Guidelines for Procedures

1. Integumentary System

A). If any repairs done we have coded in the order Complex, Intermediate, Simple
B). If any injury occurs code in the order 3rd degree, Second degree, 1st degree
3 In excision simple repair is included.

Coding guidelines:

A00–
I B99
Certain infectious and parasitic diseases

C00–
II D48
Neoplasms

Diseases of the blood and blood-forming

D50–
III D89
organs and certain disorders involving the
immune mechanism

E00– Endocrine, nutritional and metabolic

IV E90 diseases

F00–
V F99
Mental and behavioural disorders

G00–
VI G99
Diseases of the nervous system

H00–
VII H59
Diseases of the eye and adnexa

H60–
VIII H95
Diseases of the ear and mastoid process

I00–
IX I99
Diseases of the circulatory system
 J00–
X J99
Diseases of the respiratory system

K00–
XI K93
Diseases of the digestive system

L00– Diseases of the skin and subcutaneous

XII L99 tissue

M00– Diseases of the musculoskeletal system and

XIII M99 connective tissue

N00–
XIV N99
Diseases of the genitourinary system

O00–
XV O99
Pregnancy, childbirth and the puerperium

P00– Certain conditions originating in the perinatal

XVI P96 period

Q00– Congenital malformations, deformations and

XVII Q99 chromosomal abnormalities

R00– Symptoms, signs and abnormal clinical and

XVIII R99 laboratory findings, not elsewhere classified

S00– Injury, poisoning and certain other

XIX T98 consequences of external causes

V01–
XX Y98
External causes of morbidity and mortality

Z00– Factors influencing health status and

XXI Z99 contact with health services
 U00–
XXII U99
Codes for special purposes

Admin codes:
Commercial Insurance- 90460, 90461 & 90471, 90472 & 90473,, 90474

Medicare Insurance- G0008, G0009, G0010

90460 Through 18 years via any route with counseling by physician or other qualified health care
professional; first vaccine/toxoid component. Medicaid rate as of 7/1/2015 is $21.68 •

90461 Through 18 years via any route, with counseling by physician or other qualified health care
professional; each additional vaccine/toxoid component. Medicaid rate is $0.00 •

90471 Immunization administration (includes percutaneous, intradermal,

subcutaneous, or intramuscular injections); 1 vaccine (single or combination
vaccine/toxoid)
90472 Each additional vaccine injection (single or combination vaccine/toxoid) (List
separately, in addition to code for primary procedure)
90473 Immunization administration by intranasal or oral route: 1 vaccine (single or
combination vaccine/toxoid) (Do not report 90473 in conjunction with 90471)
90474 Each additional vaccine by intranasal or oral route (single or combination
vaccine/toxoid) (List separately, in addition to code for primary procedure)

Vaccine CPT Components Immun. Admin. Code

Tdap 90715 (≥7 yrs) 3 90460, 90461 x 2

Td 90714 2 90460 and 90461

Denial codes

CO-4-The procedure code is inconsistent with the modifier used

IF procedure done in LT but we take RT this denial will occur
CO-5 The procedure code/type of bill is inconsistent with the place of service
If the procedure done as 99309-SNF 31 but we took POS as 13 Assistant living
CO-6 the procedure/revenue code is inconsistent with the patient's age

99384-12 to 17 but we take mistakenly as , 99385-18 to 39

CO-7 The procedure/revenue code is inconsistent with the patient's gender

CPT 19300 Mastectomy for male CPT 19303 mastectoctomy for female
CO-8 The procedure code is inconsistent with the provider type/specialty (taxonomy).
CO-9- The diagnosis is inconsistent with the patient's age.

CO-10 The diagnosis is inconsistent with the patient's gender.

CO-11 The diagnosis is inconsistent with the procedure

If the patient’s procedure is for kidney stones, then diagnosis is given as some hand fracture then
that will be denied fir diagnosis error

CO-12 The diagnosis is inconsistent with the provider type.

