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3 Table Of Contents Introduction... 1 Welcome... 1 Copyright... 2 AMA Notice... 2 Software Features... 4 System Requirements... 5 Features by Product... 5 Contact Optum... 9 Support... 9 Data Sources NCD Data Source LCD Data Source CCI Data CCI Data Source ICD-9-CM Data Source ICD-10 Data Source Dental Codes Data Source CPT Data Source CMS Fee Schedule Data Source HCPCS Data Source ICD-9 to DRG Crosswalk Data Source Modifier Crosswalk Data Source Surgical Crosscode Data Source Coder's Essential 3-Pack Data Source ASA Crosswalk Data Source Logging In Changing the Administrator Password Administrator User Administration Edit All Users Password Add User Setting up a New User Users Changing the Administrator Password Add a User Subscription iii

4 Managing Additional Subscriptions Edit User Subscriptions Subscription Renewal User Profile User Preferences Data Versions Medicare Carrier/Locality Buttons and Icons Toolbar Buttons and Icons Add to Notepad Button Add to User Notes Button Annotations Icon APC Status Icon Assistant at Surgery Icons ASC Group Icon CCI Unbundle Edits Icon CMS Fee Schedule Icon CPT Lay Descriptions and Coding Tips Code History Button Coder's Essential 3-Pack Icon Color Coding Legend Button Compliance Check Button Conscious Sedation Icon Crosscodes Icon DRG Crosscodes Icon Help Button Home Button ICD-10 Mapping Icon Images Icon LCD Medical Necessity Edits Icon Logout Button Modifiers Icon Modifier Crosswalk Modifier -63 Icon NCD Medical Necessity Edits Icon Notepad Button OPSI Status Indicator Section Notes Icon iv

5 PQRS Icon Print Code Detail Summary Report Button Print Button Pub-100 References Icon Resequenced Codes Icon Revenue Codes User Administration Button User Notes Button User Profile Button View User Notes Icon Color Coding Legends CPT Color Coding Legend HCPCS Color Coding Legend ICD-9-CM Vol. 1 Color Coding Legend ICD-9 Vol. 3 Color Coding Legend ICD-10-CM Color Coding Legend Home Page User's Manual Subscription Renewal Code Books Contents Coding Guidance CCI Quick Check Coverage Center ABN form What's New? Local News Using EncoderPro Applications Performing a Code Search Search Box Determining Search Criteria CPT and HCPCS Search Results Spell Checking Search Terms Search Results ICD-9-CM Search Results ICD-10-CM Search Results User Defined Code List Tips For Entering Search Terms Code Sets Drop-down List Results Alert v

6 Printing Printing Copying Text to the Clipboard Copying Text to the Windows Clipboard Coding Menu Current Procedural Coding Expert CPT Codes Menu CPTCode Book Sections Code Books Contents CPT Index CPT Appendix Modifiers Using CPT Modifiers Resequenced Codes CPT Appendix Glossary CPT Appendix - Physician Quality Reporting System PQRS Lookup Table HCPCS Menu HCPCS Expert HCPCS Code Book Sections Code Books Contents HCPCS Index HCPCS Appendix Table of Drugs HCPCS Appendix Modifiers PET Scans HCPCS Appendix Abbreviations and Acronyms ICD-9-CM Dx Menu Instructional Notes ICD-9-CM Expert Vol ICD-9-CM Expert Vol. 1 Code Book Sections Code Books Contents ICD9-CM Preface, Introduction, How-to-use..., Conventions ICD9-CM Coding Guidelines ICD9 Appendix: Morphology of Neoplasms ICD9 Appendix Glossary of Mental Disorders ICD9 Appendix: Classification of Drugs ICD9 Appendix: Industrial Accidents According to Agency ICD9 Appendix: List of Three-digit Categories ICD9 Abortion Table ICD9 Burn Table vi

7 ICD9 Complications Table ICD9 Diabetes Table ICD9 Hernia Table ICD9 Ectopic Pregnancy Table ICD9 Normal Pregnancy Table ICD9 Antepartum Pregnancy Table ICD9 Postpartum Pregnancy Table ICD9 Valid Three-digit Codes ICD-9-CM Index Menu ICD-9-CM Vol.2 Indexes ICD-9-CM Vol. 2 Index to Diseases ICD-9-CM Vol. 2 Index to Diseases (Hypertension) ICD-9-CM Vol. 2 Index to Diseases (Neoplasm) ICD-9-CM Section 2- Table of Drugs and Chemicals ICD-9-CM Section 3- Index to External Causes (E Codes) ICD-9-CM Px Menu ICD-9-CM Expert Vol ICD-9-CM Px - Vol. 3 Code Book Sections Code Books Contents ICD-9 Volume 3- Index to Procedures ICD-10-PCS Menu ICD-10-PCS ICD-10-PCS Codes My PCS Notes ICD-10-CM Dx Menu ICD-10-CM Drafts ICD-10-CM Code Book Sections Code Books Contents ICD-10-CM Preface, Introduction, How-to-use..., Conventions ICD-10-CM Conventions ICD-10-CM Official Guidelines Crosscodes Submenu CPT/HCPCS to Rev Codes Rev Codes to CPT/HCPCS CPT/HCPCS Codes for Revenue Code Interventional Radiology CPT/HCPCS to Modifier DRG Cross Codes OPPS Cross Codes vii

8 LTC-DRG Cross Codes APC Cross Codes Coding Edits Submenu MCE Edits I-OCE Edits Type of Bill OCE Edits CCI Edits MUE List SNF CB Edits Future New, Revised and Deleted Codes Modifier List Search New Codes Deleted Codes Revised Codes Reinstated Codes Resequenced Codes Color Codes CPT Color Codes HCPCS Color Codes ICD-9-CM Vol. 1 Color Codes ICD-9-CM Vol. 3 Color Codes ICD-10-CM Color Codes Coding Guidelines Menu DRG Trees DRG Indicators DRG Pairs Alert Table Targeted DRGs MDC Look-up MDC References Compliance Menu MSP Guidelines Quick Reference Questionnaire Black Lung Program Reimbursement Menu Reimbursement Lookup DRG Calculator Billing Menu viii

9 Rev Codes to CPT/HCPCS CPT/HCPCS Codes for Revenue Code Revenue Codes Requiring CPT/HCPCS Revenue Code Detail Policy Lookup Menu Policy Search Results Policy Details Code Sections CPT Code Section HCPCS Code Section ICD-9-CM Volume 1 Code Section ICD-9-CM Volume 3 Code Section ICD-10-CM Code Section Code Detail CPT Code Detail Lay Descriptions Coding Tips HCPCS Code Detail ICD-9-CM Vol. 1 Code Detail ICD-9-CM Vol. 3 Code Detail ICD-10-CM Code Detail Annotations Code History Code Detail Summary Report Print Report ICD-10 Basic Mapping Notepad Editing Codes in the Notepad Deleting Codes from the Notepad Copying Codes in the Notepad Adding Codes to the Notepad Codes to Compliance Edit Exporting Codes from the Notepad Compliance Edit Edit Conflicts Claims Edits List - Commercial Claims Edits List - Medicare User Data - Outpatient Forms User Notes ix

10 Add User Notes View User Notes Edit User Notes Delete User Notes Search User Notes Medicare Reference Medical Necessity Edits LCD Medical Necessity Edits NCD Medical Necessity Edits Code-Specific Edits CPT Edits and Info HCPCS Edits and Info ICD-9-CM Vol. 1 Edits and Info ICD-9-CM Vol. 3 Edits and Info ICD-10-CM Edits and Info Pub-100 References CMS Transmittals Payment References APC Group ASC Payment Indicators Endoscopic Multiple Procedure Reduction Guidelines DRG Crosswalk DRG Codes LTC DRG Group ASP Part B Payment Physician Fee Schedule Information Medicare Physician Fee Schedule MPFS Column Descriptions Medicare Physician Fee Schedule Payment Formulas Add-on Subscriptions Coding and Information AHA Coding Clinic for ICD-9-CM AHA Coding Clinic for HCPCS AHA Coding Clinic for HCPCS Detail ASA Crosswalk and RVU Guide CPT Assistant CPT Assistant Detail CPT Changes: An Insider's View CPT Changes: An Insider's View Detail x

11 Article Detail Stedman's Dictionary Coders' Dictionary Coder's Essential 3-Pack Coder's Essential 3-Pack Pink Sheets Part B News Answer Books HCPCS Dental Codes HCPCS Dental Codes Historical Application Content Add-on Modules Claims Batch Editor Claims Batch List Add Claims Batch Claims List Repair Toolkit Batch Providers DrugReimbursement Title Bar Search Box Search Results DRC Search Results Code Information Drug Information Optum Data FeeAnalyzer Features Notice Fee Analyzer Menu Main Screen Functions Fee Loader Release Information Printing and Exporting I10 Map Manager II0 Map Manager - User Preferences I10 Map Manager I10 Add Map ICD-10-CM Mapping Page xi

12 Source Code List Patient Encounter Form Remit Advice Professional Remit Advice Professional Setup Index xii

13 Introduction Welcome Welcome to EncoderPro.com - Oputm s powerful browser-based medical coding solutions that search ICD-9- CM, ICD-10-CM, CPT, and HCPCS Level II code sets, provides information from Medicare policies, Optum publications and helps you confidently select the proper codes quickly and accurately. The following products are available in the EncoderPro Product Suite (SUITE): EncoderPro.com Expert EncoderPro.com Professional EncoderPro.com Standard MedicareReimbursementPro The following products are available in EncoderPro for Payers: EncoderPro.com for Payers Professional The following products are available in the smaller Expert products: CurrentProceduralCoding.com (CPT) HCPCSExpert.com (HCPCS) I9 ForHospitals.com (ICD9 H) I9 ForPhysicians.com (ICD9 P) All features apply to all products in the EncoderPro.com Product Suite unless otherwise noted. All Features explained in Help apply to EncoderPro.com for Payers. The smaller Expert applications features match the book products. Feature availability per product is also noted in Features by Product. 1

14 Copyright Copyright 2013 Optum/OptumInsight All rights reserved. Produced and printed in the United States of America. This document is designed to be an accurate and authoritative source of information about Optum's Online Applications. Every effort has been made to verify the accuracy of the information, and all information is believed reliable at the time of publication. However, absolute accuracy cannot be guaranteed. Since the policy of Optum is to make continuous improvements, this document is subject to change without notice. All attempts are made to ensure that the information presented in this document is correct. However, if you should find any error, please notify an Optum representative. No liability, expressed or implied, will be assumed by Optum or its affiliates for any damage resulting from the use of the information in this manual. AMA Notice CPT only 2012 American Medical Association (AMA). All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association CPT Assistant American Medical Association. All Rights Reserved. AHA Notice Copyright 2012, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express written consent of AHA. NTIS Notice The responsibility for the content of any National Correct Coding Policy included in this product is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product. U.S. Government Rights This product includes CPT and/or CPT Assistant and/or CPT Changes which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were -developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS (b)(2) (November 1995) and/or subject to the restrictions of DFARS (a) (June 1995) and DFARS (a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR (June 1987) and/or subject to the restricted rights provisions of FAR (June 1987) and FAR (June 1987), as applicable, and any applicable agency FAR Supplements, for non-department of Defense Federal procurements. Applicable FARS/DFARS Restrictions Apply to Government Use Contractor/Manufacturer is Optum, 2525 Lake Park Blvd, West Valley City, UT, MicroMedex End-User License Agreement Drug Reimbursement.com End-User License Agreement The Micromedex information contained within this application includes but is not limited to the following drug data: billing National Drug Codes (NDCs), brand and generic names, J codes, manufacturer, RX/OTC flag, product form, product strength, unit, route of administration, package size, average wholesale price (AWP), and deactivated date. The information contained in the Micromedex products is intended as an educational aid only. All Treatments or procedures are intended to serve as an information resource for physicians or other competent healthcare 2

15 professionals performing the consultation or evaluation of patients and must be interpreted in view of all attendant circumstances, indications and contraindications. The prices contained in Red Book are based on data reported by manufacturers. Micromedex has not preformed any independent analysis of the actual prices paid by wholesalers and providers in the marketplace. Thus, actual prices paid by wholesalers and providers may well vary from the prices contained in this database and all prices are subject to change without notice. Please refer to the "AWP Policy" in the product for more information. The use of the Micromedex products is at your sole risk. These products are provided "as is" and "as available" for use, without warranties of any kind, either express or implied. Micromedex makes no representation or warranty as to the accuracy, reliability, timeliness, usefulness or completeness of any of the information contained in the products. Additionally, Micromedex makes no representation or warranties as to the opinions or other service or data you may access, download or use as a result of use of the Micromedex products. All implied warranties of merchantability and fitness for a particular purpose or use are hereby excluded. Micromedex does not assume any responsibility or risk for your use of the Micromedex products. Copyright: "Copyright 2013 Thomson MICROMEDEX. All rights reserved. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes." DecisionHealth Terms of Use Agreement While DecisionHealth tries to keep the information provided on this site as accurate as possible, we disclaim any implied warranty or representation about its accuracy, completeness, or appropriateness for a particular purpose. Therefore, you assume full responsibility for using the information at this site, and you understand and agree that DecisionHealth is neither responsible nor liable for any claim, loss, or damage resulting from its use. Copyright 2013 DecisionHealth. All rights reserved. Do not modify, re-publish, re-transmit, duplicate or otherwise distribute directly or via links any Content in any form. Users are granted the right to print out any article on this site for individual, personal use only. This does not convey permission for commercial use or for making multiple copies for distribution (internal or external). Use of this web site signifies agreement with these restrictions. The trademarks, service marks and logos of DecisionHealth, its product-specific brands, or others used on this site are the property of DecisionHealth or their respective owners. You may not use any trademark displayed on the site without the written permission of DecisionHealth or the respective owner. Rev. EE EP ES MPRO PP IE PDF 12/29/2011R4, 02/29/2012R1, 06/29/2012R2, 11/16/2012R3, 12/28/2012R4 [12/19/12] 3

16 Software Features CodeLogic Search Technology Simultaneous code search across ICD-9-CM Volumes 1 and 3, ICD-10-CM, CPT, and HCPCS code sets. Your search results can bring back results in all four code sets or limited to one code set. Search Terms You can enter up to four search terms, acronyms, and/or abbreviations that allows you to narrow down the results when you first initiate a search. An automatic spell check feature ensures that you enter valid terms. Code Detail A comprehensive reference page for each HCPCS and CPT code with access to important modifiers, CCI edits and cross coder data. For ICD-9-CM codes, the Code Section displays excludes and includes notes, "code first" and "code also" references. ICD-10-CM code detail pages display description and code history information. CPT and HCPCS codes in the Code Section are grouped by section and subsection. Code-Specific Edits and Information for ICD-9-CM You can view instructional notes, AHA coding clinic references and annotations for the selected ICD-9-CM code. Code Specific Edits and Information for ICD-10 You can view codes and descriptions, section notes, and images for selected ICD-10-CM codes. ICD-10-PCS will also be available soon. Note: ICD-10 is still in draft mode. The industry is set to begin using ICD-10 in the latter part of Code-Specific Edits and Information for CPT You can view lay descriptions, CPT Assistant references, AMA guidelines and modifiers for the selected CPT code. You can view primary procedure codes for add-on codes, surgical and anesthesia crosscodes, Medicare Physician Fee Schedule information and unbundle edits from Medicare s Correct Coding Initiative. Code-Specific Edits and Information for HCPCS You can view annotations, section notes, modifiers and coverage instruction references from the Pub-100 References for the selected HCPCS code. Color Codes You can look up all codes with their color codes in sorted lists. User Notes Organizations can establish Global Notes for company-wide rules. Individuals can add and edit their own comments to codes with User Notes. Each code with a User Note attached is flagged for quick reference. Claim Compliance You can check claim charge detail for coding compliancy and fix any billing errors as needed. 4

17 System Requirements In order to run Optum applications, your system should meet certain recommended requirements. If your system doesn't meet those requirements, then you may not be able to take full advantage of the features available. Optum recommends the following minimum requirements: Operating system: Windows XP or higher Browser: Internet Explorer; version 7.0 or higher Internet connection: high speed broadband connection; such as DSL or cable. Dial up connections are not recommended. Monitor screen resolution: minimum 1024x768, recommended 1280x1024 Adobe Acrobat Reader -- see for further details. (Adobe and its products are copyrighted by Adobe Systems Inc.) Because EncoderPro is web based, it is possible to access the services through other means such as other operating systems, other browsers, and even through cell phones & other portable devices. However, it is recommended to follow the requirements listed above in order to benefit from its full performance capabilities. Features by Product CurrentProdecuralCoding.com HCPCSExpert.com ICD9ExpertHospital.com Upload Users CPT codes, CPT instructional notes and annotations CPT Section Notes, CPT Assistant References CPT Changes: An Insider's View New, Revised, and Deleted Codes Code Book Section lookup Index Listing of CPT code book User Notes Upload Users HCPCS codes, HCPCS instructional notes and annotations New, Revised, and Deleted Codes Code Book Section lookup Index Listing of HCPCS code book All color codes associated with the selected code User Notes Upload Users ICD-9-CM Volumes 1, 2 and 3, ICD-9-CM instructional notes, AHA Coding Clinic references, and annotations ICD-10-CM search, instructional notes, and references. New, Revised, and Deleted Codes Code Book Section lookup Index Listing of ICD-9-CM code book All color codes associated with the selected code Invalid codes, unspecified codes, CC exclusions ICD-9-CM crosswalk to DRG codes 5

18 User Notes Full ICD-10 Mapping ICD-9 to ICD-10 Map Manager ICD9ExpertPhysician.com EncoderPro.com/Standard All the above with these added features: EncoderPro.com/Professional All the above with these added features: EncoderPro.com/Expert All the above with these added features: Upload Users ICD-9-CM Volumes 1 and 2, ICD-9-CM instructional notes, AHA Coding Clinic references, and annotations ICD-10-CM search, instructional notes, and references. New, Revised, and Deleted Codes Code Book Section lookup Index Listing of ICD-9-CM code book All color codes associated with the selected code Invalid codes and non-specific codes User Notes Full ICD-10 Mapping ICD-9 to ICD-10 Map Manager CPT color codes identify add-on, modifier 51 exempt, age and sex specific codes HCPCS color codes identify codes carrying quantity, Special Coverage Instructions, and policy flags. User Notes, Notepad, HCPCS Notes, Lay Descriptions, Medicare Coverage Instructions ICD-10-CM code search, instructional notes, and references. Full ICD-10-CM code mapping. ICD-9 to ICD-10 Map Manager CPT Modifiers HCPCS Modifiers Medical Necessity Edits CCI Unbundle Edits Pub-100 References Surgical Crosscodes for ICD-9-CM to CPT, HCPCS to ICD-9-CM Vol 1, Vol 3 and CPT, CPT to Dental codes, CPT to CPT Anesthesia Modifier crosswalk Medicare Physician Fee Schedule dialog box LCD, NCD coverage determinations and Medicare, Pub-100 References ABN Function ICD-10-CM code search, instructional notes, and references. Full ICD-10-CM code mapping. ICD-9 to ICD-10 Map Manager Fee Calculation by Locality Compliance Edit Edit Reports Claims Batch Editor Repair Toolkit Variance Reports 6

