UPDATEABLE
Medicare Correct
Coding Guide
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Medicare Correct
Coding Guide
A guide to Medicare billing and coding edits for physicians
XXXX/XXXXXXXXXXX Made in the USA
MCCP_3024_CVR.indd 1
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1/11/17 1:40 PM
Contents
Getting Started with Medicare Correct Coding Guide ......... Introduction–1
Introduction ........................................................................ Introduction–3
Resource-Based Relative Value Scale ....................................... Introduction–3
Sequestration Budget Reduction .............................................. Introduction–3
Correct Coding Initiative .............................................................. Introduction–4
Medically Unlikely Edits .......................................................... Introduction–4
National Correct Coding Initiative (NCCI)
Add-On Codes ................................................................... Introduction–5
Manual Organization ..................................................................... Introduction–5
How to Use This Book .................................................................... Introduction–5
Resource-Based Relative Value Scale (RBRVS)
Payment Computation ................................................... Introduction–5
Modifiers ............................................................................................ Introduction–6
Surgery Modifiers ..................................................................... Introduction–6
Modifiers Affecting Correct Coding Edits ......................... Introduction–7
Other Payment Indicators ............................................................ Introduction–7
Status Indicator ......................................................................... Introduction–7
Global Period .............................................................................. Introduction–8
Physician Supervision Level .................................................. Introduction–8
Definitions ................................................................................... Introduction–8
Levels of Physician Supervision of Diagnostic Tests ..... Introduction–8
Correct Coding Initiative (CCI) .................................................... Introduction–8
Step-by-Step Instructions ............................................................ Introduction–9
C.
D.
E.
F.
G.
H.
I.
J.
Anesthesia ....................................................................... Integumentary–i
Incision and Drainage ................................................. Integumentary–ii
Lesion Removal ............................................................. Integumentary–ii
Mohs Micrographic Surgery ..................................... Integumentary–ii
Intralesional Injections ............................................... Integumentary–ii
Repair and Tissue Transfer ....................................... Integumentary–iii
Grafts and Flaps ........................................................... Integumentary–iii
Breast (Incision, Excision, Introduction,
Repair and Reconstruction) ..................................... Integumentary–iii
K. Medically Unlikely Edits (MUEs) ............................. Integumentary–iii
L. General Policy Statements ....................................... Integumentary–iii
Integumentary System ............................................................. Integumentary–1
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Symbol/Payment Indicator Key ........................................ Introduction–11
Summary of Changes ............................................ Summary of Changes–1
General Correct Coding Policies.................................................. General–1
A. Introduction ................................................................................ General–1
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B. Coding Based on Standards of Medical/
Surgical Practice ......................................................................... General–2
C. Medical/Surgical Package ...................................................... General–2
D. Evaluation and Management (E&M) Services ................. General–4
E. Modifiers and Modifier Indicators ....................................... General–4
F. Standard Preparation/Monitoring Services for
Anesthesia ................................................................................... General–6
G. Anesthesia Service Included in the Surgical
Procedure .................................................................................... General–6
H. HCPCS/CPT Procedure Code Definition ............................. General–7
I. CPT Manual and CMS Coding Manual Instructions ........ General–7
J. CPT “Separate Procedure” Definition ................................. General–7
K. Family of Codes .......................................................................... General–7
L. More Extensive Procedure ..................................................... General–7
M. Sequential Procedure .............................................................. General–8
N. Laboratory Panel ....................................................................... General–8
O. Misuse of Column Two Code with Column One Code
(Misuse of Code Edit Rationale) ............................................ General–8
P. Mutually Exclusive Procedures ............................................. General–8
Q. Gender-Specific Procedures .................................................. General–8
R. Add-on Codes ............................................................................. General–8
S. Excluded Service ........................................................................ General–9
T. Unlisted Procedure Codes ...................................................... General–9
U. Modified, Deleted, and Added Code Pairs/Edits ............ General–9
V. Medically Unlikely Edits (MUEs) ........................................... General–9
W. Add-on Code Edit Tables ...................................................... General–11
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Surgery: Integumentary System
(CPT® Codes 10000–19999) ............................................ Integumentary–i
Correct Coding Policies .............................................................. Integumentary–i
A. Introduction .................................................................... Integumentary–i
B. Evaluation and Management (E&M) Services ..... Integumentary–i
© 2017 Optum360, LLC
CPT © 2016 American Medical Association. All Rights Reserved.
