored Anesthesia Care
 Bundling & NCCI Edits Medicare’s NCCI edits may bundle certain services (e.g., invasive
lines, sedation). Always verify local LCDs for additional bundling rules.
 Modifiers Never on Anesthesia Codes Modifier 47 is used only on surgical CPT codes;
anesthesia codes use QS, QZ, QY, etc.

2. Medicare ICD-10-CM Coding Guidelines

Accurate diagnosis coding drives medical necessity and links to anesthesia services:

 Principal vs. Additional Diagnoses – Principal diagnosis: condition chiefly responsible for
anesthesia. – Additional codes: comorbidities affecting anesthetic management (e.g., Z95.1 for
pacemaker, Z79.2 for anticoagulation).
 Specificity Is Key Always choose the most specific ICD-10 code. If laterality, episode of care,
or severity is specified, it must be captured.
 Sequencing & Reporting Conventions Follow the ICD-10-CM Official Guidelines:
1. Codes from Chapter 18 (Z codes) may report pre-op assessments.
2. External cause codes (V00–Y99) only when circumstances affect management.
 Emergency & Circumstance Codes Report emergency surgery codes (e.g., +99140) only
when documentation supports “immediate threat to life or limb.”

3. Linking CPT and ICD-10 under Medicare

Ensuring valid CPT–ICD-10 pairings prevent denials and accelerates payment:

 Edit 26 Anesthesia Diagnosis Linkage Medicare enforces an Edit 26 table that lists
allowable ICD-10 codes for each anesthesia CPT. Invalid pairs will be rejected.
 Claim Form Pointers On the CMS 1500, link diagnosis pointers (digits 1–4) to line item with
the CPT code. Only valid pointers permit payment.
 Local Coverage Determinations (LCDs) Always review your MAC’s LCD for anesthesia.
Some payers impose extra documentation (e.g., ASA physical status justification, emergent
status notes).

4. Practical Tips & Audit Pointers

 Keep a master log of each payer’s conversion factor and LCD nuances; update it annually.
 Audit charts to confirm:
o Start/stop times match OR records
o ASA status is explicitly documented
o Qualifying circumstance criteria are met in physician notes
 Use 01999 only when no anesthesia code fits—explain necessity in the record.
 Distinguish MAC (QS) from moderate sedation—do not report 99152–99157 on the anesthesia
line.
Best Practices for Coding Anesthesia Services

Accurate and Complete Documentation

 Record exact start (pre-op prep) and stop (hand-off in PACU) times. Calculate time units by
dividing total minutes by 15, rounding up any fraction.
 Require explicit ASA physical status in every record. If P3 or above, include supporting clinical
details.
 Document qualifying circumstances clearly:
o Age (< 1 or > 70) for +99100
o Emergency status (“immediate threat to life or limb”) for +99140
o Special techniques (e.g., hypothermia +99116)
 Distinguish between MAC (QS) and moderate sedation; do not report 99152–99157 on the
anesthesia line.

Precise CPT Code Selection & Modifier Use

 Choose the anesthesia code that most closely reflects the procedure (avoid 01999 unless truly
unlisted).
 Pull base units from the ASA Relative Value Guide; never estimate.
 Apply the correct provider/supervision modifier:
o AA when the anesthesiologist personally performs
o QY/QK/AD/QX for medically directed CRNAs
o QZ for CRNA solo
o GC for resident under teaching physician
 Never use modifier 47 on anesthesia codes.

ICD-10-CM Linkage & Medical Necessity

 Identify the principal diagnosis that drove the need for anesthesia and list comorbidities
affecting anesthetic management.
 Link diagnosis pointers on the CMS-1500 form to your anesthesia line item, using only valid
pairings (Edit 26).
 Use the most specific ICD-10 codes (laterality, episode of care, severity) and include Z-codes
for pre-op assessments when appropriate.

Payer Policy Awareness & Conversion Factors

 Maintain an annual conversion-factor log for Medicare and all commercial payers; note
effective dates.
 Review your MAC’s Local Coverage Determinations (LCDs) for anesthesia bundling edits,
documentation requirements, and any carve-outs.
 Confirm which physical status modifiers pay in your commercial contracts—Medicare
reimburses $0 for P modifiers.

Regular Auditing & Quality Assurance

 Conduct monthly chart audits focusing on:

1. Time-unit accuracy
2. ASA status justification
3. Qualifying-circumstance documentation
 Track key metrics: average units per case, denial reasons, modifier errors.
 Establish feedback loops between coders and anesthesia providers to close documentation
gaps.