19 Code History Full ICD-10-CM code mapping ASA Crosswalk ICD-10-CM code search, instructional notes, and references. ICD-9 to ICD-10 Map Manager EncoderPro.com for Payers All the above with these added features: MedicareReimbursementPro.com All the features included in EncoderPro.com/Standard, with these additional features: Facility Code Icons CCI OCE Edits NonOPPS OCE Edits SNF Consolidated Billing Edits Crosscodes (Modifiers, PCC Crosscodes, IR Crosscodes, OPPS Crosscodes, Revenue Codes) Medicare Fee Calculator Compliance Edits Pub-100 References Facility Code Icons Crosscodes (Modifiers) Instructional Notes Section Notes Annotations Signs & Symptoms References MSP Guidelines Code History ICD-10-CM code search, instructional notes, and references. ICD-9 to ICD-10 Map Manager Medicare Physician Fee Schedule dialog box located in the code range page Medicare Physician Fee Schedule dialog box located in the code detail page Note with regards to accuracy of data within EPro applications: Medicare Reference This information is compiled from CMS/ Medicare information. The data is formatted for ease of use. Code Information Code Description - The code and the official description. CPT Codes - The full description as contained in the CPT book printed and copyrighted by the AMA. HCPCS codes - The full description as released by CMS. ICD-9-CM Volume 1 and Volume 3 codes - The full description as approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. ICD-10-CM and ICD-10-PCS codes - The codes and descriptions as proposed by CMS. Please note: ICD-10 code sets are still in draft mode. The industry is set to begin using ICD-10 in the latter part of Code History - Notes the last effective date that the code was revised. Lay Description - Optum's specific lay description of the procedure. 7

20 Notes - CPT codes - The notes for the section and subsection as contained in the CPT book printed and copyrighted by the AMA. ICD-9-CM Volume 1 and Volume 3 codes: Instructional notes contained in the ICD-9-CM. Code Specific Reference Information - CPT codes - the AMA CPT Assistant references, CPT Changes: An Insider's View CPT codes primary procedure codes - identifies appropriate primary procedures to be reported with the add-on code as derived from the instructional notes contained in the CPT book. ICD-9-CM codes - the AHA Coding Clinic references. Annotations - ICD-9-CM Volume 1 and Volume 3 codes as contained in the ICD-9-CM. ICD-10-CM and ICD-10-PCS - information regarding the code. HCPCS codes - information regarding the code. Images - Optum's illustration relating to the specific code where available. Optum Data Color codes - CPT color codes - all the icons listed in this section are taken from: the CPT book, information released by CMS, or from the Cooperating Parties for the ICD-9-CM Crosscodes - CPT and HCPCS codes - Tables or lists of appropriate modifiers or diagnosis codes that can be reported with CPT or HCPCS codes as developed and maintained by Optum using CCI, NCD, and other official sources as well as clinical expertise of Optum's staff. ICD-9-CM Volume 1 - DRG crosswalk as released by CMS and the Cooperating Parties for the ICD-9-CM NDC crosswalk identifies possible medications that may be prescribed for the diagnosis based upon official sources such as pharmaceutical information and clinical expertise of OptumInsight's staff ICD-9-CM Volume 3 DRG crosswalk as released by CMS and the Cooperating Parties for the ICD-9-CM Crosscodes - Tables or lists of appropriate modifiers or diagnosis codes that can be reported with CPT or HCPCS codes as developed and maintained by OptumInsight using CCI, NCD, and other official sources as well as clinical expertise of OptumInsight staff. Also please note: occasionally, there may be times when the information contained in different sections of the EncoderPro application may appear to be inconsistent as a result of differences between CPT as published by the AMA and the guidelines released by CMS. The information from each source is presented, and is correct. The information above should help to identify the source of the information provided and help to determine the guidelines most appropriate for professional physician practices and for insurance payers. 8

21 Contact Optum Click the " Contact Us " link at the bottom of any screen for information on how to contact Optum. Support The Support link is displayed on the bottom of each screen. Click "Support" to go to the dialog box that displays support messages, FAQs and files to download. 9

22 Data Sources NCD Data Source National Coverage Determinations (NCD) policies are coverage rules that are developed by the Centers for Medicare and Medicaid Services, or CMS (formerly the Health Care Financing Administration, or HCFA). LCD Data Source The Local Coverage Determination (LCD) medical necessity edits are carrier-specific rules that identify ICD-9- CM Vol. 1 codes that verify medical necessity for CPT or HCPCS codes. CCI Data CPT codes Copyright 2012 American Medical Association. All Rights Reserved. The Centers for Medicare and Medicaid Services (CMS), is responsible for the content of CCI data. No endorsement by the American Medical Association (AMA) is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any uses, non-use, or interpretation of information contained or not contained in this product. The Correct Coding Policies do not supersede any other specific Medicare coding, coverage, or payment policies. The Physicians' Current Procedural Terminology developed by the American Medical Association and HCPCS Level II codes developed by the Centers for Medicare and Medicaid Services (CMS) are listings of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. The codes in the CPT Manual are copyrighted by the AMA, and updated annually by the CPT Editorial Panel based on input from the AMA Advisory Committee which serves as a channel for requests from various providers and specialty societies. The purpose of both coding systems and annual updates is to communicate specific services rendered by physicians and other providers, usually for the purpose of claim submission to third party (insurance) carriers. A multitude of codes is necessary because of the wide spectrum of services provided by various medical care providers. Because many medical services can be rendered by different methods and combinations of various procedures, multiple codes describing similar services are frequently necessary to accurately reflect what service a physician performs. While often only one procedure is performed at a patient encounter, multiple procedures are performed at the same session at other times. In the latter case, the preprocedure and post-procedure work does not have to be repeated and, therefore, a comprehensive code, describing the multiple services commonly performed together, can be defined. Third party payers have adopted the CPT coding system for use by providers to communicate payable services. It therefore becomes more important to identify the various potential combinations of services to accurately adjudicate claims. CCI Data Source The National Correct Coding Policy (NCCI) for Medicare Part B carriers is a set of edits that identify CPT and HCPCS coding relationships. This data set is maintained by the Centers for Medicare and Medicaid Services (CMS). It represents the most up-to-date compilation of correct coding edits, mutually exclusive codes and HCPCS Level II codes available. Providers are encouraged to use the CCI edits to ensure full and appropriate compensation. From CMS: "It is important to understand, however, that the NCCI does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination. Should providers determine that claims have been coded incorrectly, they are responsible to contact their Medicare Carrier, Fiscal Intermediary (FI), or Medicare Administrative Contractor (MAC) about potential payment adjustments." ICD-9-CM Data Source The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is based on the official version of the World Health Organization's Ninth Revision, International Classification of Diseases (ICD- 9). ICD-9-CM classifies morbidity and mortality information for statistical purposes, indexing of hospital records by disease and operations, data storage, and retrieval. 10

23 The ICD-9-CM codes and descriptions in this application are based on the official U.S. Department of Health and Human Services ICD-9-CM codes, effective for the current year. The color coding edits, which identify coding and reimbursement issues, are derived from official federal government sources, including the Medicare Outpatient Code Editor as well as the knowledge of Optum's technical experts. ICD-9-CM Vol. 1 contains the Tabular List of codes, including the Supplementary Classification of External Causes of Injury and Poisoning (E codes) and the Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V codes). ICD-9-CM Vol. 2 contains the Index of Diseases. ICD-9- CM Vol. 3 contains codes for operations and procedures. ICD-10 Data Source ICD-10-CM Data Source The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is based on the official version of the World Health Organization's Tenth Revision, International Classification of Diseases and Related Health Problems (ICD-10). ICD-10-CM classifies morbidity and mortality information for basic health statistics, indexing of medical records, medical care review, and ambulatory and other medical care programs. The Draft of ICD-10-CM codes are not currently valid for any purpose or use other than reporting of mortality data for death certificates. The compliance date for implementation of ICD-10-CM is October 1, ICD-10-PCS Data Source The Draft of the International Classification of Disease, Tenth Revision, Procedure Classification System (ICD- 10-PCS) has been developed as a replacement for Volume 3 of the International Classification of Diseases, Ninth Revision (ICD-9-CM). The development of ICD-10-PCS was funded under contract nos , and HHSM C to 3M Health Information Systems. The 2010 Draft of ICD- 10-PCS codes are not currently valid for any purpose or use. The compliance date for implementation of ICD- 10-PCS is October 1, Note: ICD-10 is still in draft mode. The industry is set to begin using ICD-10 in October, Dental Codes Data Source HCPCS Level II D codes are used to report dental procedures. Items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered by Medicare. Additional purchase is required to access the D Codes from the ADA. Dental Codes are copyright by the American Dental Association. CPT Data Source Current Procedural Terminology, Fourth Edition (CPT ) is a listing of procedures and services performed by physicians. This code set is developed, maintained, and copyrighted by the American Medical Association. CMS Fee Schedule Data Source The Medicare Physician Fee Schedule contains information about services covered by the Medicare Physician Fee Schedule (MPFS). For more than 10,000 physician services, the file contains the associated relative value units, a fee schedule status indicator, and various payment policy indicators needed for payment adjustment (i.e., payment of assistant at surgery, team surgery, bilateral surgery, etc.). HCPCS Data Source Healthcare Common Procedure Coding System (HCPCS) Level II National Codes are required for reporting most medical services and supplies provided to Medicare and Medicaid patients and by most private payers. This code set is maintained by the Centers for Medicare and Medicaid Services, or CMS (formerly the Health Care Financing Administration, or HCFA). HCPCS Level I codes are the American Medical Association's CPT codes. ICD-9 to DRG Crosswalk Data Source The diagnosis-related group (DRG) system organizes ICD-9-CM diagnosis and procedure codes into a complex, comprehensive system based on a few simple principles. Information for the ICD-9-CM to DRG crosswalk is taken from the official data published by the Centers for Medicare and Medicaid Services, or CMS in the Federal Register ("Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems; Fiscal Rates, Etc.; Final Rules"). 11

24 Modifier Crosswalk Data Source The modifier crosswalk data is developed and maintained by Optum's technical experts and housed in our Claims Edit System (CES). This knowledge-base of cross-coding data links CPT and HCPCS codes to clinically appropriate CPT and HCPCS modifiers. The APC column displays a green checkmark with a tool-tip "Hospital Outpatient Approved". Surgical Crosscode Data Source The surgical cross-code data is developed and maintained by Optum technical experts and housed in our Claims Edit System (CES). This knowledgebase of cross-coding data links CPT Codes from the Surgery section to clinically appropriate ICD-9-CM Vol. 1, ICD-9-CM Vol. 3, ICD-10-CM, HCPCS, Dental, and CPT Anesthesia codes. Coder's Essential 3-Pack Data Source Disclaimer While DecisionHealth tries to keep the information provided on this site as accurate as possible, we disclaim any implied warranty or representation about its accuracy, completeness, or appropriateness for a particular purpose. Therefore, you assume full responsibility for using the information at this site, and you understand and agree that DecisionHealth is neither responsible nor liable for any claim, loss, or damage resulting from its use. Copyright Copyright 2013 DecisionHealth. All rights reserved. Do not modify, re-publish, re-transmit, duplicate or otherwise distribute directly or via links any Content in any form. Users are granted the right to print out any article on this site for individual, personal use only. This does not convey permission for commercial use or for making multiple copies for distribution (internal or external). Use of this web site signifies agreement with these restrictions. Trademarks The trademarks, service marks and logos of DecisionHealth, its product-specific brands, or others used on this site are the property of DecisionHealth or their respective owners. You may not use any trademark displayed on the site without the written permission of DecisionHealth or the respective owner. ASA Crosswalk Data Source NOTICE: This data comes directly from the ASA. Optum does not perform any review of this content. CROSSWALK 2013 American Society of Anesthesiologists. All Rights Reserved. CROSSWALK is a registered trademark of the American Society of Anesthesiologists. All Rights Reserved. ASA does not directly or indirectly practice medicine or dispense medical services. ASA assumes no liability for data contained or not contained herein. Reverse CROSSWALK is a registered trademark of the American Society of Anesthesiologists. All Rights Reserved. ASA does not directly or indirectly practice medicine or dispense medical services. ASA assumes no liability for data contained or not contained herein. Relative Value Guide 2013 American Society of Anesthesiologists. All Rights Reserved. ASA does not directly or indirectly practice medicine or dispense medical services. ASA assumes no liability for data contained or not contained herein. Relative Value Guide is a registered trademark of the American Society of Anesthesiologists. 12

25 Logging In User Logins To log in to EncoderPro.com, EncoderPro.com for Payers or MedicalCodeExpert.com, the Administrator must first add your User Name and password to the system. Users can add themselves only if they have the correct customer ID and subscription number. The User Name must be at least 6 characters and can be no longer than 40 characters. The names are not case-sensitive. First time users must agree to the License Agreements and the AMA Copyright. Administrator Logins Refer to Administrator for information regarding Administrator logins and privileges. Passwords Passwords must comply with the following minimum security password requirements: To meet minimum strength requirements, 1. Password cannot contain the username 2. Password cannot match any of the previous 10 passwords 3. And your new password must contain: At least 8 characters At least three of the four bullets below: Uppercase character/s Lowercase character/s Numeric character/s (0-9) Non-alphanumeric characters (e.g.,?, %, *, $, etc.) If you forget your password, see your Administrator or click on the Forgot your password link and Optum will your password to you. If you forget your User Name, see your Administrator or contact Customer Support at (800) Passwords must be changed every 90 days. A reminder message will be displayed when the 90th day is closer. A message for you to change your password will display on day 80 and again on day 85. On day 90 you must change your password in order to continue to use the EncoderPro application. Changing User Passwords You can change your User password from the User Profile screen. Click the User Profile Button to access this screen. Your Administrator can reset your password to match your user name in the event you forgot the one you set. This is accomplished via User Administration screen. Every 90 days you are required to change your password. When prompted from the login screen, type your Username, Old Password, New Password, and Confirm New Password in the corresponding fields. User and Administrator Login and Logout When you log in you may close your browser or click onto another site and return to the application without logging in again. Any time you click the Logout button on the Toolbar, you will need to log back in. Changing the Administrator Password The Administrator password can be changed by the Administrator in the User Profile screen. Click the User Profile Button and change the password. The Administrator can reset a user's password in the User Administration screen. 13

26 Administrator The Administrator title designates certain rights that a regular user does not have. The first person from your company to log in using the correct customer ID and subscription number is automatically designated as the Administrator. Only an Administrator can do the following: Upload Users. To upload a user list, the file must be in text format and contain valid and unique addresses. Each address cannot exceed 100 characters or exceed the number of available subscriptions. Any file that does not meet these requirements, will not be imported and you will receive an applicable error message. Click the User Administration Button from the Toolbar. Click Upload users from the Users screen to go to User Upload screen. Click the Browse button to locate your file and click Save. You will receive a message if your upload was successful. The new users will automatically be given a subscription to the application you use to perform the upload. Go to the Users screen to edit your new users. The address will be the "Username" and "Password" will be the initial password. An will be sent to the new users with a link to the application and login instructions. Add Global User Notes to the system. Select the Global Note for Entire Company checkbox in the Add User Note screen to make a User Note viewable by all users in the company. Change the Administrator Password. Each Administrator sets their own password when they first log in. An Administrator can change their password by clicking the User Administration Button on the Toolbar. Click the Edit icon to the right of the administrator's name and make the change in the User Profile tab. Reset another user's password. An Administrator can change any user s password by clicking the User Administration Button on the Toolbar. Click the Edit icon to the right of the affected user's name to make the change. Change any user s Medicare Carrier/Locality. Click the User Administration Button on the Toolbar, then click the Edit icon to the right of the affected user's name. From the User Preferences tab, click the Edit icon to the right of the preference and make the desired changes. Change any User's List Max Page Items. Click the User Administration Button on the Toolbar, then click the Edit icon to the right of the affected user's name. From the User Preferences tab, click the Edit icon to the right of the preference and make the desired changes to expand or limit the number of items on a page. Define any User's Code Sets. Click the User Administration Button on the Toolbar, then click the Edit icon to the right of the affected user's name. From the User Preferences tab, click the Edit icon to the right of the preference and make the desired changes. Change any User s default search criteria. Click the User Administration Button on the Toolbar, then click the Edit icon to the right of the affected user's name. From the User Preferences tab, click the Edit icon to the right of the preference and make the desired changes. Change any User's Code View option. Click the User Administration Button on the Toolbar, then click the Edit icon to the right of the affected user's name. From the User Preferences tab, click the Edit icon to the right of the preference and make the desired changes. Maintain subscription information. Click the User Administration Button on the Toolbar, then click the Edit icon to the right of the affected user's name. From the User Subscriptions tab, click Add to add any product for which your company is licensed to the user. Add users to the system. An Administrator can add users to the system. Click the User Administration Button on the Toolbar. Click the Add button and fill in the fields for the new user. View the Last Login for the users. An Administrator can specify a date range to determine who was logged in to EncoderPro.com from their organization. Click the User Administration Button on the Toolbar. Enter your date range in the Login Time Filter and click Filter. Change a user s status. An Administrator can add a new user to the program and set the user s status by selecting either Active or Inactive in the drop-down list in the User Profile tab. An Administrator can change a status to inactive if at any time the user should not have access to any product. However, if a user is logged on, the Inactive status will not take effect until the next time the user attempts to login. Activating your additional subscriptions is easy! If you have purchased more than one online product and need to give yourself or one of your end-users access, please follow this link for detailed instructions. Add a User Subscription 1. Click the Add button on the User Subscriptions tab. 14

27 2. In the Subscription field, select the subscription to grant to the user. The list contains the number of purchased subscriptions still available including new subscriptions. 3. In the Type field, set the user as either a regular user or an administrator. 4. In the Status: field, set the user s status to Active. Note: Setting the User s status to Inactive disables their login. 5. Click Save. 15

28 Edit User Subscription, Manage Add-on Modules 1. If you want to edit a subscription or give the user Add-on modules for the product, click the Edit icon next to the subscription for the user on the User Subscriptions tab. 2. Select any of the available Add-on Modules to give to the user: Note: If you need to give an Add-on Module to a new user and you do not have any available, you can remove it from one user and give it to the new user. 3. In the Type field, set the user as either a Regular User or an Administrator. 4. In the Status: field, set the user s status to Active. Note: Setting the user s status to Inactive disables their login. 5. Click Save. You must log out for your subscription changes to be completed. When you log in again, your subscription changes are displayed. 16

29 User Administration The Users screen appears when the Administrator clicks the User Administration Button on the Toolbar. All data fields can be sorted. The highlighted arrows at the top of each column show the column that was used in the sort and the type of sort, ascending or descending. Move your pointer over the arrows to display the type of sort that is available if you click the arrows. User Upload: Click the Upload users link from the Users screen to upload users quickly from a list of user's addresses. The file must be in text format and contain valid and unique addresses. Each address cannot exceed 100 characters or exceed the number of available subscriptions. Any file that does not meet these requirements will not be imported and you will receive an applicable error message. Click the Browse button to locate your file and click Save. You will receive a message if your upload was successful. The new users will automatically be given a subscription to the application that was used to upload the users. When the upload process is complete, an will be sent to the new users with a link to the application and login instructions. Go to the Users screen to edit the new usernames and passwords as necessary. Initially, the default username will be the user's address and the default password will be "pa$$word" (without the quotes). Note: The Date Created column will contain the date when the new user was created. For previous users, this field will be blank. Reset All use passwords for this ADMIN If you are an admin user, you can reset the passwords for ALL users at the same time. Please be aware that this will change the password for ALL the users on your account. You should use caution when using this feature. A message will be displayed when you click this link. "Please be aware that you are access the ability to change passwords for all users. All users currently under this Admin control will need to be informed of the new password in order to maintain access. Continue?" Click OK to reset the passwords, or click Cancel to go back without making any changes. Application Filter: The Administrator can change the product to view the users that can access each product. Name Filter: The administrator can enter a user's name and click Filter to display a single user. This search field is not case sensitive. To bring back the full list of users, remove the entry in the search field and click Filter again. Users The Users screen displays all users for your company. It displays the User Number, Subscription Number, Name, Login Name, Date Created and the Last Login. It allows the Administrator to edit or delete a user. Click the arrows to sort the columns ascending or descending. Stop your pointer over the arrows to see a tool tip that shows which sort is available. Click the Upload users link go to the User Upload screen. The add subscription link and the Add-on module link goes to instructions for activating additional subscriptions and Add-on modules. Edit Click the pencil icon to the right of the User Name to edit the User. 17