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Surgery: Musculoskeletal System
(CPT® Codes 20005–29999) ...........................................Musculoskeletal–i
Correct Coding Policies ............................................................ Musculoskeletal–i
A. Introduction .................................................................. Musculoskeletal–i
B. Evaluation and Management (E&M) Services ... Musculoskeletal–i
C. Anesthesia ..................................................................... Musculoskeletal–i
D. Biopsy .............................................................................. Musculoskeletal–i
E. Arthroscopy ................................................................. Musculoskeletal–ii
F. Spine (Vertebral Column) ...................................... Musculoskeletal–ii
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G. Fractures, Dislocations, and Casting/
Splinting/Strapping ................................................. Musculoskeletal–iii
H. Medically Unlikely Edits (MUEs) ........................... Musculoskeletal–iv
I. General Policy Statements ..................................... Musculoskeletal–iii
Musculoskeletal System ......................................................... Musculoskeletal–1
Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems
(CPT® Codes 30000–39599) ................................................. Respiratory–i
Correct Coding Policies ..................................................................... Respiratory–i
A. Introduction ........................................................................... Respiratory–i
B. Evaluation and Management (E&M) Services ............ Respiratory–i
C. Respiratory System .............................................................. Respiratory–i
D. Cardiovascular System ..................................................... Respiratory–iii
E. Hemic and Lymphatic Systems ..................................... Respiratory–vi
F. Mediastinum ........................................................................ Respiratory–vi
G. Medically Unlikely Edits (MUEs) .................................... Respiratory–vi
H. General Policy Statements ............................................. Respiratory–vii
Respiratory System ........................................................................... Respiratory–1
Cardiovascular System ...................................................................Respiratory–74
Hemic and Lymphatic System ................................................. Respiratory–234
Mediastinum and Diaphragm ................................................... Respiratory–246
Surgery: Digestive System (CPT® Codes 40000–49999) ..........Digestive–i
Correct Coding Policies ......................................................................... Digestive–i
A. Introduction ............................................................................... Digestive–i
B. Evaluation and Management (E&M) Services ................ Digestive–i
C. Endoscopic Services ................................................................ Digestive–i
D. Esophageal Procedures ........................................................ Digestive–ii
E. Abdominal Procedures ......................................................... Digestive–ii
F. Laparoscopy .............................................................................Digestive–iii
G. Medically Unlikely Edits (MUEs) ........................................Digestive–iii
H. General Policy Statements ..................................................Digestive–iii
Digestive System ...................................................................................Digestive–1
Surgery: Urinary, Male Genital, Female Genital, Maternity
Care and Delivery Systems (CPT® Codes 50000–59999) ............. Urinary–i
Correct Coding Policies .............................................................................Urinary–i
A. Introduction ...................................................................................Urinary–i
B. Evaluation and Management (E&M) Services ....................Urinary–i
C. Urinary System ..............................................................................Urinary–i
D. Male Genital System .................................................................Urinary–iii
E. Female Genital System ............................................................Urinary–iii
January 2017
Contents–1
General Correct Coding Policies
A. Introduction
Healthcare providers utilize HCPCS/CPT® codes to report medical services
performed on patients to Medicare Carriers (A/B MACs processing practitioner
service claims) and Fiscal Intermediaries (FIs). HCPCS (Healthcare Common
Procedure Coding System) consists of Level I CPT (Current Procedural
Terminology) codes and Level II codes. CPT codes are defined in the American
Medical Association’s (AMA’s) CPT Manual which is updated and published
annually. HCPCS Level II codes are defined by the Centers for Medicare and
Medicaid Services (CMS) and are updated throughout the year as necessary.
Changes in CPT codes are approved by the AMA CPT Editorial Panel which
meets three times per year.
Editor’s note: CPT Category II and Category III codes are updated twice yearly—in
January and July—and can be found on the AMA website prior to their inclusion in
the printed book.
CPT and HCPCS Level II codes define medical and surgical procedures
performed on patients. Some procedure codes are very specific defining a
single service (e.g., CPT code 93000 (electrocardiogram)) while other codes
define procedures consisting of many services (e.g., CPT code 58263 (vaginal
hysterectomy with removal of tube(s) and ovary(s) and repair of enterocele)).
Because many procedures can be performed by different approaches, different
methods, or in combination with other procedures, there are often multiple
HCPCS/CPT codes defining similar or related procedures.
CPT and HCPCS Level II code descriptors usually do not define all services
included in a procedure. There are often services inherent in a procedure or
group of procedures. For example, anesthesia services include certain
preparation and monitoring services.
The CMS developed the NCCI to prevent inappropriate payment of services
that should not be reported together. Three types of edits are included in the
NCCI—NCCI Procedure-to-Procedure (PTP) edits, Medically Unlikely Edits
(MUE), and Add-on Code Edits.
Each edit table contains edits which are pairs of HCPCS/CPT codes that in
general should not be reported together. Each edit has a column one and
column two HCPCS/CPT code. If a provider reports the two codes of an edit
pair, the column two code is denied, and the column one code is eligible for
payment. However, if it is clinically appropriate to utilize an NCCI-associated
modifier, both the column one and column two codes are eligible for payment.
(NCCI-associated modifiers and their appropriate use are discussed elsewhere
in this chapter.)
Medically Unlikely Edits (MUEs) prevent payment for an inappropriate number/
quantity of the same service on a single day. An MUE for a HCPCS/CPT code is
the maximum number of units of service (UOS) under most circumstances
reportable by the same provider for the same beneficiary on the same date of
service. The ideal MUE value for a HCPCS/CPT code is one that allows the vast
majority of appropriately coded claims to pass the MUE. More information
concerning MUEs is discussed in Section V of this chapter.
Add-on code edits are comprised of a list of HCPCS and CPT add-on codes and
their associated primary codes. Payment is provided for an add-on code only
when one of its primary codes is also eligible for payment.