Education, Collaboration & Reference Tools

  Host quarterly training sessions on new CPT codes, modifier rules, and ICD-10 updates.
 Build interdisciplinary forums where coders, anesthesiologists, and CRNAs discuss tough cases
and share best practices.
 Keep quick-access tools on hand: ASA RVG, Medicare’s Anesthesia Billing Manual, NCCI edits,
and payer-specific cheat sheets.

Common Pitfalls & Recommendations

Pitfall Recommendation
Missing or inconsistent start/stop Implement EHR templates with mandatory
times time fields
Unspecified ASA physical status Add ASA status to pre-op consent and notes
Misapplied supervision/provider
Use a modifier decision tree or flowchart
modifiers
Invalid CPT–ICD-10 linkages (Edit 26 Integrate an Edit 26 crosswalk into coding
rejects) software
Schedule annual CF reviews with revenue
Outdated conversion factors
staff

Combined CPT & ICD-10-CM Coding

Guidelines: Radiology & Laboratory
1 CPT Coding Guidelines
1.1 Radiology Services (70010–79999)

Documentation Requirements

 Specify body part, laterality, number of views, and contrast use in the report.
 Distinguish professional (interpretation) and technical (equipment, tech) components.

Modifier Usage

 -26 for professional component

 -TC for technical component
 -52 for reduced service
 -76 for repeat service by same provider
 -77 for repeat service by different provider

Code Selection

 Choose the code range matching the modality (e.g., 70010–76499 for plain films).
 Use global codes (no modifier) only in freestanding or outpatient facilities that bill both
components.

Bundling & Unbundling

  Do not unbundle inherent services (e.g., multiple views in one X-ray code).
 Consult NCCI edits and your MAC’s LCD for bundled procedures.

1.2 Pathology & Laboratory Services (80047–89398)

Documentation Requirements

 Record specimen source, collection method, and reason for test.

 Document medical necessity and frequency justification for repeat testing.

Panel vs. Single-Test Reporting

 Bill bundled panels (e.g., CMP 80053) as a single code.

 Only unbundle when a panel component is separately ordered or not included.

Modifier & Add-On Use

 Use -QW for CLIA-waived tests (when required by payer).

 Report add-on codes for special techniques (e.g., immunohistochemistry 88341–88346).

Specimen Handling

 Assign surgical pathology codes by complexity level (I–VI).

 Report molecular/genetic tests with the correct CPT range (81200–81479).

2 ICD-10-CM Coding Guidelines

2.1 General Principles

 Principal diagnosis reflects the main reason for the service.

 Report all comorbidities or conditions that affect management.
 Always code to the highest specificity (laterality, episode of care, severity).

2.2 Radiology-Specific ICD-10

 Link each imaging CPT to a medically necessary diagnosis (e.g., R07.9 → chest X-ray).
 Use Z codes for routine screenings (e.g., Z12.31 for mammography).
 Only report external cause codes (V00–Y99) if they influence imaging interpretation or
management.

2.3 Laboratory-Specific ICD-10

 Map each lab CPT to a condition that justifies testing (e.g., E11.9 → HbA1c 83036).
 Avoid R79.89 (“abnormal labs”) if a more specific code exists.
  Use Z00-Z13 codes for preoperative or routine exams only when they drive additional
testing.

3 CPT–ICD-10 Linkage & Claim Submission

 On the CMS-1500, assign diagnosis pointers (1–4) to each CPT line.
 Validate CPT–ICD pairings against Edit 26 crosswalks to prevent rejections.
 Include a brief narrative or chart note statement linking the service to the underlying
diagnosis when needed.

4 Audit, Compliance & Best Practices

 Maintain an up-to-date log of payer-specific LCDs and conversion factors.
 Perform regular chart audits covering:
1. Time/unit accuracy (for anesthesia or MRI procedures).
2. Documentation of medical necessity and modifiers.
3. CPT–ICD linkage validity.
 Track denials by reason to identify recurring documentation or coding gaps.
 Host interdisciplinary coding reviews with radiologists, pathologists, and coders.

5 Quick Reference Summary

Area Core Guideline
Radiology CPT Use correct range; apply –26/–TC; confirm bundling
Lab CPT Bill panels as bundled; document specimen & necessity
ICD-10 Imaging Link to precise dx; use Z-screening codes appropriately
ICD-10 Laboratory Map to specific conditions; avoid catch-all R codes
Claim Submission Pointer mapping; verify Edit 26; include narrative

Would you like to explore examples of complex CPT–ICD pairings or dig into a payer’s LCD
for radiology support next?

Can you provide examples of CPT–ICD-10 pairings?