30 This screen has three tabs. Delete User Profile tab On the User Profile tab, you can edit the Name or User Name, reset the password, change the address and status of any user. User Preferences tab List Preferences screen is displayed with a list of preferences on the User Preferences tab. You can create lists with unique preferences that apply when you click on a preference in this list. When you first access this tab, the Select a Preference Set will be empty. Click Add to create your preferences. Add Preferences - Click Add on the User Preferences tab. In the Set Name field, enter a name for your preference. Select the CCI Version. List Max Page Items (default is 50 items) - The number of lines displayed on a page is regulated by the number entered in the List Max Page Items field. If the number of items is increased or decreased, the number of pages increases or decreases also. Select the Medicare Physician Fee Schedule - Locality. (EncoderPro.com Expert, Professional and EncoderPro.com for Payers only) View search results according to either weighted ranking or Alphabetical listing. Code View of the Range Page or Detail Page. Define All Code Sets (EncoderPro.com Suite and for Payers only) Edit Preferences - Click the pencil icon in the Edit column. Edit Preferences screen appears with the same fields that are displayed in the Add Preferences screen. Make any changes and click Save. Delete - Click the icon in the Delete column to delete the preference. User Subscriptions tab Add User Subscription - Click Add on the User Subscription tab. Subscription has a drop-down list that displays products that are licensed to the User. Select the type of user in the Type field. Assign the Status. Active gives access to the product. Inactive cancels access to the product. Edit User Subscription - Click the pencil icon in the Edit column for the product. The Administrator can add one, two or three available Add-on modules for the user. The Administrator can change the Type or Status for the user. Delete - Click the icon in the Delete column to disable the user's access to the product. Select the Delete icon on the Users screen to delete the user. Activating your additional subscriptions is easy! If you have purchased more than one online product and need to give yourself or one of your end-users access, please follow these detailed instructions. Add a User Subscription Click the User Profile Button on the Toolbar to open User Subscriptions. The User Subscriptions tab displays a list of the products that are licensed to the User. The Assigned Add-ons column displays which modules have been assigned to the user. The Available Add-ons column displays which modules are available to assign to the user. The Administrator can add additional subscriptions for users by 18

31 clicking Add. The Administrator can edit or change the subscription status by clicking on the pencil icon in the Edit column. Edit User Subscription, Manage Add-on Modules 1. If you want to edit a subscription or give the user an Add-on module, click the Edit icon next to the subscription for the user on the User Subscriptions tab. 2. Select one, two or all three of the available Add-on modules to give to the user: Note: If you need to give an Add-on Module to a new user and you do not have any available, you can remove it from one user and give it to the new user. 3. In the Type field, set the user as either a regular user or an administrator. 4. In the Status: field, set the user s status to Active. Note: Setting the user s status to Inactive disables their login. 5. Click Save. You must log out for your subscription changes to be completed. When you log in again, your subscription changes are displayed. 19

32 Edit All Users Password The Administrator can change the passwords for ALL users in the account with one click of the mouse if needed. Please be cautious when using this feature. Access this screen by clicking the 'Reset All user passwords for this ADMIN' link on the User Administration page. This screen example will be similar depending on your application subscription. Customer Id: This field is for display only. It shows your current customer identification number New 'All User' Password: Type a new password for your account. Verify 'All User' Password: Type the new password again to verify it. Save: Click the Save button the make the password changes. Cancel: Click the Cancel button to go back without making any changes. Once again, please be cautious when using this feature as it will reset all the user password for your account. You must log out for your subscription changes to be completed. When you log in again, your subscription changes are displayed. 20

33 Add User After purchasing the application, the Add User screen is displayed for you to add an Administrator. An Administrator can add users to the system. Click the User Administration Button on the Toolbar, click the Add button and fill in the fields for the new user. Activating your additional subscriptions is easy! If you have purchased more than one online product and need to give yourself or one of your end-users access, please follow the detailed instructions provided below. Add a User Subscription 1. Click the Add button on the User Subscriptions tab. The Add User Subscription screen appears. 2. In the Subscription field, select the subscription to grant to the user. The list contains the number of purchased subscriptions still available including the new subscriptions. 3. In the Type field, set the user as either a regular user or an administrator. 21

34 4. In the Status: field, set the user s status to Active. Note: Setting the User s status to Inactive disables their login. 5. Click the Save button. Edit User Subscription, Manage Add-on Modules 1. If you want to edit a subscription or give the user Add-on modules for the product, click the Edit icon next to the subscription for the user on the User Subscriptions tab. 2. Select one, two or all three of the available Add-on Modules to give to the user. Note: If you need to give an Add-on Module to a new user and you do not have any available, you can remove it from one user and give it to the new user. 3. In the Type field, set the user's access to a Regular User or an Administrator User. 4. In the Status: field, set the user s status to Active. Note: Setting the user s status to Inactive disables their login. 5. Click Save. You must log out for your subscription changes to be completed. When you log in again, your subscription changes are displayed. 22

35 Setting up a New User As an Administrator, you have the ability to set up new users in the program. After you have successfully logged on for the first time, follow the steps below to add a new user: 1. On the Toolbar, click the User Administration Button. The Users screen appears. 2. Click the Add button on the top right of the screen. The Add User screen appears. Type in: a. The new User s full name in the Name: field b. The new User s Username in the Username: field Note: You can create a naming convention for your organization s Usernames. c. The new User s password in the Password: field d. The new User s password again in the Verify Password: field e. The new User s address in the field 3. Use the drop-down list in the Status: field to set the new User s status to Active. 4. If you have a subscription available for Encoder Pro Expert, mark the checkbox that reads, "Give this user a subscription to selected application." If you do not have one available, leave the checkbox blank. 5. Click Save. At this point, you may instruct the new User on how to log in, or you may define the User s Preferences and/or Subscriptions. Activating your additional subscriptions is easy! If you have purchased more than one online product and need to give yourself or one of your end-users access, please follow the detailed instructions provided below. Add a User Subscription Click the User Profile Button on the Toolbar to open the User Subscriptions screen. The User Subscriptions tab displays a list of the products that are licensed to the User. The Assigned Add-ons column displays which Add-on modules have been assigned to the user. The Available Add-ons column indicates which Add-on modules are available. The Administrator can add additional subscriptions for users by clicking Add. The Administrator can edit, change the subscription status or assign Add-on modules by clicking the pencil icon in the Edit column for the product. You must log out for your subscription changes to be completed. When you log in again, your subscription changes are displayed. 23

36 Users The administrator can access the Users screen displaying all users for the organization. It displays the User Number, Subscription Number, Name, Login Name, Date Created, and the Last Login. The Administrator can edit the user's information or delete a user. Click the arrows to sort the columns ascending or descending. Hover your mouse over the arrows to see a tool tip that shows which sort is available. Click the User Administration Application Filter 24 icon from the Toolbar. The Administrator can change the product to view the users that can access each product. Name Filter The administrator can enter a user's name and click Filter. This search field is not case sensitive. To bring back the full list of users, remove the entry in the search field and click Filter again. Users The Users screen displays all users for your organization. It displays the User Number, Subscription Number, Name, Login Name and the Last Login. The administrator can edit the user's information or delete a user. Click the arrows to sort the columns ascending or descending. Stop your pointer over the arrows to see a tool tip that shows which sort is available. Upload users Click the Upload users link from the Users screen to upload users quickly from a list of user's addresses. The file must be in text format and contain valid and unique addresses. Each address cannot exceed 100 characters or exceed the number of available subscriptions. Any file that does not meet these requirements will not be imported and you will receive an applicable error message. Click the Browse button to locate your file and click Save. You will receive a message if your upload was successful. The new users will automatically be given a subscription to the application that was used to upload the users. When the upload process is complete, an will be sent to the new users with a link to the application and login instructions. Go to the Users screen to edit the new usernames and passwords as necessary. Initially, the default username will be the user's address and the default password will be "pa$$word" (without the quotes). Note: The Date Created column will contain the date when the new user was created. For previous users, this field will be blank.

37 View User Click the link for the user in the Name field to display the user's information. Edit Click the pencil icon to the right of the user's Name on the User's screen to edit the user's information or subscriptions. This screen has three sections. User Profile You can edit the Name of the user, Username, reset the password, change the address and status of the user. User Preferences You can create multiple unique preferences and save them to this list. You can quickly apply one of the preferences by selecting it from the Select a Preference Set field. The Edit and Delete icons are available for User Preferences. The Edit and Delete icons are not displayed for Hospital Preferences unless you are an Administrator. User Subscriptions Add Click Add in the User Subscriptions section. Add User Subscription has a drop-down list that displays products that are licensed to the User. Select the type of user in the Type field. Assign the Status. Active gives access to the product. Inactive cancels access to the product. Click the pencil icon in the Edit column for the product. The Administrator can add one, two or three available Add-on modules for the user. The Administrator can change the Type or Status for the user. Delete - Click the icon in the Delete column to disable the user's access to the product. Click the Add button on the User's screen to access the Add User screen. Type the user's Name, Username, Password, the address and select the user's Status. Delete Select the icon in the Delete column to delete the user. 25

38 Changing the Administrator Password The Administrator password can be changed by the Administrator in the User Profile screen. Click the User Profile Button and change the password. The Administrator can reset a user's password in the User Administration screen. Add a User Subscription It is very important for the Administrator to manage additional subscriptions and Add-ons within the current subscription for the best use of the application. You can access the User Subscriptions tab with the following: 1. Click the User Administration Button on the Toolbar and click the icon in the Edit column for the user. Select the User Subscriptions tab. 2. Or, click the User Profile Button on the Toolbar and select the User Subscriptions tab. Note: The User Subscriptions tab is displayed for administrators, only. The User Subscriptions tab displays a list of the products that are licensed to the user. The Assigned Addons column displays which Add-on modules have been assigned to the user. The Available Add-ons column displays which Add-on modules are available. The Administrator can add additional subscriptions for the users by clicking the Add button. The Administrator can edit, change the subscription status or assign Add-on modules by clicking the pencil icon in the Edit column for the product. Add User Subscription 1. Click the Add button on the User Subscriptions tab. 2. In the Subscription field, select the subscription to grant to the user. The list contains the number of purchased subscriptions still available including the new subscriptions. 3. In the Type field, set the user as either a Regular User or an Administrator User. 4. In the Status: field, set the user s status to Active. Note: Setting the User s status to Inactive disables their login. 5. Click Save. 26

39 Edit User Subscription, Manage Add-on Modules 1. If you want to edit a subscription or give the user Add-on modules for the product, click the Edit icon next to the subscription for the user on the User Subscriptions tab. 2. Select any of the available Add-on modules to give to the user. Note: If you need to give an Add-on module to a new user and you do not have any available, you can remove it from one user and give it to the new user. 3. In the Type field, set the user's access to a Regular User or an Administrator User. 4. In the Status: field, set the user s status to Active. Note: Setting the user s status to Inactive disables their login. 5. Click Save. You must log out for your subscription changes to be completed. When you log in again, your subscription changes are displayed. 27

40 Managing Additional Subscriptions It is very important for the Administrator to manage additional subscriptions within the current subscription for the best use of the coding website. When you purchase additional subscriptions, assign access to your users through User Administration. As an Administrator, you can add or delete subscriptions for any User from the User Subscriptions screen. To see how much time is left on your application subscription click the Subscription Renewal link on the Home Page. To access and make changes to this screen: 1. Click the User Administration Button on the Toolbar. 2. Click the Edit icon next to the User whose subscriptions you want to view or edit. 3. From the Edit User screen, click the User Subscriptions tab. 4. If you want to add a subscription, click the Add button in the top right of the screen. The Add User Subscription screen appears. 5. Using the drop-down list in the Subscription field, select the subscription to grant the User. Notice that the list contains the number of purchased subscriptions still available to you including new subscriptions. 6. In the Type: field, set the User as either a regular user or an Administrator. 7. In the Status: field, set the User s status to Active. Note: Setting the User s status to Inactive disables their login. 8. Click Save. 28

41 Edit User Subscription, Manage Add-on Modules 1. If you want to edit a subscription or give the user an Add-on module, click the Edit icon next to the subscription for the user on the User Subscriptions tab. 2. Select any of the available Add-on modules to give to the user. Note: If you need to give an Add-on module to a new user and you do not have any available, you can remove it from one user and give it to the new user. 3. In the Type field, set the user as either a regular user or an administrator. 4. In the Status: field, set the user s status to Active. Note: Setting the user s status to Inactive disables their login. 5. Click Save. NOTE: You must log out for your subscription changes to be completed. When you log in again, your subscription changes are displayed. 29

42 Edit User Subscriptions It is very important for the Administrator to manage additional subscriptions and Add-ons within the current subscription for the best use of the coding website. You can access the User Subscriptions tab by the following: Click the User Administration Button on the Toolbar and click the icon in the Edit column for the user. Select the User Subscriptions tab. Then click the pencil icon in the Edit column for the user's subscriptions. Or, click the User Profile Button on the Toolbar and select the User Subscriptions tab. Then click the pencil icon in the Edit column for the user's subscriptions. Note: The User Subscriptions tab is displayed for administrators, only. The User Subscriptions tab displays a list of the products that are licensed to the user. The Assigned Addons column displays which Add-on modules have been assigned to the user. The Available Add-ons column displays which Add-on modules are available. The Administrator can add additional subscriptions for the users by clicking the Add button. The Administrator can edit, change the subscription status or assign Add-on modules by clicking the pencil icon in the Edit column for the product. 30

43 If you want to edit a subscription or give the user Add-on modules for the product, click the Edit icon next to the subscription for the user on the User Subscriptions tab. 1. Select any of the available Add-on modules to give to the user. Note: If you need to give an Add-on module to a new user and you do not have any available, you can remove it from one user and give it to the new user. 2. In the Type field, set the user's access to a Regular User or an Administrator User. 3. In the Status: field, set the user s status to Active. Note: Setting the user s status to Inactive disables their login. 4. Click Save. You must log out for your subscription changes to be completed. When you log in again, your subscription changes are displayed. NOTE: You must log out for your subscription changes to be completed. When you log in again, your subscription changes are displayed. 31

44 Subscription Renewal Clicking on the Subscription Renewal icon or on the link on the Home Page displays this information screen that shows your subscription information. Hover the mouse over the alarm clock icon to see a quick summary of how may days until expiration. The color of the alarm clock indicates the length of time until expiration. Green indicates more than 30 days, Orange indicates 7-30 days, and Red indicates less than 7 days. The information included on the screen shows your subscription number, the application name, the date of expiration, and the amount of days left in the subscription. If you are an administrative user, you can also see which subscriptions you have, the numbers of users of each and expiration date. Contact information is also shown so you know who to contact for help with the renewal process. 32

45 User Profile Click the User Profile Button on the Toolbar. User Profile tab On the User Profile tab, you can edit your Name, User Name, reset your password, change your address and status. User Subscriptions tab The User Subscriptions tab displays the products that are licensed to the user. Only the Administrator can add or delete subscriptions in this tab. User Preferences User Preferences Click User Preferences tab. View Preferences List Preferences and the User Preferences tab is displayed with your list of preferences. You can create multiple unique preferences and save them to this list. You can quickly apply one of the preferences by selecting it from the Select a Preference Set field. When you access this tab for the first time, the Select a Preference Set contains the default preference. Click Add to create your preferences. Click the link from the list in the Set Name column to view your preference. 33

46 Add Preferences Click Add on the User Preferences tab. Add Preferences is displayed and you can add your unique preferences. Set Name You can create various preferences that enable quick changes. The list is available in the User Preferences screen. Enter a name for this preference in the Set Name field. CCI Version (EncoderPro.com Expert, Professional and Payer only) Select a CCI Version from the drop-down list. The default is the most current version. List Max Page Items This preference sets the number of items you will see on each page. For example, in the CPT Unbundles screen, when you use the default for List Max Page Items, you are presented with the first 50 items that apply. You access the next 50 by clicking the next page navigation tools in the top right of the screen: If you would rather have all codes that apply displayed on one screen, bump up your List Max Page Items to a higher number (max is 5,000 items). You will use the scroll bar to see all pertinent codes. Medicare Physician Fee Schedule - /Locality (EncoderPro.com Expert, Professional and Payer only) Set your Medicare Physician Fee Schedule. View search results according to (EncoderPro.com Suite and Payer only) 34

47 Use the drop-down arrow in the box to select the Weighted ranking option and the search results will return codes according to a frequency weight applied to the codes. Or choose Alphanumeric option to receive the results in that form. Code View This option displays the Range Page (Code Sections) or the Detail Page (Code Detail) after a search. Define All Codes Sets From here you determine the default code sets you want to search when you use the Search Box. The default is to search all code sets (CPT, HCPCS, ICD-9-CM Vol. 1, ICD-9-CM Vol.3, and ICD-10-CM) for the term you typed in the Search Box. If you want to search CPT and HCPCS codes only, for example, uncheck the ICD-9-CM Vol. 1 and the ICD-9-CM Vol. 3 checkboxes. If you have purchased add-on modules, the corresponding codes will be listed within the Code Sets drop down box, for example Dental Codes. Show Fee Data: (EncoderPro.com Expert and Professional only) If you have purchased the Fee Analyzer add-on, you can select the check boxes corresponding to the desired percentile and variance to be dispayed within the Fee Analyzer data. You can choose from the 25th up to the 95th. LCD Part B - Medicare Carrier/MAC (EncoderPro.com Expert with Patient Encounter Plus only) Select your Medicare Carrier/MAC. Coding Answer User Name (EncoderPro.com Expert only) If you have a subscription to Coding Answers (available through Compliance Edit) and the field is populated, you will have a seamless login into Coding Answers. Coding Answer User Password (EncoderPro.com Expert only) Cost To Charge Ratio (Payer only) Enter the Cost to Charge Ratio. The cost to charge ratio (CCR) is a hospital-specific ratio that is derived from hospital cost report data compiled by Centers for Medicare and Medicaid Services (CMS). The CCR is used in calculating the reimbursement rate for pass-through device items (with an OPSI code of H). Wage Index (Payer only) Edit Preferences Select your Wage Index hospital. Code View Select the option from the drop down list to choose which screen is displayed by default when you click on an underline linked code. The choices are: Range Page (Code Sections) or the Detail Page (Code Detail). Click the pencil icon in the Edit column on the User Preferences tab. Edit Preferences appears with the same fields that are displayed in Add Preferences, above. Delete Click the icon in the Delete column on the User Preferences tab to delete the preference. The icon will be available only for the preferences that can be deleted. 35

48 Data Versions Select your CCI data version preference in the Edit Preferences dialog box. 1. Click the User Profile Button. 2. Click the User Preferences tab. 3. Click the pencil icon in the Edit column on the row for your Set Name. 4. Use the arrow-down box in the CCI Version field to select one of the last four CCI data versions. The default is the most current version. Medicare Carrier/Locality To select the Medicare Carrier/Locality when viewing area-specific information such as calculating fees from the Medicare Physician Fee Schedule: 1. Click the User Profile button on the Toolbar. The Edit User screen appears. 2. Click the User Preferences tab. 3. Click the icon in the Edit column for the preference you want to change. 4. Using the drop-down list, select a Medicare Physician Fee Schedule - Locality. This determines the medical necessity edits that are available for CPT codes in your area. The data provided in this screen is from the Local Coverage Determination (LCD) and vary by carrier. 36