In this Manual many policies are described utilizing the term “physician.” Unless
indicated differently the usage of this term does not restrict the policies to
physicians only but applies to all practitioners, hospitals, providers, or suppliers
eligible to bill the relevant HCPCS/CPT codes pursuant to applicable portions of
the Social Security Act (SSA) of 1965, the Code of Federal Regulations (CFR),
and Medicare rules. In some sections of this Manual, the term “physician”
would not include some of these entities because specific rules do not apply to
them. For example, Anesthesia Rules (e.g., CMS Internet-Only Manual,
Publication 100-04 [Medicare Claims Processing Manual], Chapter 12 [Physician/
Nonphysician Practitioners], Section 50 [Payment for Anesthesiology Services])
and Global Surgery Rules (e.g., CMS Internet-Only Manual, Publication 100-04
[Medicare Claims Processing Manual], Chapter 12 [Physician/Nonphysician
Practitioners], Section 40 [Surgeons and Global Surgery]) do not apply to
hospitals.
Providers reporting services under Medicare’s hospital outpatient prospective
payment system (OPPS) should report all services in accordance with
appropriate Medicare Internet Only Manual (IOM) instructions.
Physicians must report services correctly. This manual discusses general coding
principles in Chapter I and principles more relevant to other specific groups of
HCPCS/CPT codes in the other chapters. There are certain types of improper
coding that physicians must avoid.
Procedures should be reported with the most comprehensive CPT code that
describes the services performed. Physicians must not unbundle the services
described by a HCPCS/CPT code. Some examples follow:

A physician should not report multiple HCPCS/CPT codes when a single
comprehensive HCPCS/CPT code describes these services. For example if
a physician performs a vaginal hysterectomy on a uterus weighing less
than 250 grams with bilateral salpingo-oophorectomy, the physician
should report CPT code 58262 (Vaginal hysterectomy, for uterus 250 g or
less; with removal of tube(s), and/or ovary(s)). The physician should not report CPT code 58260 (Vaginal hysterectomy, for uterus 250 g or less;) plus
CPT code 58720 (Salpingo-oophorectomy, complete or partial, unilateral
or bilateral (separate procedure)).

A physician should not fragment a procedure into component parts. For
example, if a physician performs an anal endoscopy with biopsy, the physician should report CPT code 46606 (Anoscopy; with biopsy, single or
multiple). It is improper to unbundle this procedure and report CPT code
46600 (Anoscopy; diagnostic,...) plus CPT code 45100 (Biopsy of anorectal
wall, anal approach...). The latter code is not intended to be utilized with
an endoscopic procedure code.

A physician should not unbundle a bilateral procedure code into two unilateral procedure codes. For example if a physician performs bilateral
mammography, the physician should report CPT code 77066 (Diagnostic
mammography... bilateral). The physician should not report CPT code
77065 (Diagnostic mammography... unilateral) with two units of service,
or 77065LT plus 77065RT.

A physician should not unbundle services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical
procedure. A physician should not report CPT code 49000 (Exploratory
laparotomy,...) when performing an open abdominal procedure such as a
total abdominal colectomy (e.g., CPT code 44150).
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Physicians must avoid downcoding. If a HCPCS/CPT code exists that describes
the services performed, the physician must report this code rather than report
a less comprehensive code with other codes describing the services not
included in the less comprehensive code. For example if a physician performs a
unilateral partial mastectomy with axillary lymphadenectomy, the provider
should report CPT code 19302 (Mastectomy, partial...; with axillary
lymphadenectomy). A physician should not report CPT code 19301
(Mastectomy, partial...) plus CPT code 38745 (Axillary lymphadenectomy;
complete).
Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all
services described by that code have been performed. For example, if a
physician performs a superficial axillary lymphadenectomy (CPT code 38740),
the physician should not report CPT code 38745 (Axillary lymphadenectomy;
complete).
Physicians must report units of service correctly. Each HCPCS/CPT code has a
defined unit of service for reporting purposes. A physician should not report
units of service for a HCPCS/CPT code using a criterion that differs from the
code’s defined unit of service. For example, some therapy codes are reported in
fifteen minute increments (e.g., CPT codes 97110-97124). Others are reported
per session (e.g., CPT codes 92507, 92508). A physician should not report a “per
session” code using fifteen minute increments. CPT code 92507 or 92508
should be reported with one unit of service on a single date of service.
MUE and NCCI PTP edits are based on services provided by the same physician
to the same beneficiary on the same date of service. Physicians should not
inconvenience beneficiaries nor increase risks to beneficiaries by performing
services on different dates of service to avoid MUE or NCCI PTP edits.