CO-50 -These are non-covered services because this is not deemed a 'medical
necessity' by the payer
Need to bill with valid Dx or get valid dx from client or appeal with MR
CO-58 Treatment was deemed by the payer to have been rendered in an inappropriate or
invalid place of service
If the procedure done as 99309-SNF 31 but we took POS as 13 Assistant living

CO-96 Non-covered charge(s)

Need to verify dx
CO-B13 New patient qualification were not met
Instead of do establishment code we mistakenly take initial visit code this denial will
occur

CO-97 The benefit for this service is included in the payment/allowance for another
service/procedure that has already been adjudicated.

24 unrelated evaluation and management service by the same physician or other

qualified health care professional during a post-operative period.

25 Significant, Separately Identifiable Evaluation and Management Service by the Same

Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

... 57 Decision for Surgery

Modifier 51, 58, 59

51-Multiple procedures( the same provider performed multiple procedures (other than E/M
services) during the same session.
  12031 (wound closure)
 11600-51 (excision of malignant lesion
 11100-51 (biopsy of skin, single lesion)

 Modifier : 58 : staged or related procedure or service by the same physician or

other qualified healthcare professional during the postoperative period
 : The physician may need to indicate that the performance of a procedure or service during
the postoperative period was: a) planned or anticipated

 Modifier 59 Distinct procedural service indicates a:
 Different encounter or session;
 Different procedure;
 Different site; or
 Separate incision, excision, injury, lesion, or body part.
 XE – “Separate Encounter, a service that is distinct because it occurred during a separate
encounter.” Only use XE to describe separate encounters on the same date of service. •
 XS – “Separate Structure, a service that is distinct because it was performed on a separate
organ/ structure” •
 XP – “Separate Practitioner, a service that is distinct because it was performed by a different
practitioner” •
 XU – “Unusual Non-Overlapping Service, the use of a service that is distinct because it does
not overlap usual components of the main service”

Example: 11721-59, 11056

Preventive visit code

New patient: CPT 99381 to 99387 Established Patient: 99391 to 99397

99382-1 to 4 , 99383-5to 11, 99384-12 to 17, 99385-18 to 39, 99386-40 to 64, 99387-
65 years or old

99392-1 to 4 , 99393-5to 11, 99394-12 to 17, 99395-18 to 39, 99396-40 to 64, 99397-
65 years or old

For Medicare

G0402-benefit available only to patients newly enrolled in the Medicare

Program and must be received within the first 12 months of the effective date
of their Medicare Part B coverage

G0438- First Annual wellness visit

G0439-subsequent annual wellness visits.

3R(Request, Render, Report.)

CPT99201 deleted why?
Based on the CPT changes, code 99201 is no longer valid for dates of service on and after
January 1, 2021, as clinicians may choose the E/M visits level based on either medical
decision making or time
Minimal problem CPT 99211: A problem that may not require the presence of the physician
or other qualified healthcare professional, but the service is provided under the physician’s
or other qualified health care professional’s supervision.

Post covid ICD; U09.9

Couch ICD changed for 2022 as R05.9, Fever R50.9,

Headache- R51.9
Type of service: What type of service done by the doctor to the patient it is called type of service.
It has consultation, anesthesia, radiology, surgery. 1. 00100 to 01999 and 99100 to 99140 –
Asnesthesia codes. 2. 10000 to 69999- surgical. 3. 70000 to 79999- Radiology 4. 80000-89999- Lab
codes 5. 90281 to 99199- medicine codes. 6. 99201 to 99499- Evaluation and management code 7.
99211 to 99215 – office visit 8. 99221 to 99223 – Ip visit 9. 99231 to 99233-follow up 10. 99241 to
99245- consultation visit 11. 99251 to 99255-hospital consultation visit. 12. 99238&99239-
discharge codes 13. 99291- Critical care 14. 99024- private pay

1. Place of service: It is the place where service were rendered. Ip-21, Op-22, ER-23, Office-
11, Home-12, 24-Surgical center, 31-Skilled nursing facility, 32-Nursing facility , 33-
Custodial care facility