49 Buttons and Icons Toolbar EncoderPro.com Expert EncoderPro.com Professional, EncoderPro.com, and MedicareReimbursmentPro.com The toolbar contains several features to help you quickly access information. Use the code search drop-down list to search for all codes or a specific code set (CPT, HCPCS, ICD-9-CM Vol.1, ICD-9-CM Vol.3, or ICD-10-CM). Enter your search terms in the Search Box. You can type a valid code number that bypasses the search and goes directly to the Code Section or Code Detail (set in User Preferences ). You can type multiple code numbers separated by commas in the Search Box to go to the User Defined Code List. Click Search to initiate the search or press the Enter key. For help or questions about how to use the search, click the link "Help with Search?". The drop-down menus on the toolbar provide quick access to Coding (Current Procedural Coding Expert, HCPCS, ICD-9-CM Dx, ICD-9-CM Index, ICD-9-CM Px, ICD-10-CM, menus and submenus to navigate through the code books. Your toolbar may appear slightly different depending on the Add-on modules you have purchased. EncoderPro.com for Payers Professional The toolbar contains several features to help you quickly access information. Use the code search drop-down list to search for all codes or a specific code set (CPT, HCPCS, ICD-9-CM Vol.1, ICD-9-CM Vol.3, or ICD-10-CM). Enter your search terms in the Search Box. You can type a valid code number that bypasses the search and goes directly to the Code Section or Code Detail (set in User Preferences ). You can type multiple code numbers separated by commas in the Search Box to go to the User Defined Code List. Click Search to initiate the search or press the Enter key. For help or questions about how to use the search, click the link "Help with Search?". The drop-down menus on the toolbar provide quick access to Coding Tools, Coding Guidelines, Compliance Tools, Reimbursement Tools, Billing Tools and submenus. Your toolbar may appear slightly different depending on the Add-on modules you have purchased. MedicalCodeExpert.com The toolbar contains several features to help you quickly access information. Enter your search terms in the Search Box. You can type a valid code number that bypasses the search and goes directly to the Code Section or Code Detail (set in User Preferences). Click Search to initiate the search or press the Enter key. For help or questions about how to use the search, click the link "Help with Search?". 37

50 The drop-down menus on the toolbar provide quick access to Current Procedural Coding Expert, HCPCS, ICD- 9-CM Dx, ICD-9-CM Index, ICD-9-CM Px, and ICD-10-CM menus and submenus to navigate through the code books. The menu options displayed will be different depending upon the versions to which you subscribe. Some examples of options are: ICD-9-CM for the physician and hospital application, or HCPCS for the HCPCS application, Current Procedural Coding Expert for the procedure code application. Add-ons are also available with additional purchase. If you have subscriptions to other applications, additional buttons are available to toggle back and forth between the applications without having to log off and log back in again. Button Application This button will take you to ASCExpert.com This button will take you to ChargemasterExpert.com This button will take you to EncoderPro.com This button will take you to EncoderPro.com for Payers This button will take you to RevenueCyclePro.com This button will take you to MedicalReferenceEngine.com The Add-ons menu displays on the Toolbar when any Add-on Subscriptions and Add-on Modules are available. These options require an additional purchase. Click AHA Coding Clinic I-9 to search the unique list of articles. Click AHA Coding Clinic HCPCS to search the unique list of articles. Click Claims Batch Editor to access the module for claims processing edit messages. Click Coder's Essential 3-Pack to access Decision Health reference information. Click CPT Assistant to search the unique list of articles. Click CPT Changes: An Insider's View for search for annual CPT code changes. Click Dental Codes to access the list of Dental Codes (HCPCS D-codes) for billing purposes. Click I-10 Map Manager to access the mapping tool for ICD-9 to ICD-10 codes. Click Patient Encounter Plus to access the encounter form/charge slip module. Click Stedman's Dictionary to find medical terms and definitions. Click Optum Coders' Dictionary to find terms, definitions and codes in the Coders' Dictionary. The codes are displayed as links. Click a code to go to the appropriate code section. 38

51 Buttons and Icons Icons: Icons for the Color Codes and edits are displayed in the Code Section and the Code Detail. The icons appear when they are applicable to the code and the product. Legend Descriptions (click): 3rd Character Required -, Codes Sets: ICD-9-CM, ICD-10-CM This icon indicates that the code requires a third character. 4th Character Required -, Codes Sets: ICD-9-CM, ICD-10-CM This icon indicates that the code requires a fourth character. 5th Character Required -, Codes Sets: ICD-9-CM, ICD-10-CM This icon indicates that the code requires a fifth character. 6th Character Required - Codes Sets: ICD-10-CM This icon indicates that the code requires a sixth character. 7th Character Required - Codes Sets: ICD-10-CM This icon indicates that the code requires a seventh character. x7th Character Required - Codes Sets: ICD-10-CM This icon indicates that the code requires a seventh character after placeholder(s) characters 'X'. Add-on Code - Codes Sets: CPT This icon identifies procedures reported in addition to the primary procedure and is neither a stand-alone code nor subject to multiple procedure rules since it describes work in addition to the primary procedure. Adult Diagnosis -, Codes Sets: ICD-9-CM, ICD-10-CM This icon represents diagnoses for the patients between the age of 15 and 124 years. Adjunct Code - This icon identifies codes that are not to be reported alone. Adjunct codes are assigned only in addition to a primary procedure. They are not procedure codes and their purpose is to provide supplemental information about the primary procedure performed. Age Restrictions - Codes Sets: CPT This icon denotes codes intended for use with a specific age group, such as neonate, newborn, pediatric and adult. Carefully review the code description to assure the code you report most appropriately reflects the patient's age. ASC Payment Indicators - Codes Sets: CPT, HCPCS CPT and HCPCS codes have associated ASC Payment Indicators used to determine the payment amount for covered services. 39

52 Bilateral Procedure - Codes Sets: ICD-9-CM (Vol. 3) Due to the lack of laterality in ICD-9-CM, there are certain lower extremity joint procedure codes that do not accurately reflect procedures that are performed in one admission on two or more different bilateral joints. To group to DRG 471, Bilateral or Multiple Joint Procedures of Lower Extremity, a case must be coded with a combination of two or more different major lower extremity joint procedures. The bilateral procedure icon identifies those procedure codes that when coded twice represent the same procedure performed on both of the same bilateral joints of the lower extremity. Otherwise, a code edit will instruct the fiscal intermediary to verify that the two different procedures were performed on two different bilateral joints. Bilateral Surgery Allowed - Codes Sets: CPT This icon identifies codes that can be reported bilaterally when the same surgeon provides the service for the same patient on the same date. Medicare allows payment for both procedures at 150 percent of the usual amount for one procedure. The modifier does not apply to bilateral procedures inclusive to one code. CCI Comprehensive Code - Codes Sets: CPT This icon identifies the greater procedure code and the component code could be considered an edit. It allows you to see the complete CCI relationships, regardless of the selected code. Comorbidity or Complication (IP) -, Codes Sets: ICD-9-CM, ICD-10-CM This icon indicates an in-patient diagnosis for complication or comorbidity that may change DRG assignment. A complication is defined as a condition that arises during the hospital stay that extends the length of stay by at least one day in 75 percent of the cases. A comorbidity is a pre-existing condition that will, because of its presence with a specific principal diagnosis that extends the length of stay by at lease one day in 75 percent of the cases. Complex Dx (IP) -, Codes Sets: ICD-9-CM, ICD-10-CM This icon represents an in-patient diagnosis that causes the DRG assignment to change from DRG 125 to DRG 124. Contractor Discretion - Codes Sets: HCPCS This icon identifies services that are covered or not covered by the Medicare contractor. It is for issues that are left to "contractor discretion" - contact the contractor for specific coverage information on those codes. Clinical Note: "The'' '2010 Alpha-Numeric HCPCS File' (ANWEB) file compiled by CMS shows HCPCS code A4245 with a coverage indicator of 'C' signifying this code is paid at the carrier s judgment (discretion). This code is also classified with a primary type of service indicator of L = ESRD supply. Therefore, the OPPS indicator is E and MPFS has a status of X as the ESRD payment system is a separate payment system outside of OPPS and MPFS. The ANWEB file, specific to the HCPCS codes indicates that this is carrier specific. The ANWEB file is considered the primary source for HCPCS codes, and inclusion in the MPFS is secondary, but may not be as current as the ANWEB. So, although this may not be consistent with the MPFS, it is correct. " DMEPOS Paid - This icon identifies durable medical items paid under the CMS DMEPOS fee schedule. Female Procedure/Female Diagnosis -, Codes Sets: CPT, ICD-9-CM, ICD-10-CM This icon identifies procedures that should only be reported for female patients. HIV Related Dx (IP) -, Codes Sets: ICD-9-CM, ICD-10-CM This icon indicates an in-patient diagnosis that the condition is considered a major HIV related diagnosis. When the condition is coded in combination with a diagnosis of human immunodeficiency virus (HIV), code 042, the case will move from DRG 490 to DRG

53 Limited Coverage Procedure - Codes Sets: ICD-9-CM (Vol. 3) This icon represents a procedure whose medical complexity and serious nature incur associated costs that are deemed extraordinary and Medicare limits coverage to a portion of the cost. Major Complication (IP) -, This icon indicates an in-patient major complication or comorbidity condition. Male Procedure/Male Diagnosis -, Codes Sets: CPT, ICD-9-CM, and ICD-10-CM This icon identifies procedures that should only be reported for male patients. Manifestation Code - Not a Primary Diagnosis -, Codes Sets: ICD-9-CM, ICD-10-CM This icon represents codes that describes a manifestation of some other underlying disease and not the disease itself. It cannot be used as a primary diagnosis. Mapping to ICD-9 codes -, Code Sets: ICD-9-CM, ICD-10-CM Mapping from ICD-10-CM codes to related ICD-9-CM codes. Mapping to ICD-10 codes - Code Sets: ICD-9-CM, ICD-10-CM Mapping from ICD-9-CM codes to related ICD-10-CM codes. Maternity/Maternity Diagnosis -, Codes Sets: CPT, ICD-9-CM, and ICD-10-CM This icon identifies procedures and diagnoses that should only be used for maternity patients generally between 12 and 55 years of age. Medicare Secondary Payer Primary Diagnosis -, Codes Sets: ICD-9-CM, ICD-10-CM This icon indicates that specific trauma diagnoses are identified to alert fiscal intermediaries (FIs) that another carrier should be billed first and Medicare billed second if payment from the first payer does not equal or exceed the amount Medicare would pay. Newborn Diagnosis -, Codes Sets: ICD-9-CM, ICD-10-CM This icon represents diagnoses that are intended for newborns and neonates. The patient's age must be 0 years. New Code -, Codes Sets: CPT, HCPCS, ICD-9-CM, and ICD-10-CM This icon indicates new codes. Non-OR Procedure affecting DRGs - Codes Sets: ICD-9-CM (Vol. 3) This icon represents a non-operating room procedure that affects the DRG code assignment. Nonspecific OR Procedure - Codes Sets: ICD-9-CM (Vol. 3) 41

54 This icon represents a nonspecific operating room procedure and a more precise code should be used. The code is recognized as a nonspecific operating room procedure only if all operating room procedures performed are coded NOS. Medicare code edit (MCE) 10 Nonspecific Principal Diagnosis (IP) -, Code Sets: ICD-9-CM, ICD-10-CM This icon represents a nonspecific principal diagnosis for inpatient services. Medicare code edit (MCE) 7 Not Covered By or Valid For Medicare - Code Sets: HCPCS This icon identifies codes that are not covered by or invalid for Medicare. OPSI Code Outpatient Payment Status Indicator (OPSI) for each CPT Code or HCPCS Code describes how a service will be reimbursed under the Medicare outpatient prospective payment system. Other Specified Code (OP) -, Codes Sets: ICD-9-CM, ICD-10-CM This icon indicates the code represents other specified outpatient codes. Medicare code edit (MCE) 7 Pediatric Diagnosis -, Codes Sets: ICD-9-CM, ICD-10-CM This icon represents diagnoses that are intended for newborns and neonates. The patient's age must be between 0 and 17 years. Pub-100 References / Internet Only Manuals - Codes Sets: CPT and HCPCS This icon identifies Internet Only Manuals Pub-100-References (Part A) that are the special coverage instructions from Medicare for CPT and HCPCS codes. Special coverage instructions apply. Special instruction are also typically found in the Medicare Pub 100 reference. Quantity Alert - Code Sets: HCPCS This icon indicates that care should be taken to verify quantities in this code. Many codes in HCPCS report quantities that may not coincide with quantities available in the marketplace. The code should be used to report each item instead of the number of packages containing multiple items. In Optum's publications, this indicates that there is a discrepancy in the usual manufacturers packaging and the HCPCS code. For example a supply may come in a package of 10, but the HCPCS code is each. The provider should be careful to report a quantity of 10 if the full box is dispensed. NOTE: this is NOT related to the MUE values. Clinical note:a quantity alert is notification that the supply of the code from the manufacturer or vendor may not match the HCPCS code description. In the case of J9190, fluorouracil 500 mg there are multiple dosages available. By NDC number one package is 500 mg, the next 1000 mg, another is 2500 mg, and the largest is 5000 mg. If the patient is receiving one of the dosage vials that is more than 500 mg it would be appropriate to report J9190 with a unit value corresponding to the amount of medication given to the patient. The MUE or Medically Unlikey Edits are developed and maintained by the CMS. These edits limit the number of times a procedure code may be reported or the number of units reported on a CMS 1500 or 837P electronic format. Initially the MUE edits were unpublished edits. Currently CMS has released edits of 1-4 units for many, but not all codes. CMS has chosen not to publish edits for some services, even though there are assigned MUE values. As a result there are some codes that CMS will process and edit according to the published MUE and other codes are reviewed according to the unpublished MUE. Questionable Pdx -, This icon identifies codes for a condition that usually is insufficient justification for hospital admission. Reinstated Code - 42

55 Codes Sets: CPT, HCPCS This icon indicates codes that were discontinued by the industry previously and then subsequently brought back into use. Resequenced Code - Codes Sets: CPT This icon indicates codes that have been reassigned to another sequence. Revised Code -, Codes Sets: CPT, HCPCS, ICD-9-CM, and ICD-10-CM This icon indicates codes with revisions; codes with minor terminology changes are not identified. Services Not Covered by Medicare (CPT) - This icon identifies codes for services and procedures that are never a covered benefit under Medicare. Services and procedures that are not covered may be billed directly to the patient at the time of the service. SNF Excluded - Code Sets: HCPCS This icon identifies certain codes that are excluded from the SNF consolidated billing. Unacceptable Principal Dx (IP) -, Code Sets: ICD-9-CM, ICD-10-CM This icon represents codes that do not describe a current illness or injury, but a circumstance which influences a patient's health status. These codes are considered an unacceptable principal diagnosis for an inpatient admission. Medicare code edit (MCE) 9 Unlisted Code - Codes Sets: CPT This icon indicates unlisted CPT codes that have not been assigned a specific code number. An unlisted code delays payment due to the extra time necessary for review. When using an unlisted procedure code, include cover notes, documentation of medical necessity and operative reports. Unspecified Code (OP) -, Codes Sets: ICD-9-CM, ICD-10-CM This icon indicates that the code is an unspecified outpatient code that is considered valid, however, a more specific principal diagnosis should be assigned. These codes are used when neither the diagnostic statement nor the documentation provides enough information to assign a more specific diagnosis code. Medicare code edit (MCE) 7 User Note - Codes Sets: CPT, HCPCS, ICD-9-CM, and ICD-10-CM This icon identifies codes that have an attached User Note. Valid OR Procedure - Codes Sets: ICD-9-CM (Vol. 3) This icon represents a valid operating room procedure that triggers a change in DRG assignment. V Code as Primary Dx (OP) -, Codes Sets: ICD-9-CM, ICD-10-CM This icon indicates that a V Code is used as a primary diagnosis because there is no further documentation to permit more precise coding for an outpatient service. V Code as Secondary Dx (OP) -, Codes Sets: ICD-9-CM, ICD-10-CM This icon indicates that a V Code is used as a secondary diagnosis for an outpatient service. 43

56 Buttons: The following buttons are available in the EncoderPro applications. Add to Notepad Button From the Code Sections, click the Add to Notepad button in the Actions column to open the Edit Notepad screen. Add to User Notes Button From the Code Sections, click the Add to User Notes button in the Actions column to open the Add User Note screen. Annotations Icon Select a code that contains an annotation from the Code Sections. Click the icon to open the annotation for the code. For procedural codes, this icon is also used to indicate that a lay description (common description), and coding tips information are available for the code. APC Status Icon The icon displays the APC Status that is associated with the code. The APC is an Ambulatory Payment Classification system that groups services that have certain characteristics. The APC Status code provides additional information about the code under Medicare. Assistant at Surgery Icons Select a code that has an associated Assistant at Surgery Edit from the Code Sections. An ASA icon is displayed on the row and the edit represents "assistant surgeon allowed." This icon is displayed when the code does not require additional documentation. Select a code that has an associated Assistant at Surgery Edit from the Code Sections. An ASA icon is displayed on the row and the edit represents "assistant surgeon allowed with documentation." This icon is displayed when the code does require additional documentation. ASC Group Icon Select a code that has an associated ASC Group edit from the Code Section or Code Detail. Stop your pointer over the icon to display the ASC payment group number. CCI Unbundle Edits Icon Select a code that has an associated CCI Unbundle Edit from the Code Sections. Click the icon from the References column to access the CCI Unbundle Edits associated with the code. CMS Fee Schedule Icon Select a CPT code that has a Medicare Fee Schedule from the CPT Code Section. Click this icon to access the Medicare Physician Fee Schedule for the code. CPT Lay Descriptions and Coding Tips The lay descriptions are non-clinical descriptions that are available for many CPT surgery and medicine codes. The lightbulb icon is also used for Coding Tips and Annotations. 44

57 Click the Annotations/Lay Descriptions icon to the right of the code in the CPT Code Section. Lay Descriptions and Coding Tips are available middle section under Code Information in the CPT Code Detail. Code History Button The complete history of a code including start date, revisions, etc. is available with this button. Click the Parchment icon in the references column to the right of the code in the CPT Code Section page. A brief overview of the code history is available in the Code History section under Code Information in the CPT Code Detail page. Also click the Parchment icon in the Code Detail page for a complete history of the code. Coder's Essential 3-Pack Icon After selecting a code that contains information for the Coder's Essential 3-Pack, clicking this icon opens the Pink Sheets information available from DecisionHealth for the code on that row. This icon also provides access to Section Notes, Instructions, References, Clinical Examples, Part B News, Answer Books, and Guidelines. Color Coding Legend Button This button appears on the Toolbar when you are in the Code Sections, CPT Code Detail, HCPCS Code Detail, ICD-9-CM Vol. 1 Code Detail, ICD-9-CM Vol. 3 Code Detail and ICD-10-CM Code Details screens. It opens the various color coding icon definitions. Compliance Check Button Click this button to go to the Compliance Edit screen. Conscious Sedation Icon Conscious Sedation Icon is an indicator that applies to codes from the Code Sections. This sedation would not be separately reported when performed at the same session by the same provider. Crosscodes Icon The Crosscodes Icon is displayed in the Code Sections for the codes that have crosscodes. Click this icon to access the crosscodes associated with the code. DRG Crosscodes Icon When you select an ICD-9-CM code in the ICD-9-CM Volume 1 Code Section or ICD-9-CM Volume 3 Code Section and it has a DRG Crosscode, click this icon to access DRG Crosscodes associated with the code. Help Button Click this button to open online help. Home Button Click this button to go to the Home Page. ICD-10 Mapping Icon ICD-10 mapping available 45