January 2017
General–1
Surgery: Musculoskeletal System
20610
Medicare Correct Coding Guide (CCI Version 23.0)
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder,
hip, knee, subacromial bursa); without ultrasound guidance
RELATIVE VALUE UNITS
Work
MP
PE-nf
0.79
0.12
0.81
MODIFIERS
50
51
62
1
2
0
OTHER
Global P MUE
0
4(3)
INDICATORS
66
80,82
Suprv
Status
0
1
09
A
CORRECT CODING EDITS 00400 l 01380 l 0232T r 10030 t 10060 f 10061 f 10140 t 10160 f
11010 3 11900 f 12001 f 12002 f 12020 f 12031 f 12044 f 15851 f 20500 m 20501 f 20527 n
20550 n 20551 n 20552 n 20553 n 24300 f 25259 f 26340 f 27370 r 29065 f 29075 f 29085 f
29105 f 29125 f 29130 f 29240 f 29260 f 29345 f 29355 f 29365 f 29405 f 29425 f 29505 f
29515 f 29530 f 29540 f 29580 f 29581 f 29582 f 29583 f 29584 f 36000 f 36400 f 36405 f
36406 f 36410 f 36420 f 36425 f 36430 f 36440 f 36591 r 36592 r 36600 f 36640 f 43752 f
51701 f 51702 f 51703 f 64400 f 64402 f 64405 f 64408 f 64410 f 64413 f 64415 n 64416 n
64417 n 64418 f 64420 f 64421 f 64425 f 64430 f 64435 f 64445 f 64446 f 64447 f 64448 f
64449 f 64450 l 64461 n 64463 n 64486 n 64487 n 64488 n 64489 n 64505 f 64508 f 64510 f
64517 f 64520 f 64530 f 69990 n 72255 f 72265 f 72295 f 76000 m 76001 r 76080 f 76882 n
76942 r 76970 n 76998 u 77001 n 92012 r 92014 r 93000 f 93005 f 93010 f 93040 f 93041 f
93042 f 93318 f 93355 f 94002 f 94200 f 94250 f 94680 f 94681 f 94690 f 94770 f 95812 f
95813 f 95816 f 95819 f 95822 f 95829 f 95907 f 95908 f 95909 f 95910 f 95911 f 95912 f
95913 f 95955 f 96360 f 96361 n 96365 f 96366 n 96367 n 96368 n 96372 f 96374 f 96375 f
96376 f 96377 f 99155 u 99156 u 99157 u 99211 r 99212 r 99213 r 99214 r 99215 r 99217 r
99218 r 99219 r 99220 r 99221 r 99222 r 99223 r 99231 r 99232 r 99233 r 99234 r 99235 r
99236 r 99238 r 99239 r 99241 r 99242 r 99243 r 99244 r 99245 r 99251 r 99252 r 99253 r
99254 r 99255 r 99291 r 99292 r 99304 r 99305 r 99306 r 99307 r 99308 r 99309 r 99310 r
99315 r 99316 r 99334 r 99335 r 99336 r 99337 r 99347 r 99348 r 99349 r 99350 r 99374 r
99375 r 99377 r 99378 r 99446 r 99447 r 99448 r 99449 r 99495 r 99496 r G0168 f G0463 r
G0471 f J0670 n J2001 n
20611
PE-f
0.42
Total-nf
1.72
Total-f
1.33
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder,
hip, knee, subacromial bursa); with ultrasound guidance, with permanent
recording and reporting
OTHER
PE-f
Total-nf Total-f
Global P MUE
0.51
2.59
1.77
0
4(3)
INDICATORS
66
80,82
Suprv
Status
0
1
09
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CORRECT CODING EDITS 00400 l 01380 l 0213T n 0216T n 0228T n 0230T n 0232T r 10030 t
10060 f 10061 f 10140 t 10160 f 11900 f 12001 n 12002 n 12004 n 12005 n 12006 n 12007 n
12011 n 12013 n 12014 n 12015 n 12016 n 12017 n 12018 n 12020 n 12021 n 12031 n 12032 n
12034 n 12035 n 12036 n 12037 n 12041 n 12042 n 12044 n 12045 n 12046 n 12047 n 12051 n
12052 n 12053 n 12054 n 12055 n 12056 n 12057 n 13100 n 13101 n 13102 n 13120 n 13121 n
13122 n 13131 n 13132 n 13133 n 13151 n 13152 n 13153 n 15851 f 20500 m 20501 f 20527 n
20550 n 20551 n 20552 n 20553 n 20610 u 24300 f 25259 f 26340 f 27370 r 29065 f 29075 f
29085 f 29105 f 29125 f 29130 f 29240 f 29260 f 29345 f 29355 f 29365 f 29405 f 29425 f
29505 f 29515 f 29530 f 29540 f 29580 f 29581 f 29582 f 29583 f 29584 f 36000 f 36400 f
36405 f 36406 f 36410 m 36420 f 36425 f 36430 f 36440 f 36591 r 36592 r 36600 f 36640 f
43752 f 51701 f 51702 f 51703 f 62320 n 62321 n 62322 n 62323 n 62324 n 62325 n 62326 n
62327 n 64400 n 64402 n 64405 n 64408 n 64410 n 64413 n 64415 n 64416 n 64417 n 64418 n
64420 n 64421 n 64425 n 64430 n 64435 n 64445 n 64446 n 64447 n 64448 n 64449 n 64450 n
64461 n 64463 n 64479 n 64483 n 64486 n 64487 n 64488 n 64489 n 64490 n 64493 n 64505 n