Examples of CPT–ICD-10 Pairings

Radiology Examples
These pairings show how imaging services link to a diagnosis that justifies medical necessity.
Each CPT is matched to a common ICD-10 code or two that drives the exam.
 CPT Example ICD-10
Procedure Rationale
Code Code
Chest pain evaluation often prompts
71046 Chest X-ray, 2 views R07.9 (Chest pain)
a two-view CXR
S06.0X0A Head trauma or altered
70450 CT head without contrast
(Concussion) consciousness
MRI lumbar spine w/ & M51.26 (Disc Suspected herniated disc causing
72158
w/o contrast displacement) radiculopathy

Laboratory Examples
These lab tests illustrate linking panels and single-analyte codes to specific conditions. Always
choose the most precise ICD-10 code to reflect the underlying disease.

CPT
Test Example ICD-10 Code Rationale
Code
Comprehensive Metabolic Routine metabolic monitoring
80053 E11.9 (Type 2 diabetes)
Panel (CMP) in diabetic patients
E11.65 (Type 2 DM w/
83036 Hemoglobin A1c Glycemic control assessment
hyperglycemia)
Urinalysis, automated, non- N39.0 (Urinary tract
81001 Screening for UTI signs
micro infection)

Claim Form Linking Tips

 On CMS-1500, assign diagnosis pointers (1–4) to each CPT line.
 Pointer “1” links to the primary ICD-10; additional pointers map comorbidities.
 Confirm all CPT–ICD pairs against your payer’s Edit 26 or similar crosswalk.
 Include a brief narrative note if a pairing is borderline or may trigger a review.

What area would you like to explore next—anesthesia CPT–ICD examples, coding for
interventional radiology, or advanced audit strategies?

Can you provide examples in anesthesia coding?

Examples of CPT–ICD-10 Pairings in Anesthesia Coding

Below are common anesthesia procedures with sample ICD-10 codes that justify medical necessity.
Each pairing reflects a typical clinical scenario and the principal diagnosis that drives the anesthesia
service.

1. General Surgery & Endoscopy

CPT
Procedure ICD-10 Code Rationale
Code
00740 Anesthesia for intraperitoneal K35.80 (Acute appendicitis, Acute appendicitis
CPT
Procedure ICD-10 Code Rationale
Code
procedure (e.g., laparoscopic requiring laparoscopic
unspecified)
appendectomy) removal
K63.5 (Polyp of colon) or
Anesthesia for lower intestinal Diagnostic colonoscopy to
00810 R19.4 (Change in bowel
endoscopy (colonoscopy) evaluate colonic polyps
habit)

2. Obstetric & Gynecologic Procedures

CPT
Procedure ICD-10 Code Rationale
Code
Anesthesia for cesarean O82.0XX0 (Single liveborn, Cesarean section for delivery of a
01967
delivery unspecified) single fetus
Anesthesia for dilation and N93.9 (Abnormal uterine D&C performed to manage
00851
curettage (D&C) bleeding, unspecified) dysfunctional uterine bleeding

3. Orthopedic Surgery

CPT
Procedure ICD-10 Code Rationale
Code
M16.9 (Osteoarthritis of Hip osteoarthritis leading to
00590 Anesthesia for total hip arthroplasty
hip, unspecified) elective hip replacement
Anesthesia for procedures on ankle M20.1 (Hallux valgus
01200 Correction of bunion deformity
or toes (e.g., bunionectomy) [acquired])

4. Ophthalmologic & ENT Procedures

CPT
Procedure ICD-10 Code Rationale
Code
Anesthesia for procedures on H02.8 (Other disorders of Blepharoplasty to repair eyelid
00100
eyelids and nose eyelid) ptosis
Anesthesia for intracranial D35.2 (Benign neoplasm Biopsy of pituitary mass under
00300
procedures (e.g., pituitary biopsy) of pituitary gland) general anesthesia

5. Linking & Claim Submission Tips

 On CMS-1500, map diagnosis pointers (1–4) to each anesthesia line.

 Run your pairings through your payer’s Edit 26 crosswalk to verify allowable CPT–ICD
combinations.
 If a case involves multiple significant diagnoses, list secondary conditions (e.g., OSA: G47.33)
as additional pointers.
 Document qualifying circumstances (+99140 for true emergencies, +99100 for patient age)
and link them to the same principal diagnosis.

CPT & ICD-10-CM Coding Guidelines: Radiology & Laboratory

1 CPT Coding Guidelines

1.1 Radiology Services (70010–79999)

Documentation Requirements

 Specify body part, laterality, number of views, and contrast use in the report.
 Distinguish professional (interpretation) and technical (equipment, tech) components.
Modifier Usage

 -26 for professional component

 -TC for technical component
 -52 for reduced service
 -76 for repeat service by same provider
 -77 for repeat service by different provider

Code Selection

 Choose the code range matching the modality (e.g., 70010–76499 for plain films).
 Use global codes (no modifier) only in freestanding or outpatient facilities that bill both
components.