58 ICD-10 mapping not available. Select a code that has ICD-10 mapping in the Code Section page. Click the green icon to access the ICD-10 mapping screen for the selected ICD-9 code. If there is a red icon, then the ICD-10 mapping is not yet available for this ICD-9 code. As soon as the information becomes available then the icon will be changed to green and ICD-10 mapping will be available. Images Icon Click the Images icon to access Images. They provide coders with an understanding of medical terminology, anatomy and quick references to help with their coding. LCD Medical Necessity Edits Icon After selecting a code that has a Medical Necessity Edit from the Code Sections, clicking this icon opens the LCD Medical Necessity Edits screen. Logout Button Click this button to log out from the website application. The next time you access our website, you must log in again. However, if you simply want to go to another website without actually logging out, you may do so and when you return to our website you are placed directly into the last page you visited. Modifiers Icon Select a code that has a Modifier from the Code Sections and click this icon to access the Modifiers for the code. Modifier Crosswalk Click the Modifier icon in the Reference column for the code in the Code Detail to go to a list of CPT and HCPCS modifiers and descriptions that are appropriate for the selected code. Modifier -63 Icon Modifier -63 Icon is displayed and applies to the appropriate codes in the Code Sections. NCD Medical Necessity Edits Icon After selecting a code that has a Medical Necessity Edit from the Code Sections, click this icon to access the LCD Medical Necessity Edits screen. Notepad Button Clicking this button opens the Notepad screen. OPSI Status Indicator The icon displays the Outpatient Payment Status Indicator (OPSI) associated with the code. The OPSI indicates how a specific procedure, item, or service will be reimbursed under the Medicare outpatient prospective payment system. The Payment Status Indicators and definitions provided below are from the OPPS final rules published in the Federal Register. Indicator Service Payment Status 46

59 A Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS, for example: Not paid under OPPS. Paid by fiscal intermediaries under a fee schedule or payment system other than OPPS. A Ambulance Services Clinical Diagnostic Laboratory Services A Non-Implantable Prosthetic and Orthotic Devices A EPO for ESRD Patients A Physical, Occupational and Speech Therapy Routine Dialysis Services for ESRD Patients Provided in a Certified Dialysis Unit of a Hospital A Diagnostic Mammography A Screening Mammography B Codes that are not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x, 13x, and 14x). Not paid under OPPS. May be paid by intermediaries when submitted on a different bill type, for example, 75x (CORF), but not paid under OPPS. An alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x, 13x, and 14x) may be available. C Inpatient Procedures Not paid under OPPS. Admit patient. Bill as inpatient D Discontinued Codes Not paid under OPPS. E Items, Codes and Services: Not paid under OPPS. That are not covered by Medicare based on statutory exclusion. That are not covered by Medicare for reasons other than statutory exclusion. That are not recognized by Medicare but for which an alternate code for the same item or service may be available. For which separate payment is not provided by Medicare F Corneal Tissue Acquisition; Certain CRNA services and Hepatitis B Vaccines Not paid under OPPS. Paid at reasonable cost. G Pass-Through Drugs and Biologicals Paid under OPPS; Separate APC payment Includes pass-through amount. H (1) Pass-Through Device Categories (1) Separate cost-based pass-through payment; Not subject to coinsurance. (2) Brachytherapy Sources (2) Separate cost-based non-pass-through payment. 47

60 (3) Radiopharmaceutical Agents (3) Separate cost-based non-pass-through payment. K Non-Pass-Through Drugs and Biologicals Paid under OPPS; Separate APC payment. L Influenza Vaccine; Pneumococcal Pneumonia Vaccine Not paid under OPPS. Paid at reasonable cost; Not subject to deductible or coinsurance. M Items and Services Not Billable to the Fiscal Intermediary Not paid under OPPS N Items and Services Packaged into APC Rates Paid under OPPS; Payment is packaged into payment for other services, including outliers. Therefore, there is no separate APC payment. P Partial Hospitalization Paid under OPPS; Per diem APC payment. Q1 STVX-Packaged Codes Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator S, T,V, or X. (2) In all other circumstances, payment is made through a separate APC payment. Q2 T-Packaged Codes Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator T. (2) In all other circumstances, payment is made through a separate APC payment. Q3 Codes That May Be Paid Through a Composite APC Paid under OPPS; Addendum B displays APC assignments when services are separately payable. Addendum M displays composite APC assignments when codes are paid through a composite APC. (1) Composite APC payment based on OPPS composite-specific payment criteria. Payment is packaged into a single payment for specific combinations of service. (2) In all other circumstances, payment is made through a separate APC payment or packaged into payment for other services. R Blood or blood product Paid under OPPS; Separate APC payment. S Significant Procedure, Not Discounted When Multiple Paid under OPPS; Separate APC payment. T Significant Procedure, Multiple Reduction Applies Paid under OPPS; Separate APC payment. U Brachytherapy Source Paid under OPPS; Separate cost-based payment. V Clinic or Emergency Department Visit Paid under OPPS; Separate APC payment. X Ancillary Services Paid under OPPS; Separate APC payment. Y Non-Implantable Durable Medical Equipment Not paid under OPPS. All institutional providers other than home health agencies bill to DMERC. 48

61 Section Notes Icon After selecting a code that contains a note from the Code Sections, clicking this icon opens the section notes for the code on that row. This icon also provides access to Instruction, References, Pink Sheets, Part B News, Answer Books, and Guidelines. PQRS Icon Select a code that has an associated PQRS Edit from the Code Sections. Click the icon from the References column to access the PQRS Edits associated with the code. Alternately, in Code Section page or in the Code Detail page click the PQRS icon in the Color Codes section. Print Code Detail Summary Report Button From the Code Sections, click the Print Code Detail Summary Report button in the Actions column to open the Print Report screen. Print Button Clicking this button opens the Print dialog box. Pub-100 References Icon Select a code that has Pub-100 References from the Code Sections. Click this icon to access any Pub-100 References associated with the code. Pub-100 is also known as Internet Only Manuals. Resequenced Codes Icon Select a code that has been resequenced from the Code Sections. A green pound sign icon is displayed on the row and the edit represents a "resequenced code." In 2010, The American Medical Association (AMA) employed a new numbering methodology of resequencing. According to the AMA, there are instances where a new code is needed within an existing grouping of codes and an unused code number is not available. In the instance where the existing codes will not be changed or have minimal changes, the AMA will assign a code that is not in numeric sequence with the related codes. The resequenced codes and descriptions are placed with their related codes out of numeric sequence. In the CPT manual, resequenced codes appear in numeric order, referring users to their resequenced location. Revenue Codes Click the Revenue Codes icon from the Code Detail to go to the Revenue Codes, description and notes. User Administration Button Clicking this button opens the Users screen. User Notes Button Clicking this button opens the User Notes screen. User Profile Button Click this button to open your User Profile screen. 49

62 View User Notes Icon From the Code Sections, clicking this icon in the References column displays the User Notes for the code in that row. 50

63 Color Coding Legends CPT Color Coding Legend The CPT Color Coding Legend displays a legend of all CPT Color Codes and definitions. The CPT Color Codes are available from either a Code Section screen or a Code Detail screen. Click the Color Coding Legend Button on the Toolbar. DrugReimbursement.com add-on module: The Color Codes are displayed from the Code Detail. Click the Color Coding Legend Button on the Toolbar to display the applicable Color Codes. HCPCS Color Coding Legend The HCPCS Color Coding Legend displays a legend of all HCPCS Color Codes and definitions. The HCPCS Color Codes are available from either a Code Section screen or a Code Detail screen. DrugReimbursement.com add-on module: The Color Codes are displayed from the Code Detail. Click the Color Coding Legend Button on the Toolbar to display the applicable Color Codes. 51

64 ICD-9-CM Vol. 1 Color Coding Legend The ICD-9-CM Vol. 1 Color Coding Legend displays a legend of all ICD-9-CM Volume 1 Color Codes and definitions. The ICD-9-CM Vol. 1 Color Codes are available from either a Code Section screen or a Code Detail screen. ICD-9 Vol. 3 Color Coding Legend The ICD-9 Vol. 3 Color Coding Legend displays a legend of all ICD-9-CM Volume 3 Color Codes and definitions. The ICD-9-CM Vol. 3 Color Codes are available from either a Code Section screen or a Code Detail screen. 52

65 ICD-10-CM Color Coding Legend The ICD-10-CM Color Coding Legend displays a legend of all ICD-10-CM Color Codes and definitions. The ICD-10-CM Color Codes are available from either a Code Section screen or a Code Detail screen. DrugReimbursement.com add-on module: The Color Codes are displayed from the Code Detail. Click the Color Coding Legend Button on the Toolbar to display the applicable Color Codes. 53

66 Home Page The Home Page is the nerve center of EncoderPro. From here you can access a multitude of information on coding, coverage, Optum news and features, as well as links to external sources such as AAOMS News. The Code Books Section is the home page for the smaller MedicalCodeExpert applications. Click any of the links below for more information: Search Box Click the link "Help with Search?" to see helpful information about how to best utilize EncoderPro's code search capabilities with the Search Box feature. Code Books In the Code Books section, you can find the codes by looking them up in the index. Click the link to access the specific index for the desired code set. There are links for Procedure codes, HCPCS codes, ICD-9 codes, and ICD-10 codes. Coding Guidance In the Coding Guidance section you can browse through color code edits, glossaries and additional guidelines from the paper publications. CCI Quick Check In the CCI Quick Check section you can check the CCI relationships between several codes (up to 50). Coverage Center In the Coverage Center you can click links to go directly to Optum's Archive, APC Expert, Medicare Internet Only Manuals (Pub-100), medical necessity and associated policies and Oncology Drugs. What s New The What s New section lists the new versions of data that have been recently updated, what's new with the codes, code and content revisions, content changes and contains links to download data. EncoderPro.com News The EncoderPro.com News section provides items of interest or bulletins and enhancements for the product. Featured Topic The Featured Topic section is used by Optum to highlight a specific topic to present to our customers. Add to Favorites Click this link to add EncoderPro.com to your list Favorites or Bookmarks section within your internet browser. User's Manual (PDF) Click this link to open the User's Manual in PDF format. The User's Manual is this help file in printed format. AAOMS News Click this link to access the external website for the American Association of Oral and Maxillofacial Surgeons (AAOMS). Use this link to access the latest AAOMS dental news. Subscription Renewal Click this link to see expiration and renewal information for your subscription. Local News The Local News section contains message items from your local administrator. Toolbar and Buttons See Toolbar and Buttons and Icons 54

67 User's Manual This online help file is the best way to obtain information regarding the EncoderPro applications. However, if you would like a printed version of this help file, go to the Home Page and click the Users Manual link found there. The User's Manual is an Adobe Acrobat PDF file. It is a duplicate of this help file. Subscription Renewal Clicking on the Subscription Renewal icon or on the link on the Home Page displays this information screen that shows your subscription information. Hover the mouse over the alarm clock icon to see a quick summary of how may days until expiration. The color of the alarm clock indicates the length of time until expiration. Green indicates more than 30 days, Orange indicates 7-30 days, and Red indicates less than 7 days. The information included on the screen shows your subscription number, the application name, the date of expiration, and the amount of days left in the subscription. If you are an administrative user, you can also see which subscriptions you have, the numbers of users of each and expiration date. Contact information is also shown so you know who to contact for help with the renewal process. Code Books Contents This screen has all of the convenience of looking up codes by section, just as they are arranged in the Contents pages of the code books. To access this screen, select the Contents option from the submenu for the desired code set. A table of contents for the code books is displayed. Links are available for Coding Guidelines, Preface, Introduction, How to Use..., Conventions, Code Ranges, Appendixes, and other resources (depending on code set content). Click the range to go to the first code in that range in the Code Section. There are tabs for each of the major code sets; 'Current Procedural Coding Expert', 'HCPCS', 'ICD-9-CM Vol. 1', 'ICD-9-CM Vol. 3', and 'ICD-10-CM'. Each tab displays the code ranges that are in each section and subsection of the code books. If you have purchased the Dental Codes add-on module, there is an additional tab labeled 'Dental Codes'. In the smaller Medical CodeExpert applications, only the tabs for the specific applicable code books will be displayed. Coding Guidance Click the links in the Coding Guidance section on the Home Page to browse color code edits, glossaries and additional guidelines for our top-selling publications. CCI Quick Check The Correct Coding Initiative (CCI) for Medicare Part B carriers is a set of edits that identify CPT and HCPCS coding relationships. 55

68 Accessing this feature: From the EncoderPro home screen, go through the simple 3 step process to check codes against each other for correctness in billing relationships. If you need to check more than ten codes (up to 50 codes), click the "More" button to go to the CCI results screen for CCI edit checking. There are three steps to follow when running a CCI check: Step 1: Select the options for your desired results. There are two kinds of views: CCI Conflict View - this view displays only the codes that have conflict with one another in billing relationships. CCI Code View - this view displays ALL codes, regardless if there is a conflict or not in billing relationships. You can also customize the results by checking the box to view MPFS and other modifier information. Step 2: Type up to fifteen CPT or HCPCS codes in the fields on the home screen, or if more codes are needed you can click the More button to increase the number of fields. Step 3: Click the Check button. The system will check those codes for the desired coding relationships and display the results on the CCI Results screen. Coverage Center In the Coverage Center section on the Home Page, direct access is provided to Medicare special coverage instructions (Pub-100), Correct Coding Initiative (CCI) policy, medical necessity edits, and associated policies. Links are provided to access APC Expert Content and the Insights Archive. ABN form The Advance Beneficiary Notice (ABN) Form is available from the Coverage Center on the Home Page. It is also available by clicking the Print ABN button in the Compliance Edit screen. The link opens a PDF file that contains the ABN form. 56

69 What's New? The "What's New?" section on the home page provides access to any new information pertinent to the current release. Click the available link on the web page to open another page that further explains the new features and other new information. Local News The "Local News" section on the home page provides access to any local information or messages for your practice local users as provided by your local administrator. The administrator can add and change items in this section. Click the "more..." link to open a page that displays a complete list of the local news information. To Add another item to the list, click the Add button. Give your new item a title in the header field, description in the body, beginning date, and the number of days to display the item. Click the Save button. To Edit an existing news item, click the pencil icon in the Edit column for the item you want to change. Change the title in the header field, description in the body, beginning date, or the number of days to display. Click the Save button To Delete an existing news item, click the delete icon in the Delete column. Confirm your deletion by clicking the OK button. 57

70 Using EncoderPro Applications Performing a Code Search Search Box The Search Box is on the Toolbar and is accessible from most of the screens in your product. It is used to enter search terms to quickly find the code you are looking for. Click the link "Help with Search?"next to the Search button to see this information about how best to utilize the Search Box feature. The system can search for any word in size of 2 characters up to 22 characters in length. To search for terms: 1. Type up to four key words for a term search, or a code number in the search box. 2. Click the Search button or press your Enter key to initiate a search. Note: For Term searches, if you specify a code set from the drop-down list, the program searches the specific code set for codes that relate to the terms entered. If you specify All Code Sets, the program searches all code set databases for a specific match based on the entry. The Code Set drop down is not applicable to numeric searches with specific codes. If the search is too broad and has the potential to have too many results, a message will be displayed. You can narrow your search and limit the results by entering more information within the search box before executing the search process. You can also type in a valid code number to bypass the term search and go directly to the Code Section or Code Detail (set in User Preferences) for that code. The Code Set drop down box is 'ignored' in this situation. You can type multiple code numbers separated by commas in the Search Box to go to the User Defined Code List. If you do not enter anything in the Search box and click Search, or press the Enter key, you will receive a Search Term Error message that indicates that you must enter search information before a search can be initiated. When doing a term search, you can specify a code set from the Code Set drop-down list to search the specific code set for that term. If you specify "All Code Sets", the program searches all code sets (set in User Preferences). The options in this drop down are for term searches. For example, if you type "knee" in the search field and choose "HCPCS" in this drop down, then you will receive all results pertaining to "knee" in the HCPCS code set only. When entering ICD-9-CM or ICD-10-CM codes, it is possible to enter a code that can pertain to both ICD-9 and/or ICD-10 codes. When this is the case, the system will display the code in the User Defined Code List screen as it pertains to the ICD-9 code set and also as it pertains to the ICD-10 code set. These are called overlap codes and mostly occur with the E code series and the V code series. 58

71 Remember, if you type a numeric code in the search field then this drop down is not applicable. The "All Code Sets" option can be modified to include only specific code sets, if desired. See user preferences for more information. Determining Search Criteria When choosing search criteria, it is important to use terms that best identify the service or symptom. Entering the proper terms ensures that searching is quick and accurate. The suggestions below help to determine which terms to enter as search criteria. The system can search for any word in size of 2 characters up to 22 characters in length. You can specify a code set from the drop-down list to search the specific code set. If you specify All Code Sets, the program searches all code set databases. The "All Code Sets" option can be modified to include only specific code sets, if desired. See user preferences for more information. Criteria for procedure codes To determine the criteria for a procedure code search, first ask yourself what was performed, and where (anatomical site) it was performed. Generally, the first two words of your documentation identify what and where; enter these terms as search criteria. For example, the key terms "arthroscopy shoulder" answers both what (arthroscopy) and where (shoulder). Entering these two terms brings up all codes containing arthroscopy and shoulder. To further narrow the search, type one or two more terms that further explain the procedure. For example, entering "arthroscopy shoulder decompression" narrows the results to just one CPT Code, 29826, which contains all three terms. Avoid being too specific or entering too many search terms. In these instances, there may not be results that exactly match your criteria. It is best to choose two to four key search terms. Note: Some single terms explain both what was performed and where. For example, the term colonoscopy explains what was performed (scope) and where (colon). Criteria for diagnosis codes To identify the criteria for an CM code search, ask yourself why the patient received care. From the documentation, pull up to four key terms that best describe the reason. For example, if a shoulder arthroscopy was performed, ask yourself why. Entering "joint tear" returns a large variety of matches in the Tabular Results. To return more specific results, include the specific anatomical region. Entering "joint tear shoulder" returns only the diagnosis codes specific to the shoulder. To identify the criteria for a Vol. 3 code search, ask yourself what kind of procedure was performed (e.g., appendectomy, hysterectomy), and enter this term into the Search Prompt. To further define your search, include the anatomical site where the procedure was performed (e.g., abdominal region, pelvis). 59

72 CPT and HCPCS Search Results The Search Results screen is displayed after you search for a term. The results will contain codes from all applicable code sets, such as CPT, ICD-9, HCPCS, ICD-10, etc. If the search is too broad and has the potential to have too many results, a message will be displayed. You can narrow your search and limit the results by entering more information within the search box before executing the search process. Note: When obtaining search results for CPT codes, please be aware that due to the AMA resequencing guidelines some codes may appear out of numerical order. Spell Checking Search Terms When you enter a search term that is either incorrectly spelled or not found in the code databases, the Alternative Spelling screen appears. Alternative search terms are listed for the search term you originally entered, and are based on the first letter of that term or a phonetic match. This screen will show up to 100 alternative spellings organized in 4 columns. If there are more than 100 alternative spellings, you can click the 'next page' option at the top or bottom of the screen to display then next page of alternatives. To select an alternative search term from the spell check screen: 1. Select the desired search term suggestion by clicking that term s radio button. 2. Click Search, which corrects your search term and closes the Spell Check dialog box. Doing this automatically continues your search based on the alternative term. 3. Click Cancel if you want to cancel out of this dialog box. 60 Note: If you enter more than one search term, click the radio button next to all terms before clicking Search. Clicking IGNORE THIS TERM on any of the misspelled words and then clicking Search ignores that term but continues your search on all remaining words in your original search. Search Results After you initiate a term search, the Search Results screen displays the matches found in all applicable code sets. You can set your desired code sets in the Code Sets Drop-down list on the Toolbar. If there are too many results for the criteria entered a message will be displayed. You can limit the possible results by entering up to 4 terms in the search box. The Search Results screen also includes the subsection range that the code belongs to for all CPT and HCPCS results. Viewing Additional Digit ICD-9-CM and ICD-10-CM Codes The Search Results screen displays the code results. The parent grouping for ICD CM codes is the category code number without a decimal. ICD-CM codes with additional digits are consolidated into a common category. Codes that require additional digits have a plus sign to the left of their folder. Click the plus to expand the category and display subcodes. Click the minus sign to hide subcodes. Note: Only those subcodes that pertain to the search results are listed; not all additional digit codes are listed. Viewing CPT and HCPCS Codes CPT and HCPCS codes are consolidated into subsections identified by the range of codes in that subsection. For example, if CPT code Excision of torus mandibularis is part of your results, it is listed under this