64508 m 64510 n 64517 n 64520 n 64530 n 69990 n 72255 f 72265 f 72295 f 76000 m 76001 r
76080 f 76380 n 76882 n 76942 r 76970 n 76998 u 77001 n 77002 r 77003 u 77012 r 77021 r
92012 r 92014 r 93000 f 93005 f 93010 f 93040 f 93041 f 93042 f 93318 f 93355 f 94002 f
94200 f 94250 m 94680 f 94681 f 94690 m 94770 f 95812 f 95813 f 95816 f 95819 f 95822 f
95829 m 95907 f 95908 f 95909 f 95910 f 95911 f 95912 f 95913 f 95955 f 96360 f 96361 n
96365 f 96366 n 96367 n 96368 n 96372 f 96374 f 96375 f 96376 f 96377 f 99155 u 99156 u
99157 u 99211 r 99212 r 99213 r 99214 r 99215 r 99217 r 99218 r 99219 r 99220 r 99221 r
99222 r 99223 r 99231 r 99232 r 99233 r 99234 r 99235 r 99236 r 99238 r 99239 r 99241 r
99242 r 99243 r 99244 r 99245 r 99251 r 99252 r 99253 r 99254 r 99255 r 99291 r 99292 r
99304 r 99305 r 99306 r 99307 r 99308 r 99309 r 99310 r 99315 r 99316 r 99334 r 99335 r
99336 r 99337 r 99347 r 99348 r 99349 r 99350 r 99374 r 99375 r 99377 r 99378 r 99446 r
99447 r 99448 r 99449 r 99495 r 99496 r G0168 f G0463 rG0471 f J0670 n J2001 n
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Musculoskeletal — 8
Aspiration and/or injection of ganglion cyst(s) any location
RELATIVE VALUE UNITS
Work
MP
PE-nf
0.70
0.09
0.93
MODIFIERS
50
51
62
0
2
0
OTHER
Global P MUE
0
2(3)
INDICATORS
66
80,82
Suprv
Status
0
1
09
A
CORRECT CODING EDITS 00400 l 01820 l 0213T n 0216T n 0228T f 0230T f 10030 t 10060 f
10061 f 10140 t 10160 f 12001 n 12002 n 12004 n 12005 n 12006 n 12007 n 12011 n 12013 n
12014 n 12015 n 12016 n 12017 n 12018 n 12020 n 12021 n 12031 n 12032 n 12034 n 12035 n
12036 n 12037 n 12041 n 12042 n 12044 n 12045 n 12046 n 12047 n 12051 n 12052 n 12053 n
12054 n 12055 n 12056 n 12057 n 13100 n 13101 n 13102 n 13120 n 13121 n 13122 n 13131 n
13132 n 13133 n 13151 n 13152 n 13153 n 20500 t 20526 n 20527 n 20550 n 20551 n 20552 n
20553 n 36000 f 36400 f 36405 f 36406 f 36410 f 36420 f 36425 f 36430 f 36440 f 36591 r
36592 r 36600 f 36640 f 43752 f 51701 f 51702 f 51703 f 62320 f 62321 f 62322 f 62323 f
62324 n 62325 n 62326 n 62327 n 64400 f 64402 f 64405 f 64408 f 64410 f 64413 f 64415 n
64416 f 64417 n 64418 f 64420 f 64421 f 64425 f 64430 f 64435 f 64445 f 64446 f 64447 f
64448 f 64449 f 64450 n 64461 n 64463 n 64479 f 64483 f 64486 n 64487 n 64488 n 64489 n
64490 n 64493 n 64505 f 64508 f 64510 f 64517 f 64520 f 64530 f 69990 n 76000 f 76001 f
77001 n 92012 r 92014 r 93000 f 93005 f 93010 f 93040 f 93041 f 93042 f 93318 f 93355 f
94002 f 94200 f 94250 f 94680 f 94681 f 94690 f 94770 f 95812 f 95813 f 95816 f 95819 f
95822 f 95829 f 95955 f 96360 f 96361 n 96365 f 96366 n 96367 n 96368 n 96372 f 96374 f
96375 f 96376 f 96377 f 99155 u 99156 u 99157 u 99211 r 99212 r 99213 r 99214 r 99215 r
99217 r 99218 r 99219 r 99220 r 99221 r 99222 r 99223 r 99231 r 99232 r 99233 r 99234 r
99235 r 99236 r 99238 r 99239 r 99241 r 99242 r 99243 r 99244 r 99245 r 99251 r 99252 r
99253 r 99254 r 99255 r 99291 r 99292 r 99304 r 99305 r 99306 r 99307 r 99308 r 99309 r
99310 r 99315 r 99316 r 99334 r 99335 r 99336 r 99337 r 99347 r 99348 r 99349 r 99350 r
99374 r 99375 r 99377 r 99378 r 99446 r 99447 r 99448 r 99449 r 99495 r 99496 r G0463 r
G0471 f J0670 n J2001 n
20615
3
Mutually Exclusive Procedures
n Misuse of Column 2 with Column 1
January 2017
P
d
PE-f
0.41
Total-nf
1.72
Total-f
1.20
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Aspiration and injection for treatment of bone cyst
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RELATIVE VALUE UNITS
Work
MP
PE-nf
1.10
0.16
1.33
MODIFIERS
50
51
62
1
2
0
H Sequential Procedures
s Laboratory Panels
20612
RELATIVE VALUE UNITS
Work
MP
PE-nf
2.33
0.31
4.23
MODIFIERS
50
51
62
0
2
0
OTHER
Global P MUE
10
1(3)
INDICATORS
66
80,82
Suprv
Status
0
1
09
A
CORRECT CODING EDITS 0213T n 0216T n 0228T f 0230T f 11010 3 12001 n 12002 n 12004 n