E&M Codes:
Office or other outpatient services: New patient (99201-99205) Established patient
(99211-99215).
1. E& M services:
Office or other outpatient services: New patient (99201-99205) Established patient
(99211-99215).
Above mentioned the codes used to report evaluation and management services
provided in the office or in an outpatient or other ambulatory facility.
Observation care discharge service: 99217
Observation care discharge of a patient from “Observation status” includes final
examination of the patient, discussion of the hospital stay, Instruction of continuing care,
and preparation of discharge records.
Initial observation care – New (99218-99220)
Above mentioned the codes were using to report the encounters by the supervising
provider or other qualified health care professional with the patient when designated as
outpatient hospital “observation status”.
Subsequent observation care (99224-99226)
All levels of subsequent observation care include reviewing the medical records and
reviewing the results of diagnostic studies and changes in the patient status. (Changes in
history, physical condition, and response to the management) since the last assessment.
Hospital inpatient service: initial hospital care (99221-99223)
Above mentioned the codes are used to report the first hospital inpatient encounter with
patient by the admitting physician.
Subsequent hospital care (99231-99233)
All levels of subsequent hospital care include reviewing the medical records and
reviewing the results of diagnostic studies and changes in the patient status. (Changes in
history, physical condition, and response to the management) since the last assessment
Observation or Inpatient care services (Including admission and discharge)
(99234-99236)
Above mentioned the codes were used to report observation or inpatient hospital care
services provided to patient admitted and discharges on the same date of service.
Hospital discharge service: 99238-30 Min or less, 99239-More than 30 min.
Office or other outpatient consultants: 99241-99245
A consultation is a type of evaluation and management service provided at the request of
another physician or appropriate source of either recommended care for a specific
condition or problem. It has provided in the office or outpatient setting called as
Outpatient consultation
Inpatient consultants: 99251-99255
A consultation is a type of evaluation and management service provided at the request of
another physician or appropriate source of either recommended care for a specific
condition or problem. It has provided in the office or outpatient setting called as
Outpatient consultation
Emergency service: 99281-99285
Above mentioned the codes are used to report evaluation and management services
provided in the emergency department.
Other Emergency service: 99288
Critical care services: 99291-99292(Time based service)
Critical care is the direct delivery by a physician or other qualified health care
professional of medical care for a critically ill or critically injured patient.
Nursing facility service: (99304-99318)
Above mentioned the codes used to report evaluation and management services to
patient in nursing facilities.
Initial Nursing facility: 99304-99306- When the patient admission the nursing facility
Subsequent Nursing facility: 99307-99310
All levels of subsequent nursing facility include reviewing the medical records and
reviewing the results of diagnostic studies and changes in the patient status. (Changes in
history, physical condition, and response to the management) since the last assessment
Nursing facility discharge service: 99315(30 min or less)-99316 (More than 30 min)
Other Nursing facility: 99318-(When in annual nursing facility assessment)
Home service:( 99314-99350) New patient (99341-99345) Established patient
(99347-99350.)
Above mentioned the codes used to report evaluation and management services
provided in a home.
Prolonged service with direct patient contact: (99354-99357)
Above mentioned the services are used when physician or other qualified healthcare
professional provides prolonged service involving direct patient contact that is provided
beyond the usual service in either the inpatient or outpatient settings.
Prolonged service without direct patient contact: (99358-99359)
Above mentioned the services are used when physician or other qualified healthcare
professional provides prolonged service involving without patient contact that is provided
beyond the usual service in either the inpatient or outpatient settings.
Standby service: 99360
This codes are used to report physician or other qualified health care professional stand
by service that are requested by another individual and that involve prolonged
attendance without direct patient contact.
Preventive medicine service: New patient (99381-99387), Established patient
(99391-99397)
Above mentioned the codes used to report the preventive medicine evaluation and
management of infants, children, adolescents, and adults.
Telephone service: 99441-99443(Time based) 99441-5 to 10 min, 99442 11-20min,
99443-21to 30 Min
Telephone services are non-face to face evaluation and management services provided
to a patient using the telephone by a physician or other qualified health care professional.

G0438 and G0439