73 subsection range: Musculoskeletal System, Head, Excision. Each subsection range has a plus sign to the left. Click the plus to expand the subsection listing and display codes. Note: Only those codes that pertain to the search results are listed; not all codes in the subsection are listed. When you have narrowed your search results sufficiently, you can click any code in the Search Results list to select it. The full description for the code and all neighboring codes is displayed on the right side of your screen in the CPT Code Detail or the HCPCS Code Detail. Note: When obtaining search results for CPT codes, please be aware that due to the AMA resequencing guidelines some codes may appear out of numerical order. To go to the code in the Code Detail, click any code from the Code Sections. After you initiate a search, the Search Results screen displays the matches found in the applicable code set. The Search Results screen also includes the subsection range that the code belongs to for all CPT and HCPCS results. Viewing Additional Digit ICD-9-CM and ICD-10-CM Codes The Search Results screen displays the code results. The parent grouping for ICD CM codes is the category code number without a decimal. ICD-CM codes with additional digits are consolidated into a common category. Codes that require additional digits have a plus sign to the left of their folder. Click the plus to expand the category and display subcodes. Click the minus sign to hide subcodes. Note: Only those subcodes that pertain to the search results are listed; not all additional digit codes are listed. Viewing CPT and HCPCS Codes CPT and HCPCS codes are consolidated into subsections identified by the range of codes in that subsection. For example, if CPT code Excision of torus mandibularis is part of your results, it is listed under this subsection range: Musculoskeletal System, Head, Excision. Each subsection range has a plus sign to the left. Click the plus to expand the subsection listing and display codes. Note: Only those codes that pertain to the search results are listed; not all codes in the subsection are listed. When you have narrowed your search results sufficiently, you click any code in the Results to select it. The full description for the code and all neighboring codes is displayed on the right side of your screen in the CPT Code Detail or the HCPCS Code Detail. Note: When obtaining search results for CPT codes, please be aware that due to the AMA resequencing guidelines some codes may appear out of numerical order. To go to the code in the Code Detail, click any code from the Code Sections. 61

74 DrugReimbursement Add-on Module ICD-9-CM Search Results The Search Results screen is displayed after you search for a term. To access the Search Results screen, perform a code search or enter search terms. From here, click on a code to go to the ICD-9-CM Volume 1 Code Section or the ICD-9-CM Volume 3 Code Section. ICD-10-CM Search Results To access the Search Results screen, perform a code search or enter search terms. From here, click on a code to go to the ICD-10-CM Code Section. User Defined Code List You can type multiple code numbers separated by commas in the Search Box to go to the User Defined Code List. The codes that you enter and search for are displayed and arranged by code types (ICD-9, ICD-10, CPT, and HCPCS). If you enter a code that is an overlapping code in the ICD-9 or ICD-10 codes sets, this list will distinguish the code as it would pertain to either code set. 62

75 The icon button in the Actions column to add codes to the Compliance Editor is available in EncoderPro.com Expert and EncoderPro.com for Payers. Click the Add Codes to Compliance Editor icon. Tips For Entering Search Terms Choose search terms that uniquely identify the service or supply. Enter as many identifying terms as necessary, up to four word. You can search on just one word, but you may get more specific results when you enter two or three search terms. The search time may also be faster when you enter more than one word (e.g., ARM FRACTURE returns more specific results faster than searching on just ARM or FRACTURE). Avoid entering too many search terms or search terms that are too specific; in these instances there may be no results that exactly match your criteria. Avoid connecting words such as of, and, or, with, not, or punctuation such as commas, periods, dashes, etc. To go directly to a code/description in the Code Detail, enter a code number. If the number does not exist (i.e., has been deleted or is otherwise invalid), the system displays the next valid code for CPT codes, and the next valid category for ICD-9-CM codes. For ICD-9-CM codes, you must enter a decimal for codes with additional digits. If doing a word search, do not enter numbers. For example, type "chest x-ray two views" instead of "chest x-ray 2 views." Unless you are entering a code number, the search does not recognize numbers. 63

76 The Search recognizes several acronyms as search criteria. You can enter these terms just as they appear in your documentation. Encoder Pro automatically locates the correct codes. For example, to locate CPT codes for Computerized Axial Tomography, you can enter the acronym "CAT." To locate codes for arterial blood gases, you can type the acronym "ABG." Code Sets Drop-down List From this drop-down list on the Toolbar, you can narrow your search by selecting a specific code set. If you have purchased additional add-on subscriptions, the corresponding codes sets will be displayed within this list. For example Dental Codes, or Drug Codes. Results Alert This message appears when you enter a search term that has too many possible results. In the example used above, typing in "Blood" yields too many results. You need to narrow your criteria by code set using the Code Sets Drop-down List, or by being more specific. 64

77 Printing Printing The Print button on the Toolbar allows you to print the current page you are viewing. It functions the same as the print feature of your browser. Copying Text to the Clipboard Copying Text to the Windows Clipboard From the Windows clipboard, copy code information from the program to paste into other Windows software (e.g., practice management or billing program, electronic claim form, etc.). To copy text: 1. You can use the mouse to select the portion of text you want to copy. 2. Press Ctrl+C to copy the text to the Windows clipboard. 65

78 Coding Menu The Coding Menu contains a list of all the various Code Set Book as well as lists of other auxiliary code sets, such as modifiers, dental codes, etc. If you have purchased the Dental Codes add-on: Select the Coding menu on the Toolbar to go to the specific clinical code sets and tools. 66

79 Current Procedural Coding Expert Select the Coding Menu on the Toolbar to go to the coding sections. Use the Current Procedural Coding Expert menu to view all possible CPT codes and the New, Revised, Reinstated, Resequenced, and Deleted Codes, as well as Color Codes. The CPT Codes Contents selection opens a list of all CPT Codes. Use the CPT Codes Contents screen to access or view a specific code or the code range. There are subsequent ranges that are displayed with the plus sign. When you get to the lowest range value, you can click the first or last code to go to the Code Section or Code Detail (set in User Preferences). Use the forward and back arrows to access other code ranges or codes. CPT Codes Menu The drop-down menus on the toolbar provide quick access to CPT Codes, HCPCS, ICD-9-CM Dx, ICD-9-CM Index, ICD-9-CM Px, and ICD-10-CM menus and submenus to navigate the code books. Several of the Appendix menu options are only available for the current quarter. They are marked in the menu with the text "(Current Quarter Only)". If you have a subscription to Historical Application Content and have set the time period to anything previous to the current quarter, these menu options will not be displayed - since they don't apply to the previous quarters. The Current Procedural Coding Menu descriptions: CPT Codes: Hover the mouse pointer over Current Procedural Coding Expert menu, CPT Codes and select a section of codes or an Appendix section similar to the CPT code book. New Codes: Click this section to see a display of all codes that have been added for the current code year separated with tabs for each code set. Revised Codes: Click this section to see a display of all codes that have been revised for the current code year separated with tabs for each code set. Reinstated Codes: Click this section to see a display of all the codes that have been reinstated for the current code year separated with tabs for each code set. Resequenced Codes: Click this section to see a display of all the codes that have been resequenced for the current code year. Deleted Codes: Click this section to see a display of all codes that have been deleted and the year the code was deleted separated with tabs for each code set. These pages also provide links to valid codes to use instead of the deleted codes (if any). Color Codes: Click this section to see a display of all codes that have been marked for special circumstances. They are separated with tabs for each type of code. They include New codes, Revised codes, Add-on codes and -51 Exempt codes. CPTCode Book Sections Code Books Contents This screen has all of the convenience of looking up codes by section, just as they are arranged in the Contents pages of the code books. To access this screen, select the Contents option from the submenu for the desired code set. A table of contents for the code books is displayed. Links are available for Coding Guidelines, Preface, Introduction, How to Use..., Conventions, Code Ranges, Appendixes, and other resources (depending on code set content). Click the range to go to the first code in that range in the Code Section. There are tabs for each of the major code sets; 'Current Procedural Coding Expert', 'HCPCS', 'ICD-9-CM Vol. 1', 'ICD-9-CM Vol. 3', and 'ICD-10-CM'. Each tab displays the code ranges that are in each section and subsection of the code books. 67

80 If you have purchased the Dental Codes add-on module, there is an additional tab labeled 'Dental Codes'. In the smaller Medical CodeExpert applications, only the tabs for the specific applicable code books will be displayed. CPT Index Similar to the code books, you can view procedure codes as they are displayed in the Index. You can access the CPT procedure codes by using any one of the following methods: Use the Search Box. From the Toolbar, select Coding, Current Procedural Coding Expert, CPT Codes, Index. Click the Current Procedural Coding Expert Index link in the Code Books section from the Home Page. To search the CPT Index listing: To find a term, type the first few letters of the term or the complete term in the Terms Starts with: box. Or to find a specific numeric code, type the code in the Code: box. Click Find. To display the term, associated code number and subcodes (if applicable): 68

81 Click one of the terms in the Index list. Click the code number or subcode number link to go the appropriate Code Section screen. To refine the search with in the index results list, type a term in the text field in the Refine Search box and click Find. Click the magnifying glass button to find the next instance of the term within the list. You can create a printout of the index by clicking on the print button. CPT Appendix Modifiers CPT Appendix - Modifiers from the CPT book can be accessed from the menu. Select Coding, then Current Procedural Coding Expert, then CPT Codes - Appendix - Modifiers. Similar to the code books, use the EncoderPro online applications to view codes as they are displayed in CPT. The CPT Appendix - Modifiers displays the CPT modifiers, descriptions, usage, and definition. Using CPT Modifiers To view the list of CPT Modifiers, select Coding on the Toolbar, Current Procedural Coding Expert, CPT Codes, Appendix A - Modifiers. To view the list of CPT Modifiers, select Coding on the Toolbar, Current Procedural Coding Expert, Appendices, Appendix A - Modifiers. CPT codes may require the addition of two-digit modifiers. CPT modifiers allow you to show that a service was altered in some way from the stated CPT Book description. Because the use of modifiers is frequently the only way to alter the meaning of a CPT code, it is very important to know how to use modifiers correctly. Modifiers can indicate: A service or procedure has both a professional and a technical component A service or procedure was performed by more than one physician Only part of a service was performed An adjunctive service was performed A bilateral procedure was performed A service or procedure was provided more than once 69

82 Unusual events occurred Unlisted Procedures When the overall procedure and outcome of the surgery is not adequately described by an existing CPT code and modifier combination, use the unlisted procedure codes. Each section of the CPT Book (Evaluation and Management, Anesthesiology, Surgery, Radiology, Pathology and Laboratory, and Medicine) contains unlisted procedure codes. Unlisted codes are billed by report, and extensive documentation is required for proper reimbursement. Insurance claims with unlisted codes take longer to process since they are usually sent to medical review for individual consideration. Include cover notes and comprehensive operative reports in the claims submission. Documentation should include the following: Definition or description of the nature, extent, and medical necessity for the procedure Statement of the time and effort necessary to provide the service Comparison of the procedure to existing procedure codes and descriptions Resequenced Codes Beginning in 2010, The American Medical Association (AMA) employed a new numbering methodology of resequencing. According to the AMA, there are instances where a new code is needed within an existing grouping of codes and an unused code number is not available. In the instance where the existing codes will not be changed or have minimal changes, the AMA will assign a code that is not in numeric sequence with the related codes. The resequenced codes and descriptions are placed with their related codes out of numeric sequence. In the CPT manual, resequenced codes appear in numeric order, referring users to their resequenced location. A resequenced code is a CPT procedure code that has been reassigned to another sequence, or CPT range set of codes. For example, procedure code 28039, which normally falls outside the official range of (numerically it is less than 28043), and in accordance with the AMA resequencing guidelines, the procedure is reassigned into the range of , but still retains its numerical code From the Coding menu on the Toolbar, select Current Procedural Coding Expert. Then select Resequenced Codes. From the Current Procedural Coding Expert menu on the toolbar, select Resequenced Codes. From the Coding menu on the Toolbar, select Current Procedural Coding Expert. Then select Appendices, and then select Resequenced Codes. The screen displays a list of the Resequenced Codes, code effective date, description, references and edits. Some edit icons provide basic information about the code and others can be clicked to access more detailed information. The green pound sign icon indicates that this code is a resequenced code. Click the colored code links to go to the Code Section. CPT Appendix Glossary Select the Coding menu on the Toolbar, Current Procedural Coding Expert and CPT Codes, Appendix - Glossary. Select the Coding menu from the Toolbar, Current Procedural Coding Expert and Appendixes and Appendix - Glossary. To search the CPT Appendix Glossary: To find a term, type the first few letters of the term or the complete term in the Terms Starts with: box. Or to find a specific numeric code, enter the code in the Code: box. Click Find. 70

83 Terms and the descriptions are displayed. CPT Appendix - Physician Quality Reporting System PQRS Lookup Table To Access the PQRS Information: On the Toolbar, select the Coding menu, Current Procedural Coding Expert, CPT Codes, and Appendix - Physician Quality Reporting System. Select the Coding menu from the Toolbar, Current Procedural Coding Expert and Appendixes and Appendix - Physician Quality Reporting System. You can also select the Appendix from the contest list on the Code Books page. Or click the PQRS icon for the code in the Code Section page or the Code Detail page. To search the PQRS Lookup Table: When you access the PQRS table through the Appendix menu option, this screen will be blank for you to search for PQRS information. Enter a valid CPT/HCPCS/ICD9 code in the code field. Or you can enter a topic measure number (with numeric radio button) or a topic measure word search within the description (with text radio button). Click the Find button. The system will find all the PQRS topic measures that match the search criteria. It will show the topic measure number, age related restrictions, and description. When you access the PQRS table by clicking on the PQRS icon for an existing code, this screen will be already populated with the search results for that code. The left column shows the Topic Measure number for the code, the age restrictions, and the description. To see additional PQRS information for the specific topic measure, click the topic measure number link in the left column. 71

84 The selected topic measure information will be displayed on the right. It will show the numerator/denominator, code type, code, code description, associated modifier, place or service and date of service. Clicking on the associated modifiers link further refines the topic measure results to information limited to that modifier. 72

85 HCPCS Menu The drop-down menus on the toolbar provide quick access to CPT Codes, HCPCS, ICD-9-CM Dx, ICD-9-CM Index, ICD-9-CM Px, and ICD-10-CM menus and submenus to navigate through the code books. Several of the Appendix menu options are only available for the current quarter. They are marked in the menu with the text "(Current Quarter Only)". If you have a subscription to Historical Application Content and have set the time period to anything previous to the current quarter, these menu options will not be displayed - since they don't apply to the previous quarters. The HCPCS menu descriptions: HCPCS Expert: Stop your pointer over HCPCS menu, HCPCS Expert and select a section of codes or an Appendix section similar to the HCPCS code book. New Codes: Click this section to display all codes that have been added for the current code year, separated with tabs for each code set. Revised Codes: Click this section to display all codes that have been revised for the current code year, separated with tabs for each code set. Reinstated Codes: Click this section to display all codes that have been reinstated for the current code year, separated with tabs for each code set. Deleted Codes: Click this section to display all codes that have been deleted including the year the code was deleted, separated with tabs for each code set. These pages provide links to valid codes to use instead of the deleted codes (if any). Color Codes: Click this section to display all codes that have been marked for special circumstances. They are separated with tabs for each type of code. They include New codes, Revised codes, Quantity codes and Medicare codes. HCPCS Expert Select the Coding Menu on the Toolbar to go to the coding sections. Use the HCPCS menu to view all possible HCPCS codes and the New Codes, Revised Codes, and Deleted Codes, as well as Color Codes. The submenu, HCPCS Expert, Contents selection opens a list of all HCPCS Codes. Use the HCPCS Codes contents screen to access or view the code or the code range. There are subsequent ranges that are displayed with the plus sign. When you get to the lowest range value, you can click the first or last code to go to the Code Section or Code Detail (set in User Preferences). Use the forward and back arrows to access other code ranges or codes. HCPCS Code Book Sections Code Books Contents This screen has all of the convenience of looking up codes by section, just as they are arranged in the Contents pages of the code books. To access this screen, select the Contents option from the submenu for the desired code set. A table of contents for the code books is displayed. Links are available for Coding Guidelines, Preface, Introduction, How to Use..., Conventions, Code Ranges, Appendixes, and other resources (depending on code set content). Click the range to go to the first code in that range in the Code Section. There are tabs for each of the major code sets; 'Current Procedural Coding Expert', 'HCPCS', 'ICD-9-CM Vol. 1', 'ICD-9-CM Vol. 3', and 'ICD-10-CM'. Each tab displays the code ranges that are in each section and subsection of the code books. If you have purchased the Dental Codes add-on module, there is an additional tab labeled 'Dental Codes'. In the smaller Medical CodeExpert applications, only the tabs for the specific applicable code books will be displayed. HCPCS Index Similar to the code books, you can view codes as they are displayed in the Index. 73

86 You can access the HCPCS procedure codes by using any one of the following methods: Use the Search Box From the Toolbar, select the Coding menu, HCPCS menu, HCPCS Expert, Index. Click the HCPCS Index link in the Code Books section from the Home Page. To search the HCPCS Index listing: To find a term, type the first few letters of the term or the complete term in the text-box. Click the Find button. To display the term, associated code number and subcodes (if applicable): Click one of the terms in the Index list. Click the code number or subcode number links to go to the corresponding Code Section screen. To refine the search with in the index results list, type a term in the text field in the Refine Search box and click Find. Click the magnifying glass button to find the next instance of the term within the list. You can create a printout of the index by clicking on the print button. HCPCS Appendix Table of Drugs Select Coding HCPCS from the Toolbar and HCPCS Expert, Appendix - Table of Drugs. Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click the Find button. Display: The HCPCS Appendix - Table of Drugs displays an alphabetical list of drugs, strength, route and the code. 74

87 Click the code number link to go to the corresponding Code Sections screen. HCPCS Appendix Modifiers Similar to the code books, you can view codes as they are displayed in HCPCS Appendix. Select the Coding menu, HCPCS, HCPCS Expert, Appendix - Modifiers to display a numerical list of modifiers and descriptions. Select the Coding menu, HCPCS Expert, Appendices, Appendix - Modifiers to display a numerical list of modifiers and descriptions. PET Scans CMS no longer requires modifiers for PET Scans. HCPCS Appendix Abbreviations and Acronyms Select Coding HCPCS from the Toolbar menu and HCPCS Expert, Appendix 3 - Abbreviations and Acronyms. Search: To find a term, type the first few letters of the term or the complete term in the Starts with: box. Click Find. Display: 75

88 The HCPCS Appendix 3 - Abbreviations and Acronyms displays an alphabetical list of terms. ICD-9-CM Dx Menu The drop-down menus on the toolbar provide quick access to CPT Codes, HCPCS, ICD-9-CM Dx, ICD-9-CM Index and ICD-9-CM Px menus and submenus to navigate the code books. ICD-9-CM Dx submenu descriptions: ICD-9-CM Expert Vol.1: Stop your pointer over ICD-9-CM Dx menu, ICD-9-CM Expert Vol.1 to display an additional submenu in which you can select Contents to display a section of codes, Preface and Introduction information, Coding Guidelines, Appendix information, or Resources tables similar to the ICD-9-CM code book. New Codes: Click this section to see a display of all codes that have been added for the current code year separated with tabs for each code set. Revised Codes: Click this section to see a display of all codes that have been revised for the current code year separated with tabs for each code set. Deleted Codes: Click this section to see a display of all codes that have been deleted and the year the code was deleted separated with tabs for each code set. These pages also provide links to valid codes to use instead of the deleted codes (if any). Color Codes: Click this section to see a display of all codes that have been marked for special circumstances. They are separated with tabs for each type of code. They include New codes, Revised codes, CC codes, Age codes, and Sex codes, and Manifestation codes. Instructional Notes The following clinical information will help. In order to assign diagnostic codes at the highest level of specificity, you must follow four kinds of instructional notes. These notes affect code descriptions in the Code Detail. Includes This note appears immediately under a three-digit code in the tabular list to further define or give an example of the contents of the category. 800 Fracture of vault of skull Includes: frontal bone parietal bone Excludes This note identifies terms in the tabular list that should not be coded under the referenced term. This note does not prevent you from using the excluded code in addition to the code from which it was excluded when both conditions are present Sensorineural hearing loss Perceptive hearing loss or deafness Excludes: abnormal auditory perception ( ) mixed conductive and sensorineural hearing loss ( ) 76