12005 n 12006 n 12007 n 12011 n 12013 n 12014 n 12015 n 12016 n 12017 n 12018 n 12020 n
12021 n 12031 n 12032 n 12034 n 12035 n 12036 n 12037 n 12041 n 12042 n 12044 n 12045 n
12046 n 12047 n 12051 n 12052 n 12053 n 12054 n 12055 n 12056 n 12057 n 13100 n 13101 n
13102 n 13120 n 13121 n 13122 n 13131 n 13132 n 13133 n 13151 n 13152 n 13153 n 20526 n
29365 f 36000 f 36400 f 36405 f 36406 f 36410 f 36420 f 36425 f 36430 f 36440 f 36591 r
36592 r 36600 f 36640 f 43752 f 51701 f 51702 f 51703 f 62320 f 62321 f 62322 f 62323 f
62324 n 62325 n 62326 n 62327 n 64400 f 64402 f 64405 f 64408 f 64410 f 64413 f 64415 n
64416 n 64417 n 64418 f 64420 f 64421 f 64425 f 64430 f 64435 f 64445 f 64446 f 64447 f
64448 f 64449 f 64450 n 64461 n 64463 n 64479 f 64483 f 64486 n 64487 n 64488 n 64489 n
64490 n 64493 n 64505 f 64508 f 64510 f 64517 f 64520 f 64530 f 69990 n 92012 r 92014 r
93000 f 93005 f 93010 f 93040 f 93041 f 93042 f 93318 f 93355 f 94002 f 94200 f 94250 f
94680 f 94681 f 94690 f 94770 f 95812 f 95813 f 95816 f 95819 f 95822 f 95829 f 95955 f
96360 f 96361 n 96365 f 96366 n 96367 n 96368 n 96372 f 96374 f 96375 f 96376 f 96377 f
99155 u 99156 u 99157 u 99211 r 99212 r 99213 r 99214 r 99215 r 99217 r 99218 r 99219 r
99220 r 99221 r 99222 r 99223 r 99231 r 99232 r 99233 r 99234 r 99235 r 99236 r 99238 r
99239 r 99241 r 99242 r 99243 r 99244 r 99245 r 99251 r 99252 r 99253 r 99254 r 99255 r
99291 r 99292 r 99304 r 99305 r 99306 r 99307 r 99308 r 99309 r 99310 r 99315 r 99316 r
99334 r 99335 r 99336 r 99337 r 99347 r 99348 r 99349 r 99350 r 99374 r 99375 r 99377 r
99378 r 99446 r 99447 r 99448 r 99449 r 99495 r 99496 r G0463 rG0471 f J2001 n
PE-f
2.01
Total-nf
6.87
Standard Preparation/Monitoring Services
Modifier use may allow separate payment
CPT © 2016 American Medical Association. All Rights Reserved.
Total-f
4.65
l Anesthesia Included in Surgical Procedure
f
Standards of Medical/Surgical Practice
© 2017 Optum360, LLC
Medicare Correct Coding Guide (CCI Version 23.0)
81422
Pathology and Laboratory Services
Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge
syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal
blood
RELATIVE VALUE UNITS
Work
MP
PE-nf
0.00
0.00
0.00
MODIFIERS
50
51
62
9
9
9
OTHER
Global P MUE
XXX
—
INDICATORS
66
80,82
Suprv
Status
9
9
09
X
CORRECT CODING EDITS 81161 n 81162 n 81170 n 81200 n 81201 n 81202 n 81203 n 81205 n
81206 n 81207 n 81208 n 81209 n 81210 n 81211 n 81212 n 81213 n 81214 n 81215 n 81216 n
81217 n 81218 n 81219 n 81220 n 81221 n 81222 n 81223 n 81224 n 81225 n 81226 n 81227 n
81228 r 81229 r 81235 n 81240 n 81241 n 81242 n 81243 n 81244 n 81245 n 81246 n 81250 n
81251 n 81252 n 81253 n 81254 n 81255 n 81256 n 81257 n 81260 n 81261 n 81262 n 81263 n
81264 n 81265 n 81266 n 81267 n 81268 n 81270 n 81272 n 81273 n 81275 n 81276 n 81287 n
81288 n 81290 n 81291 n 81292 n 81293 n 81294 n 81295 n 81296 n 81297 n 81298 n 81299 n
81300 n 81301 n 81302 n 81303 n 81304 n 81310 n 81311 n 81313 n 81314 n 81315 n 81316 n
81317 n 81318 n 81319 n 81321 n 81322 n 81323 n 81324 n 81325 n 81326 n 81327 n 81330 n
81331 n 81332 n 81340 n 81341 n 81342 n 81350 n 81355 n 81400 n 81401 n 81402 n 81403 n
81404 n 81405 n 81406 n 81407 n 81408 n 81493 3 81504 3 81507 3 81519 3 81525 3 81528 3
81540 3 81545 3 81595 3 84311 n 88271 r 88272 n 88273 n 88274 n 88275 n 88291 n 88364 n
88365 n 88366 n 88367 n 88368 n 88369 n 88373 n 88374 n 88377 n 96523 r G0452 n
81425
PE-f
0.00
Total-nf
0.00
Total-f
0.00
Genome (eg, unexplained constitutional or heritable disorder or syndrome);
sequence analysis
RELATIVE VALUE UNITS
Work
MP
PE-nf
0.00
0.00
0.00
MODIFIERS
50
51
62
9
9
9
OTHER
PE-f
Total-nf Total-f
Global P MUE
0.00
0.00
0.00
XXX
1(1)
INDICATORS
66
80,82
Suprv