Bundling & Unbundling

 Do not unbundle inherent services (e.g., multiple views in one X-ray code).
 Consult NCCI edits and your MAC’s LCD for bundled procedures.

1.2 Pathology & Laboratory Services (80047–89398)

Documentation Requirements

 Record specimen source, collection method, and reason for test.

 Document medical necessity and frequency justification for repeat testing.

Panel vs. Single-Test Reporting

 Bill bundled panels (e.g., CMP 80053) as a single code.

 Only unbundle when a panel component is separately ordered or not included.

Modifier & Add-On Use

 Use -QW for CLIA-waived tests (when required by payer).

 Report add-on codes for special techniques (e.g., immunohistochemistry 88341–88346).

Specimen Handling

 Assign surgical pathology codes by complexity level (I–VI).

 Report molecular/genetic tests with the correct CPT range (81200–81479).

2 ICD-10-CM Coding Guidelines

2.1 General Principles

 Principal diagnosis reflects the main reason for the service.

 Report all comorbidities or conditions that affect management.
 Always code to the highest specificity (laterality, episode of care, severity).

2.2 Radiology-Specific ICD-10

 Link each imaging CPT to a medically necessary diagnosis (e.g., R07.9 → chest X-ray).
 Use Z codes for routine screenings (e.g., Z12.31 for mammography).
 Only report external cause codes (V00–Y99) if they influence imaging interpretation or
management.
2.3 Laboratory-Specific ICD-10

 Map each lab CPT to a condition that justifies testing (e.g., E11.9 → HbA1c 83036).
 Avoid R79.89 (“abnormal labs”) if a more specific code exists.
 Use Z00-Z13 codes for preoperative or routine exams only when they drive additional testing.

3 CPT–ICD-10 Linkage & Claim Submission

 On the CMS-1500, assign diagnosis pointers (1–4) to each CPT line.

 Validate CPT–ICD pairings against Edit 26 crosswalks to prevent rejections.
 Include a brief narrative or chart note statement linking the service to the underlying diagnosis
when needed.

4 Audit, Compliance & Best Practices

 Maintain an up-to-date log of payer-specific LCDs and conversion factors.

 Perform regular chart audits covering:
1. Time/unit accuracy (for anesthesia or MRI procedures).
2. Documentation of medical necessity and modifiers.
3. CPT–ICD linkage validity.
 Track denials by reason to identify recurring documentation or coding gaps.
 Host interdisciplinary coding reviews with radiologists, pathologists, and coders.

5 Quick Reference Summary

Area Core Guideline

Use correct range; apply –26/–TC; confirm
Radiology CPT
bundling
Bill panels as bundled; document specimen &
Lab CPT
necessity
Link to precise dx; use Z-screening codes
ICD-10 Imaging
appropriately
ICD-10 Map to specific conditions; avoid catch-all R
Laboratory codes
Claim Pointer mapping; verify Edit 26; include
Submission narrative

Examples of CPT–ICD-10 Pairings

Radiology Examples

These pairings show how imaging services link to a diagnosis that justifies medical necessity. Each CPT
is matched to a common ICD-10 code or two that drives the exam.

CPT Example ICD-10

Procedure Rationale
Code Code
Chest pain evaluation often prompts a
71046 Chest X-ray, 2 views R07.9 (Chest pain)
two-view CXR
S06.0X0A
70450 CT head without contrast Head trauma or altered consciousness
(Concussion)
MRI lumbar spine w/ & w/o M51.26 (Disc Suspected herniated disc causing
72158
contrast displacement) radiculopathy

Laboratory Examples
These lab tests illustrate linking panels and single-analyte codes to specific conditions. Always choose
the most precise ICD-10 code to reflect the underlying disease.

CPT
Test Example ICD-10 Code Rationale
Code
Comprehensive Metabolic Routine metabolic monitoring in
80053 E11.9 (Type 2 diabetes)
Panel (CMP) diabetic patients
E11.65 (Type 2 DM w/
83036 Hemoglobin A1c Glycemic control assessment
hyperglycemia)
Urinalysis, automated, non- N39.0 (Urinary tract
81001 Screening for UTI signs
micro infection)

Claim Form Linking Tips

 On CMS-1500, assign diagnosis pointers (1–4) to each CPT line.

 Pointer “1” links to the primary ICD-10; additional pointers map comorbidities.
 Confirm all CPT–ICD pairs against your payer’s Edit 26 or similar crosswalk.
 Include a brief narrative note if a pairing is borderline or may trigger a review.