89 psychogenic deafness (306.7) Use additional code This note appears in categories in the tabular list where you may add further information (by using an additional code) to give a more complete picture of the diagnosis from the available information Infections of kidney Use additional code to identify organism, such as Escherichia coli [E. coli] (041.4) Code first underlying disease This instruction is used with codes in the tabular list that are not intended to be the principal diagnosis. The note requires that the underlying disease (etiology) be recorded first, and the particular manifestation second. Some possible underlying disease choices are listed following the instructional note with code references in parentheses. Always refer to the underlying disease in its own tabular section before coding it as the principal diagnosis to ensure that all other coding instructions are followed and the code is reported to its highest specificity level Acute and subacute infective endocarditis in diseases classified elsewhere Code first underlying disease, as: blastomycosis (116.0) Q Fever (083.0) typhoid (fever) (002.0) ICD-9-CM Expert Vol. 1 Select the Coding Menu on the Toolbar, then select ICD-9-CM Dx, then select ICD-9-CM Expert Vol. 1. Select the Coding Menu on the Toolbar, then select ICD-9-CM Expert Vol. 1. Select ICD-9-CM Dx on the Toolbar, then select ICD-9-CM Expert Vol.1. Use the ICD-9-CM Expert Vol. 1 menu to view the Contents, Preface, Introduction, How to Use..., Conventions, Coding Guidelines, Appendixes, and Resources, as well as other information that is found in the ICD-9-CM publications. Several of the menu options are only available for the current quarter. They are marked in the menu with the text "(Current Quarter Only)". If you have a subscription to Historical Application Content and have set the time period to anything previous to the current quarter, these menu options will not be displayed - since they don't apply to the previous quarters. Select New Codes, Revised Codes, Deleted Codes, Color Codes. to see the diagnosis codes in each of the selected list. Use the ICD-9-CM Expert Vol. 1, Contents selection to access or view the code or the code range. There are subsequent ranges that are displayed with the plus sign. When you get to the lowest range value, you can click the first or last code to go to the Code Section or Code Detail (set in User Preferences). Use the forward and back arrows to access other code ranges or codes. ICD-9-CM Expert Vol. 1 Code Book Sections Code Books Contents This screen has all of the convenience of looking up codes by section, just as they are arranged in the Contents pages of the code books. To access this screen, select the Contents option from the submenu for the desired code set. A table of contents for the code books is displayed. Links are available for Coding Guidelines, Preface, Introduction, How to Use..., Conventions, Code Ranges, Appendixes, and other resources (depending on code set content). Click the range to go to the first code in that range in the Code Section. 77

90 There are tabs for each of the major code sets; 'Current Procedural Coding Expert', 'HCPCS', 'ICD-9-CM Vol. 1', 'ICD-9-CM Vol. 3', and 'ICD-10-CM'. Each tab displays the code ranges that are in each section and subsection of the code books. If you have purchased the Dental Codes add-on module, there is an additional tab labeled 'Dental Codes'. In the smaller Medical CodeExpert applications, only the tabs for the specific applicable code books will be displayed. ICD9-CM Preface, Introduction, How-to-use..., Conventions This menu option opens a PDF file that provides ICD-9-CM Preface, Introduction, How-to-use..., and other diagnosis code conventions. ICD9-CM Coding Guidelines This menu option opens a PDF file that provides ICD-9-CM official coding guidelines for coding and reporting. ICD9 Appendix: Morphology of Neoplasms Similar to the code books, you can view codes as they are displayed in the Index. Display: The ICD-9-CM Appendix: Morphology of Neoplasms displays the ICD-9-CM diagnosis codes and descriptions. ICD9 Appendix Glossary of Mental Disorders NOTE: This is no longer an official Appendix. CMS has deleted Appendix B - Glossary of Mental Disorders from the official ICD-9-CM release (since 2005) because terms in this glossary no longer align with the revised code titles found in the Mental Disorders (Chapter 5) and DSM-IV terminology. 78

91 ICD9 Appendix: Classification of Drugs Similar to the code books, you can view codes as they are displayed in ICD-9-CM. Display: The ICD-9-CM Appendix - Classification of Drugs by AHFS List displays the ICD-9-CM diagnosis code for each AHFS list. Click the code number or subcode number link to go to the appropriate Code Section or Code Detail screen. ICD9 Appendix: Industrial Accidents According to Agency This menu option opens a PDF file that contains the classification of industrial accidents according to agency. ICD9 Appendix: List of Three-digit Categories This menu option opens a PDF file that contains a list of ICD-9-CM three-digit categories. ICD9 Abortion Table You can search for and view codes for termination of pregnancy. This table includes miscarriage codes as well. 79

92 Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Display: Click one of the terms in the left column to display the term, its associated code number and subcodes (if applicable). Click the code number or subcode number link to go to the appropriate Code Section or Code Detail screen. 80

93 ICD9 Burn Table You can search for and view codes for burns. Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Display: The ICD-9-CM Resources: Burn Table displays an alphabetical list of terms. Click one of the terms in the left column to display the term and its associated code number and subcodes (if applicable). Click the code number or subcode number link to go to the appropriate Code Section or Code Detail screen. 81

94 ICD9 Complications Table You can search for and view codes as they relate to medical complications. Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Display: The ICD-9-CM Resources: Complications Table displays an alphabetical list of terms. If you click one of the terms, the term and its associated code number and subcodes (if applicable) are displayed. Click the code number or subcode number link to go to the appropriate Code Section screen. 82

95 ICD9 Diabetes Table Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Display: The ICD-9-CM Resources: Diabetes Table displays an alphabetical list of terms. If you click one of the terms, the term and its associated code number and subcodes (if applicable) are displayed. Click the code number or subcode number link to go to the appropriate Code Section screen. 83

96 ICD9 Hernia Table Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Display: The ICD-9-CM Resources: Hernia Table displays an alphabetical list of terms. If you click one of the terms, the term and its associated code number and subcodes (if applicable) are displayed. Click the code number or subcode number link to go to the appropriate Code Section screen. 84

97 ICD9 Ectopic Pregnancy Table Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Display: The ICD-9-CM Resources: Ectopic Pregnancy Table displays an alphabetical list of terms. If you click one of the terms, the term and its associated code number and subcodes (if applicable) are displayed. Click the code number or subcode number link to go to the appropriate Code Section screen. 85

98 ICD9 Normal Pregnancy Table Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Display: The ICD-9-CM Resources: Normal Pregnancy Table displays an alphabetical list of terms. If you click one of the terms, the term and its associated code number and subcodes (if applicable) are displayed. Click the code number or subcode number link to go to the appropriate Code Section screen. 86

99 ICD9 Antepartum Pregnancy Table Similar to the code books, you can view codes as they are displayed in the Index. Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Display: Click one of the terms to display the term, its associated code number and subcodes (if applicable). Click the code number or subcode number link to go to the appropriate Code Section screen. 87

100 ICD9 Postpartum Pregnancy Table Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Display: The ICD-9-CM Resources: Postpartum Pregnancy Table displays an alphabetical list of terms. If you click one of the terms, the term and its associated code number and subcodes (if applicable) are displayed. Click the code number or subcode number link to go to the appropriate Code Section screen. ICD9 Valid Three-digit Codes This menu option opens a PDF file that contains a list of valid three-digit ICD-9-CM codes. 88

101 ICD-9-CM Index Menu The drop-down menus on the toolbar provide quick access to CPT Codes, HCPCS, ICD-9-CM Dx, ICD-9-CM Index and ICD-9-CM Px menus and submenus to navigate the code books. Select the ICD-9-CM Index to Diseases link in the Code Books section from the Home Page Select the Coding Menu on the Toolbar, ICD-9-CM Index and click the Section 1 - Index to Diseases. Click the letter of the alphabet in the ABC list to go to that section of the index. To find a term, type the first few letters of the term and select the complete term from the auto complete drop down text-box. Click Search or enter. The list of applicable terms and codes will be displayed. Click the term to expand the list to further detail, or click the code number or subcode number link to go the appropriate Code Section or Code Detail (set in User Preferences). To refine the search within the index results list, type a term in the text field in the Refine Search box and click Find. The term as entered will be highlighted in the index listing. Click the reset button to reset the screen back to the ABC list. ICD-9-CM Vol.2 Indexes ICD-9-CM Vol. 2 Index to Diseases Similar to the code books, you can view codes as they are displayed in the Index. You can access the ICD-9-CM Vol. 2 Index to Diseases tabled indexes through either the Coding Menu drop down or the Code Books reference on the home page. From the Toolbar, select Coding, ICD-9-CM Index, then Section 1 - Index to Diseases. Coding Menu 89

102 Or, select ICD-9-CM Vol. 2 Index to Diseases in the Code Books section from the Home Page. Code Books Home Page: Example of ICD-9-CM Vol. 2 Index to Disease page (A-Z) 90

103 Example of ICD-9-CM Vol. 2 Index to Disease page with expansion Control Panel: Example of Vol. 2 Index to Disease Control Panel Term Search- You are able to put in a term or phrase for location in the ICD-9-CM Index. The search field will auto-populate after 3 characters allowing the selection of a specific term by selecting with mouse or arrow keys. A partial term can be used with enter/select at anytime. The first item that matches input criteria will select. Previous - Selecting the 'previous' arrow will return you to the ICD-9-CM Index home (A-Z) page with the item above selected and highlighted. It is expanded so you are able to select. Scroll bar allows movement up and down Next- Selecting the 'next' arrow will return you to ICD-9-CM Index home (A-Z) page with the item below selected and bolded. It is expanded so you are able to select. Scroll bar allows movement up and down Reset- Clears out all of the search information and returns the user to ICD-9-CM Index home (A-Z) page. Print- Option is not available with ICD-9-CM Index home (A-Z) page, unless there is an expanded or selected item. Report will print only the items selected. The selection process does not become available until the user selects Select Term to Print. Selecting the items within the expanded list will choose the codes/terms to print. If the bolded/ root term is selected to print, all sub-terms will print. All options will show on header if the are available with the current selection or function. If it does not appear, it is not available. Examples are Print, Index, and Next etc. 91

104 Search: To find a term, type the first few letters of the term or the complete term in the text-box or select from auto populated drop down list. Click the Search button. Click Reset button to return to ICD-9 Vol. 2 Index to Diseases home page Example of Returned Search 92

105 Refine Search: To find a refined term, type the term or phrase you are looking for. Click the Find button. Click Next to locate the next term or phrase in the list Click Reset button to return to ICD-9 Vol. 2 Index to Diseases home page Example of Refined Search Print: To create a printout of the ICD-9 Vol. 2 Index to Diseases Click the Select Term to Print button Select for phrase/term with sub-terms to print Select to generate the report Example of Vol. 2 Index to Disease report 93

106 Selecting an term or phrase that has been expanded to the maximum level, will direct you to either the range or detail page dependant on preference settings. 94

107 ICD-9-CM Vol. 2 Index to Diseases (Hypertension) Similar to the code books, you can view codes as they are displayed in the Index. From the Toolbar, select Coding, ICD-9-CM Vol. 2 Index to Diseases (Hypertension) or select ICD-9-CM Vol. 2 Index to Diseases (Hypertension) in the Code Books section from the Home Page. You can access the ICD-9-CM Vol. 2 Index to Diseases (Hypertension) tabled indexes through either the Coding Menu drop down or the Code Books reference on the home page. Coding Menu Code Books 95

108 Home Page: Example of ICD-9-CM Vol. 2 Index to Disease (Hypertension) home page (A-Z) Example of ICD-9-CM Vol. 2 Index to Disease (Hypertension)home page with expansion 96

109 Control Panel: Example of Vol. 2 Index to Disease (Hypertension) Control Panel Term Search- You are able to put in a term or phrase for location in the ICD-9-CM Index. The search field will auto-populate after 3 characters allowing the selection of a specific term by selecting with mouse or arrow keys. A partial term can be used with enter/select at anytime. The first item that matches input criteria will select. Previous - Selecting will return you to the ICD-9-CM Index home (A-Z) page with the item above selected and highlighted. It is expanded so you are able to select. Scroll bar allows movement up and down Next- Selecting will return you to ICD-9-CM Index home (A-Z) page with the item below selected and bolded. It is expanded so you are able to select. Scroll bar allows movement up and down Reset- Clears out all of the search information and returns the user to ICD-9-CM Index home (A-Z) page. Print- Option is not available with ICD-9-CM Index home (A-Z) page, unless there is an expanded or selected item. Report will print only the items selected. The selection process does not become available until the user selects Select Term to Print. Selecting the items within the expanded list will choose the codes/terms to print. If the bolded/ root term is selected to print, all sub-terms will print. All options will show on header if the are available with the current selection or function. If it does not appear, it is not available. Examples are Print, Index, and Next etc. 97

110 Search: To find a term, type the first few letters of the term or the complete term in the text-box or select from auto populated drop down list. Click the Search button. Click Reset button to return to ICD-9 Vol. 2 Index to Diseases (Hypertension) home page Example of Returned Search Print: To create a printout of the ICD-9 Vol. 2 Index to Diseases (Hypertension) Click the Select Term to Print button Select for phrase/term with sub-terms to print Select to generate the report Example of Vol. 2 Index to Disease (Hypertension) report Selecting an term or phrase that has been expanded to the maximum level, will direct you to either the range or detail page dependant on preference settings. 98

111 ICD-9-CM Vol. 2 Index to Diseases (Neoplasm) Similar to the code books, you can view codes as they are displayed in the Index. From the Toolbar, select Coding, ICD-9-CM Vol. 2 Index to Diseases (Neoplasm) or select ICD-9-CM Vol. 2 Index to Diseases (Neoplasm) in the Code Books section from the Home Page. You can access the ICD-9-CM Vol. 2 Index to Diseases (Neoplasm) tabled indexes through either the Coding Menu drop down or the Code Books reference on the home page. Coding Menu Code Books 99

112 Home Page: Example of ICD-9-CM Vol. 2 Index to Disease (Neoplasm) home page (A-Z) Example of ICD-9-CM Vol. 2 Index to Disease (Neoplasm)home page with expansion Control Panel: Example of Vol. 2 Index to Disease (Neoplasm) Control Panel 100 Term Search- You are able to put in a term or phrase for location in the ICD-9-CM Index. The search field will auto-populate after 3 characters allowing the selection of a specific term by selecting with mouse or arrow keys. A partial term can be used with enter/select at anytime. The first item that matches input criteria will select.

113 Previous - Selecting will return you to the ICD-9-CM Index home (A-Z) page with the item above selected and highlighted. It is expanded so you are able to select. Scroll bar allows movement up and down Next- Selecting will return you to ICD-9-CM Index home (A-Z) page with the item below selected and bolded. It is expanded so you are able to select. Scroll bar allows movement up and down Reset- Clears out all of the search information and returns the user to ICD-9-CM Index home (A-Z) page. Print- Option is not available with ICD-9-CM Index home (A-Z) page, unless there is an expanded or selected item. Report will print only the items selected. The selection process does not become available until the user selects Select Term to Print. Selecting the items within the expanded list will choose the codes/terms to print. If the bolded/ root term is selected to print, all sub-terms will print. All options will show on header if the are available with the current selection or function. If it does not appear, it is not available. Examples are Print, Index, and Next etc. Search: To find a term, type the first few letters of the term or the complete term in the text-box or select from auto populated drop down list. Click the Search button. Click Reset button to return to ICD-9 Vol. 2 Index to Diseases (Neoplasm) home page Example of Returned Search 101

114 Print: To create a printout of the ICD-9 Vol. 2 Index to Diseases (Neoplasm) Click the Select Term to Print button Select for phrase/term with sub-terms to print Select to generate the report Example of Vol. 2 Index to Disease (Neoplasm) report Selecting an term or phrase that has been expanded to the maximum level, will direct you to either the range or detail page dependant on preference settings. 102

115 ICD-9-CM Section 2- Table of Drugs and Chemicals Similar to the code books, you can view codes as they are displayed in the Index. From the Toolbar, select Coding, ICD-9-CM Section 2- Table of Drugs and Chemicals or select ICD-9-CM Section 2- Table of Drugs and Chemicals in the Code Books section from the Home Page. You can access the ICD-9-CM Vol. 2 Index to Diseases (Neoplasm) tabled indexes through either the Coding Menu drop down or the Code Books reference on the home page. Coding Menu Code Books 103

116 Home Page: Example of ICD-9-CM Section 2- Table of Drugs and Chemicals home page (A-Z) Example of ICD-9-CM Section 2- Table of Drugs and Chemicals home page with expansion 104

117 Control Panel: Example of ICD-9-CM Section 2- Table of Drugs and Chemicals Control Panel Term Search- You are able to put in a term or phrase for location in the ICD-9-CM Index. The search field will auto-populate after 3 characters allowing the selection of a specific term by selecting with mouse or arrow keys. A partial term can be used with enter/select at anytime. The first item that matches input criteria will select. Previous - Selecting will return you to the ICD-9-CM Index home (A-Z) page with the item above selected and highlighted. It is expanded so you are able to select. Scroll bar allows movement up and down Next- Selecting will return you to ICD-9-CM Index home (A-Z) page with the item below selected and bolded. It is expanded so you are able to select. Scroll bar allows movement up and down Reset- Clears out all of the search information and returns the user to ICD-9-CM Index home (A-Z) page. Print- Option is not available with ICD-9-CM Index home (A-Z) page, unless there is an expanded or selected item. Report will print only the items selected. The selection process does not become available until the user selects Select Term to Print. Selecting the items within the expanded list will choose the codes/terms to print. If the bolded/ root term is selected to print, all sub-terms will print. All options will show on header if the are available with the current selection or function. If it does not appear, it is not available. Examples are Print, Index, and Next etc. 105

118 Search: To find a term, type the first few letters of the term or the complete term in the text-box or select from auto populated drop down list. Click the Search button. Click Reset button to return to ICD-9-CM Section 2- Table of Drugs and Chemicals home page Example of Returned Search Print: To create a printout of the ICD-9-CM Section 2- Table of Drugs and Chemicals Click the Select Term to Print button Select for phrase/term with sub-terms to print Select to generate the report Example of ICD-9-CM Section 2- Table of Drugs and Chemicals report Selecting an term or phrase that has been expanded to the maximum level, will direct you to either the range or detail page dependant on preference settings. 106

119 ICD-9-CM Section 3- Index to External Causes (E Codes) Similar to the code books, you can view codes as they are displayed in the Index. From the Toolbar, select Coding, ICD-9-CM Section 3- Index to External Causes (E Codes) or select ICD- 9-CM Section 3- Index to External Causes (E Codes) in the Code Books section from the Home Page. You can access the ICD-9-CM Vol. 2 Index to Diseases (Neoplasm) tabled indexes through either the Coding Menu drop down or the Code Books reference on the home page. Coding Menu Code Books 107

120 Home Page: Example of ICD-9-CM Section 3- Index to External Causes (E Codes) home page (A-Z) Example of ICD-9-CM Section 3- Index to External Causes (E Codes) home page with expansion 108