Status
9
9
09
X
CORRECT CODING EDITS 81161 n 81162 n 81170 n 81200 n 81201 n 81202 n 81203 n 81205 n
81206 n 81207 n 81208 n 81209 n 81210 n 81211 n 81212 n 81213 n 81214 n 81215 n 81216 n
81217 n 81218 n 81219 n 81220 n 81221 n 81222 n 81223 n 81224 n 81225 n 81226 n 81227 n
81235 n 81240 n 81241 n 81242 n 81243 n 81244 n 81245 n 81246 n 81250 n 81251 n 81252 n
81253 n 81254 n 81255 n 81256 n 81257 n 81260 n 81261 n 81262 n 81263 n 81264 n 81265 n
81266 n 81267 n 81268 n 81270 n 81272 n 81273 n 81275 n 81276 n 81287 n 81288 n 81290 n
81291 n 81292 n 81293 n 81294 n 81295 n 81296 n 81297 n 81298 n 81299 n 81300 n 81301 n
81302 n 81303 n 81304 n 81310 n 81311 n 81313 n 81314 n 81315 n 81316 n 81317 n 81318 n
81319 n 81321 n 81322 n 81323 n 81324 n 81325 n 81326 n 81327 n 81330 n 81331 n 81332 n
81340 n 81341 n 81342 n 81350 n 81355 n 81400 n 81401 n 81402 n 81403 n 81404 n 81405 n
81406 n 81407 n 81408 n 81493 n 81504 n 81507 n 81519 n 81525 n 81528 n 81540 n 81545 n
81595 n 84311 n 88271 r 88272 n 88273 n 88274 n 88275 n 88291 n 88364 n 88365 n 88366 n
88367 n 88368 n 88369 n 88373 n 88374 n 88377 n G0452 n
81426
m
a
OTHER
Global P MUE
XXX
2(1)
INDICATORS
66
80,82
Suprv
Status
9
9
09
X
CORRECT CODING EDITS 81161 n 81162 n 81170 n 81200 n 81201 n 81202 n 81203 n 81205 n
81206 n 81207 n 81208 n 81209 n 81210 n 81211 n 81212 n 81213 n 81214 n 81215 n 81216 n
81217 n 81218 n 81219 n 81220 n 81221 n 81222 n 81223 n 81224 n 81225 n 81226 n 81227 n
81235 n 81240 n 81241 n 81242 n 81243 n 81244 n 81245 n 81246 n 81250 n 81251 n 81252 n
81253 n 81254 n 81255 n 81256 n 81257 n 81260 n 81261 n 81262 n 81263 n 81264 n 81265 n
81266 n 81267 n 81268 n 81270 n 81272 n 81273 n 81275 n 81276 n 81287 n 81288 n 81290 n
81291 n 81292 n 81293 n 81294 n 81295 n 81296 n 81297 n 81298 n 81299 n 81300 n 81301 n
81302 n 81303 n 81304 n 81310 n 81311 n 81313 n 81314 n 81315 n 81316 n 81317 n 81318 n
81319 n 81321 n 81322 n 81323 n 81324 n 81325 n 81326 n 81327 n 81330 n 81331 n 81332 n
81340 n 81341 n 81342 n 81350 n 81355 n 81400 n 81401 n 81402 n 81403 n 81404 n 81405 n
81406 n 81407 n 81408 n 81493 n 81504 n 81507 n 81519 n 81525 n 81528 n 81540 n 81545 n
81595 n 84311 n 88271 r 88272 n 88273 n 88274 n 88275 n 88291 n 88364 n 88365 n 88366 n
88367 n 88368 n 88369 n 88373 n 88374 n 88377 n G0452 n
PE-f
0.00
S
r CPT/CMS Coding Manual Instructions
u CPT/HCPCS Procedure Code Definition ©
2017 Optum360, LLC
Total-nf
0.00
Total-f
0.00
´ Designation of Gender-specific Procedures
MUE 1 Line Edit
Genome (eg, unexplained constitutional or heritable disorder or syndrome);
re-evaluation of previously obtained genome sequence (eg, updated knowledge
or unrelated condition/syndrome)
RELATIVE VALUE UNITS
Work
MP
PE-nf
0.00
0.00
0.00
MODIFIERS
50
51
62
9
9
9
OTHER
Global P MUE
XXX
1(1)
INDICATORS
66
80,82
Suprv
Status
9
9
09
X
CORRECT CODING EDITS 81161 n 81162 n 81170 n 81200 n 81201 n 81202 n 81203 n 81205 n
81206 n 81207 n 81208 n 81209 n 81210 n 81211 n 81212 n 81213 n 81214 n 81215 n 81216 n
81217 n 81218 n 81219 n 81220 n 81221 n 81222 n 81223 n 81224 n 81225 n 81226 n 81227 n
81235 n 81240 n 81241 n 81242 n 81243 n 81244 n 81245 n 81246 n 81250 n 81251 n 81252 n
81253 n 81254 n 81255 n 81256 n 81257 n 81260 n 81261 n 81262 n 81263 n 81264 n 81265 n
81266 n 81267 n 81268 n 81270 n 81272 n 81273 n 81275 n 81276 n 81287 n 81288 n 81290 n
81291 n 81292 n 81293 n 81294 n 81295 n 81296 n 81297 n 81298 n 81299 n 81300 n 81301 n
81302 n 81303 n 81304 n 81310 n 81311 n 81313 n 81314 n 81315 n 81316 n 81317 n 81318 n
81319 n 81321 n 81322 n 81323 n 81324 n 81325 n 81326 n 81327 n 81330 n 81331 n 81332 n
81340 n 81341 n 81342 n 81350 n 81355 n 81400 n 81401 n 81402 n 81403 n 81404 n 81405 n
81406 n 81407 n 81408 n 81493 n 81504 n 81507 n 81519 n 81525 n 81528 n 81540 n 81545 n
81595 n 84311 n 88271 r 88272 n 88273 n 88274 n 88275 n 88291 n 88364 n 88365 n 88366 n
88367 n 88368 n 88369 n 88373 n 88374 n 88377 n G0452 n
81430
PE-f
0.00
Total-nf
0.00
Total-f
0.00
a
p
e
g
Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred
syndrome); genomic sequence analysis panel, must include sequencing of at
least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A,
MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G,
USH2A, and WFS1
OTHER
Global P MUE
XXX
1(2)
INDICATORS
66
80,82
Suprv
Status
9
9
09
X
CORRECT CODING EDITS 81161 n 81162 n 81170 n 81200 n 81201 n 81202 n 81203 n 81205 n
81206 n 81207 n 81208 n 81209 n 81210 n 81211 n 81212 n 81213 n 81214 n 81215 n 81216 n
81217 n 81218 n 81219 n 81220 n 81221 n 81222 n 81223 n 81224 n 81225 n 81226 n 81227 n
81235 n 81240 n 81241 n 81242 n 81243 n 81244 n 81245 n 81246 n 81250 n 81251 n 81252 n
81253 n 81254 n 81255 n 81256 n 81257 n 81260 n 81261 n 81262 n 81263 n 81264 n 81265 n
81266 n 81267 n 81268 n 81270 n 81272 n 81273 n 81275 n 81276 n 81287 n 81288 n 81290 n
81291 n 81292 n 81293 n 81294 n 81295 n 81296 n 81297 n 81298 n 81299 n 81300 n 81301 n
81302 n 81303 n 81304 n 81310 n 81311 n 81313 n 81314 n 81315 n 81316 n 81317 n 81318 n
81319 n 81321 n 81322 n 81323 n 81324 n 81325 n 81326 n 81327 n 81330 n 81331 n 81332 n
81340 n 81341 n 81342 n 81350 n 81355 n 81400 n 81401 n 81402 n 81403 n 81404 n 81405 n
81406 n 81407 n 81408 n 81493 n 81504 n 81507 n 81519 n 81525 n 81528 n 81540 n 81545 n
81595 n 84311 n 88271 r 88272 n 88273 n 88274 n 88275 n 88291 n 88364 n 88365 n 88366 n
88367 n 88368 n 88369 n 88373 n 88374 n 88377 n G0452 n
RELATIVE VALUE UNITS
Work
MP
PE-nf
0.00
0.00
0.00
MODIFIERS
50
51
62
9
9
9
e
l
p
Genome (eg, unexplained constitutional or heritable disorder or syndrome);
sequence analysis, each comparator genome (eg, parents, siblings) (List
separately in addition to code for primary procedure)
RELATIVE VALUE UNITS
Work
MP
PE-nf
0.00
0.00
0.00
MODIFIERS
50
51
62
9
9
9
81427
81431
PE-f
0.00
Total-nf
0.00
Total-f
0.00
Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred
syndrome); duplication/deletion analysis panel, must include copy number
analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes
RELATIVE VALUE UNITS
Work
MP
PE-nf
0.00
0.00
0.00
MODIFIERS
50
51
62
9
9
9
OTHER
Global P MUE
XXX
1(2)
INDICATORS
66
80,82
Suprv
Status
9
9
09
X
CORRECT CODING EDITS 81161 n 81162 n 81170 n 81200 n 81201 n 81202 n 81203 n 81205 n
81206 n 81207 n 81208 n 81209 n 81210 n 81211 n 81212 n 81213 n 81214 n 81215 n 81216 n
81217 n 81218 n 81219 n 81220 n 81221 n 81222 n 81223 n 81224 n 81225 n 81226 n 81227 n
81235 n 81240 n 81241 n 81242 n 81243 n 81244 n 81245 n 81246 n 81250 n 81251 n 81252 n
81253 n 81254 n 81255 n 81256 n 81257 n 81260 n 81261 n 81262 n 81263 n 81264 n 81265 n
81266 n 81267 n 81268 n 81270 n 81272 n 81273 n 81275 n 81276 n 81287 n 81288 n 81290 n
81291 n 81292 n 81293 n 81294 n 81295 n 81296 n 81297 n 81298 n 81299 n 81300 n 81301 n
81302 n 81303 n 81304 n 81310 n 81311 n 81313 n 81314 n 81315 n 81316 n 81317 n 81318 n
81319 n 81321 n 81322 n 81323 n 81324 n 81325 n 81326 n 81327 n 81330 n 81331 n 81332 n
81340 n 81341 n 81342 n 81350 n 81355 n 81400 n 81401 n 81402 n 81403 n 81404 n 81405 n
81406 n 81407 n 81408 n 81493 n 81504 n 81507 n 81519 n 81525 n 81528 n 81540 n 81545 n
81595 n 84311 n 88271 r 88272 n 88273 n 88274 n 88275 n 88291 n 88364 n 88365 n 88366 n
88367 n 88368 n 88369 n 88373 n 88374 n 88377 n G0452 n
PE-f
0.00
Total-nf
0.00
m CPT Separate Procedure Definition
MUE 2 DOS Edit: Policy
CPT © 2016 American Medical Association. All Rights Reserved.
January 2017
Total-f
0.00
t More Extensive Procedure
MUE 3 DOS Edit: Clinical
Pathology — 25