121 Control Panel: Example of ICD-9-CM Section 3- Index to External Causes (E Codes) Control Panel Term Search- You are able to put in a term or phrase for location in the ICD-9-CM Index. The search field will auto-populate after 3 characters allowing the selection of a specific term by selecting with mouse or arrow keys. A partial term can be used with enter/select at anytime. The first item that matches input criteria will select. Previous - Selecting will return you to the ICD-9-CM Index home (A-Z) page with the item above selected and highlighted. It is expanded so you are able to select. Scroll bar allows movement up and down Next- Selecting will return you to ICD-9-CM Index home (A-Z) page with the item below selected and bolded. It is expanded so you are able to select. Scroll bar allows movement up and down Reset- Clears out all of the search information and returns the user to ICD-9-CM Index home (A-Z) page. Print- Option is not available with ICD-9-CM Index home (A-Z) page, unless there is an expanded or selected item. Report will print only the items selected. The selection process does not become available until the user selects Select Term to Print. Selecting the items within the expanded list will choose the codes/terms to print. If the bolded/ root term is selected to print, all sub-terms will print. All options will show on header if the are available with the current selection or function. If it does not appear, it is not available. Examples are Print, Index, and Next etc. 109

122 Search: To find a term, type the first few letters of the term or the complete term in the text-box or select from auto populated drop down list. Click the Search button. Click Reset button to return to ICD-9-CM Section 3- Index to External Causes (E Codes) home page Example of Returned Search Print: To create a printout of the ICD-9-CM Section 3- Index to External Causes (E Codes) Click the Select Term to Print button Select for phrase/term with sub-terms to print Select to generate the report Example of ICD-9-CM Section 3- Index to External Causes (E Codes) report Selecting an term or phrase that has been expanded to the maximum level, will direct you to either the range or detail page dependant on preference settings. 110

123 ICD-9-CM Px Menu The drop-down menus on the toolbar provides quick access to CPT Codes, HCPCS, ICD-9-CM Dx, ICD-9-CM Index and ICD-9-CM Px menus and submenus to navigate the code books. ICD-9-CM Px submenu descriptions: ICD-9-CM Expert Vol.3: Hover your mouse pointer over ICD-10-CM Dx menu, ICD-10-CM Expert Vol.3 to display an additional submenu in which you can select Contents to display a section of codes, Index to Procedures, Guidelines, or Resources tables for operations. New Codes: Click this section to see a display of all codes that have been added for the current code year separated with tabs for each code set. Revised Codes: Click this section to see a display of all codes that have been revised for the current code year separated with tabs for each code set. Deleted Codes: Click this section to see a display of all codes that have been deleted and the year the code was deleted separated with tabs for each code set. These pages also provide links to valid codes to use instead of the deleted codes (if any). Color Codes: Click this section to see a display of all codes that have been marked for special circumstances. They are separated with tabs for each type of code. They include New codes, Revised codes, OR codes, Sex codes, and Medicare codes. ICD-9-CM Expert Vol. 3 Select the Coding Menu on the Toolbar to go to the coding sections. Use the ICD-9-CM Px menu to view all possible ICD-9-CM Expert Vol. 3 codes ICD-9-CM Expert Vol.3 and Appendices to view and the New Codes, Revised Codes and Deleted Codes. The ICD-9-CM Expert Vol.3, Contents selection opens a list of all ICD-9- CM Expert Vol. 3 Codes. Use the ICD-9-CM Expert Vol. 3 and Contents selection to access or view the code or the code range. You can click the first or last code to go to the Code Section or Code Detail (set in User Preferences). Use the forward and back arrows to access other code ranges or codes. ICD-9-CM Px - Vol. 3 Code Book Sections Code Books Contents This screen has all of the convenience of looking up codes by section, just as they are arranged in the Contents pages of the code books. To access this screen, select the Contents option from the submenu for the desired code set. A table of contents for the code books is displayed. Links are available for Coding Guidelines, Preface, Introduction, How to Use..., Conventions, Code Ranges, Appendixes, and other resources (depending on code set content). Click the range to go to the first code in that range in the Code Section. There are tabs for each of the major code sets; 'Current Procedural Coding Expert', 'HCPCS', 'ICD-9-CM Vol. 1', 'ICD-9-CM Vol. 3', and 'ICD-10-CM'. Each tab displays the code ranges that are in each section and subsection of the code books. If you have purchased the Dental Codes add-on module, there is an additional tab labeled 'Dental Codes'. In the smaller Medical CodeExpert applications, only the tabs for the specific applicable code books will be displayed. ICD-9 Volume 3- Index to Procedures Similar to the code books, you can view codes as they are displayed in the Index. You can access the ICD-9-CM procedures by using one of the following methods: Use the Search Box Select the Coding ICD-9-CM Px menu on the Toolbar, ICD-9-CM Expert Vol.3, Index to Procedures. 111

124 Or, click the ICD-9-CM Index to Procedures link in the Code Books section from the Home Page. Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Display: The ICD-9-CM Volume 3 - Index to Procedures listing displays with an alphabetical list of terms. Click one of the terms to display the term and its associated code number and subcodes (if applicable). Click the code number or subcode number link to go the appropriate Code Section screen. To refine the search with in the index results list, type a term in the text field in the Refine Search box and click Find. Click the magnifying glass button to find the next instance of the term within the list. You can create a printout of the index by clicking on the print button. 112

125 ICD-10-PCS Menu Note: ICD-10-PCS is still in draft mode. The industry is set to begin using ICD-10-PCS in the latter part of The drop-down menus on the toolbar provide quick access to CPT Codes, HCPCS, ICD-9-CM Dx, ICD-9-CM Index, ICD-9-CM Px menus, ICD-10-CM drafts, and ICD-10-PCS and submenus to navigate through the code books. Several of the menu options are only available for the current quarter. They are marked in the menu with the text "(Current Quarter Only)". If you have a subscription to Historical Application Content and have set the time period to anything previous to the current quarter, these menu options will not be displayed - since they don't apply to the previous quarters. ICD-10-PCS ICD-10-PCS Codes Use the ICD-10-PCS feature to prepare for a successful transition to the new ICD-10-PCS coding system. ICD-10-PCS Code Layout: 7-character alpha/numeric codes; Digits 0-9 Letters A-H, J-N, P-Z (letters I and O have been omitted to limit confusion) Code Format : Alphanumeric No decimals The Section, Body System and Root Operation will be the main drivers for the data narrowing down the remaining the characters 1 Section Determines broad procedure category 2 Body System General physiological or anatomic region 3 Root Operation Objective of procedure 4 Body Part Specific anatomic site 5 Approach Technique used to reach procedure site 6 Device Not all procedures utilize a device 7 Qualifier Not all procedures utilize a qualifier 1. Select the Coding menu on the Toolbar, and ICD-10-PCS to go to the ICD-10-PCS page. 2. Or, click the ICD-10-PCS Index of Procedures link under Code Books section on the Home Page. 113

126 Index search: To find a term: type the first few letters of the term type the complete term type a phrase in the text box Click the Search button. To refine the search within the index results list, type a term in the text field in the Refine Search box and click Find. Index Display: Click one of the terms to display the term, any associated code number and subcodes (if applicable) Additional Index functionality: The Search box, provides a list of matching terms as you type. The Find box looks for matching items within the Search results based on a minimum of 3 characters. Click Find again to go to additional matching items. The Reset button in the Index section clears your Search box, Find box and the results display. Use the Alphabetical letters in the Index section to scroll terms in a list. These Alphabetical letters are not visible when your Search is activated. Use the Index Arrows go to either the 'Previous' or 'Next' section of the Index. Arrows will appear when the selected term or phrase has the option to move forward or backward. Tabular Display: Click any code to populate the Tabular display with the corresponding code information. 114

127 In the example pictured above, the selected code OWBF from the Index in the left column completes the Tabular fields on the right side of the screen. The Section, Body System, Operation (Root Operation) and the Body Part fields are completed in the Tabular section because it contains 4 characters. In order to complete the display, select the Approach, Device and Qualifier (if applicable) from the table to display the complete code and description in the Code section. When you click an item in each column of the table, the screen updates to display only the remaining applicable options to complete the code. Click to show a sample of the ICD-10-PCS screen with code F13Z03Z: Additional Tabular functionality: Use the Tabular Arrows go to either the 'Previous' or 'Next' Root Operation. Click the Approach Definitions button, Device Definitions button, Guidelines or PCS Definitions button to display specific information. My PCS Notes My PCS notes are custom notes that are created by you. You can attach user notes to selected ICD-10-PCS codes. They are accessible for you to keep track of and can be added/edited/deleted at any time. 115

128 You can add multiple notes to any given code. My PCS columns: The columns can be sorted. Click the arrows to sort ascending or descending. Stop your pointer over the arrows to display which sort is available. The Title column shows the title the author gave to the user note. Click on the title to view the entire note. The Note column displays the text you added to the code. The Code column displays the code that has a PCS Note. Click the colored code link to go to the PCS Code Builder. The Description column displays the code description that is associated with the code selected from the PCS Code Builder page. When a code is added from the My PCS page description is user defined. The Modify Date column shows the date and time the PCS Note was added or modified. The Create Date column shows the date and time the PCS Note was created. 116

129 Add PCS Notes To add PCS Notes, select the "Add" button at the top of the "User Notes". You can also add PCS Notes by clicking the Save to my PCS notes on the PCS Code Builder page. Give your PCS Note a Title and type text in the Note field. Click Save. View User Notes Click the "My PCS" icon from the Toolbar. Click the "Go to My PCS notes" Edit User Notes Click the icon icon from the PCS Code Builder page. in the Edit column for the PCS Note. Make your changes and click Save. Click the hyper linked "Title" user comments. Select the "Edit User Note" button. Make your changes and click Save. Delete User Notes Click the icon in the Delete column for the PCS Note. A verification box appears confirming if you wan to permanently delete the note. Click OK. Search User Notes Enter text in the Search PCS Notes field and click Search, to find a Title/Note/Code or Description contained in that text. Click Reset to refresh the notes page and display all notes. 117

130 ICD-10-CM Dx Menu Note: ICD-10-CM is still in draft mode. The industry is set to begin using ICD-10-CM in the latter part of The drop-down menus on the toolbar provide quick access to CPT Codes, HCPCS, ICD-9-CM Dx, ICD-9-CM Index, ICD-9-CM Px menus, and ICD-10-CM drafts, and submenus to navigate through the code books. Several of the menu options are only available for the current quarter. They are marked in the menu with the text "(Current Quarter Only)". If you have a subscription to Historical Application Content and have set the time period to anything previous to the current quarter, these menu options will not be displayed - since they don't apply to the previous quarters. The ICD-10-CM menu descriptions: ICD-10-CM Drafts: Hover your mouse pointer over ICD-10-CM Dx menu, ICD-10-CM Drafts and select a PDF document for proposed guidelines or conventions regarding the use of ICD-10 codes New Codes: Click this section to display all codes that have been added for the current code year, separated with tabs for each code set. Revised Codes: Click this section to display all codes that have been revised for the current code year, separated with tabs for each code set. Deleted Codes: Click this section to display all codes that have been deleted including the year the code was deleted, separated with tabs for each code set. These pages provide links to valid codes to use instead of the deleted codes (if any). Color Codes: Click this section to display all codes that have been marked for special circumstances. They are separated with tabs for each type of code. They include New codes, Revised codes, and other tabs as new color codes sections are created. ICD-10-CM Drafts Note: ICD-10-CM is still in draft mode. The industry is set to begin using ICD-10-CM in the latter part of Select the Coding Menu on the Toolbar to go to the coding sections. Use the ICD-10-CM Drafts menu to view all possible ICD-10-CM codes and the New Codes, Revised Codes, and Deleted Codes, as well as Color Codes. The submenu, ICD-10-CM Drafts, Contents selection opens a list of all proposed ICD-10-CM Codes. Use the ICD-10-CM Codes contents screen to access or view the code or the code range. There are subsequent ranges that are displayed with the plus sign. When you get to the lowest range value, you can click the first or last code to go to the Code Section or Code Detail (set in User Preferences). Use the forward and back arrows to access other code ranges or codes. ICD-10-CM Code Book Sections Code Books Contents This screen has all of the convenience of looking up codes by section, just as they are arranged in the Contents pages of the code books. To access this screen, select the Contents option from the submenu for the desired code set. A table of contents for the code books is displayed. Links are available for Coding Guidelines, Preface, Introduction, How to Use..., Conventions, Code Ranges, Appendixes, and other resources (depending on code set content). Click the range to go to the first code in that range in the Code Section. There are tabs for each of the major code sets; 'Current Procedural Coding Expert', 'HCPCS', 'ICD-9-CM Vol. 1', 'ICD-9-CM Vol. 3', and 'ICD-10-CM'. Each tab displays the code ranges that are in each section and subsection of the code books. If you have purchased the Dental Codes add-on module, there is an additional tab labeled 'Dental Codes'. In the smaller Medical CodeExpert applications, only the tabs for the specific applicable code books will be displayed. 118

131 ICD-10-CM Preface, Introduction, How-to-use..., Conventions Note: ICD-10-CM is still in draft mode. The industry is set to begin using ICD-10-CM in the latter part of This menu option opens a PDF file that provides ICD-10-CM Preface, Introduction, How-to-use..., and other diagnosis code conventions. ICD-10-CM Conventions Note: ICD-10-CM is still in draft mode. The industry is set to begin using ICD-10-CM in the latter part of This menu option opens a PDF file that provides ICD-10-CM Draft Conventions. These conventions are general rules for the use of the classification system, independent of the guidelines. They are incorporated within the Index and Tabular List as instructional notes and are applicable regardless of the health care setting. ICD-10-CM Official Guidelines Note: ICD-10-CM is still in draft mode. The industry is set to begin using ICD-10-CM in the latter part of This menu option opens a PDF file that provides the official ICD-10-CM coding guidelines for coding and reporting. 119

132 Crosscodes Submenu CPT/HCPCS to Rev Codes The CPT/HCPCS to Rev Codes page provides a search box where you can type any CPT or HCPCS code and look up any Revenue Codes that may be appropriate with the code. The table shows the Revenue Code, description and notes associated with the OPPS and pertain to the revenue code. In addition, you can click the Revenue Code to go to the Code Detail. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Cross Codes menu, click CPT/HCPCS to Rev Codes. 3. Enter a CPT or HCPCS code and click Search. Rev Codes to CPT/HCPCS The Rev Codes to CPT/HCPCS page provides a search box that allows you to enter a Revenue Code and search for all CPT/HCPCS Codes that may be associated with the Revenue Code. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Cross Codes menu, select Rev Codes to CPT/HCPCS. When you access the Rev Codes to CPT/HCPCS codes, the table displays a list of Revenue Codes. Enter a Revenue Code in the search field, or click a Revenue Code to display the applicable CPT and HCPCS codes, descriptions and any applicable notes. CPT/HCPCS Codes for Revenue Code The CPT/HCPCS Codes for Revenue Code page provides a search box that allows you to enter a Revenue Code. After entering the code and clicking Search, all CPT/HCPCS Codes that may be associated with the Revenue Code are displayed. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Cross Codes menu, select Rev Codes to CPT/HCPCS. 3. Click a Revenue Code from the displayed list, or enter a Revenue code and click Search. The CPT/HCPCS Cross Codes for Revenue Code screen will be displayed. When you access the Rev Codes to CPT/HCPCS codes, the table displays the applicable CPT and HCPCS codes, descriptions and any applicable notes. In addition, you can click the link for a CPT or HCPCS code and go to the Code Section. Interventional Radiology Interventional radiology procedures are an advance in medicine that replaces open surgical procedures. An interventional radiology procedure is one that involves a surgical intervention of the patient that is greater than an injection of simple contrast media. For proper reimbursement under Medicare, the supervision and interpretation (S&I) codes describe the imaging component of the procedure, and a surgical procedure code (or codes) reflects the surgical intervention and must be reported on the bill to accurately reflect all aspects of the procedure performed in the hospital setting. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Cross Codes menu, click Interventional Radiology. When you access the Interventional Radiology Procedure codes, the table displays the applicable CPT and HCPCS codes and descriptions. Click the code to go to the applicable Surgical Procedure Codes. 120

133 CPT/HCPCS to Modifier Modifiers in an outpatient setting may affect reimbursement. Choose a modifier based on the documented circumstances of the procedure. The CPT/HCPCS to Modifier page provides a search box where you can type any CPT or HCPCS code to look up any modifiers that may be billed with the code. The table shows the Modifier, description, and an OPPS column that indicates whether the modifier is appropriate for OPPS claims. The modifiers with a No may be suitable for claims submitted in settings other than an outpatient hospital setting under OPPS. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Cross Codes menu, click Modifiers. 3. Enter a code and click Search. 4. Click a Modifier link to get additional information about the Modifier. DRG Cross Codes To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Cross Codes menu, click DRG Cross Codes. The DRG List displays all DRG codes, DRG descriptions, MDC, MDC descriptions and an indicator if the DRG is for a surgical diagnosis. Click the links in the DRG column to go to a list of all ICD-9-CM codes and descriptions that are associated with the ICD-9-CM code from the DRG Crosswalk. OPPS Cross Codes Hospitals are required to use specific CPT/HCPCS codes instead of the codes that other providers use. This detail page shows the CPT/HCPCS code, description and the crosscodes to other CPT/HCPCS codes and the effective date. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Cross Codes menu, click OPPS Cross Codes. Click the LTC-DRG Cross Codes icon from the Code Detail. Long Term Care Diagnosis-Related Groups (LTC-DRGs) are based on the principal diagnosis, up to eight additional (secondary) diagnoses, up to six procedures performed during the stay, age, sex and discharge status. LTCs are assigned to patients with an extended length of stay, high levels of acuity and a host of complications. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Cross Codes menu, click LTC-DRG Cross Codes. APC Cross Codes Select the Coding menu on the Toolbar, Cross Codes option and then the APC Cross Codes option. The APC Cross Codes list is displayed with the APC codes and Descriptions on the APC tab. The Composite APC tab is displayed if the code is included in any Composite APC group. Click the code link from the APC or CAPC column to go to the APC/CAPC Codes page with the applicable HCPCS/CPT Codes, OPSI Code, Description, Relative Weight, Pay Rate, National Unadjusted Copay and Minimum Unadjusted Copay. 121

134 Coding Edits Submenu MCE Edits The Medicare Code Editor displays inpatient Medicare code edits, descriptions and explanations. To access this page: I-OCE Edits Select the Coding Menu on the Toolbar. From the Coding Edits menu, click MCE Edits. Click the icon from the Code Section or Code Detail. The I-OCE Edits displays outpatient Medicare code edits with the descriptions and explanations. The table shows the edit number and description, the Edit Result/Claim Disposition, and the Provider Action/Response that needs to be taken. To access this page: Select the Coding Menu on the Toolbar, Coding Edits and the I-OCE Edits option. NOTE: For DrugReimbursement.com add on module, see Integrated OCE Edits. Type of Bill OCE Edits This screen shows all of the type of bill OCE edits grouped by type of bill code. It provides links to the Edit Number, Edit Descriptions, Edit Result/Claim Disposition, and Provider Action/Response. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Coding Edits menu, click Type of Bill OCE Edits. CCI Edits This screen displays Medicare s Correct Coding Initiative unbundle edits for the selected CPT code or HCPCS code. It displays codes that should not be billed with the selected code and the reason for the unbundle edit, as defined by the Medicare Correct Coding Initiative. You can also run a check of up to ten codes against each other for CCI billing relationship correctness. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Coding Edits menu, click CCI Edits. 3. Enter a code and click Search to go to the CCI Unbundles screen. MUE List MUEs, or Medically Unlikely Edits, are applied to specific codes and limits units of service to 1, 2 or 3. This list displays the list of codes with the units and provides links to the HCPCS and CPT Code information. To access the MUE list page: Select the Coding Menu on the Toolbar. From the Coding Edits menu, click MUE List. Click the icon from the Code Section Edits column or Code Detail Color Codes section, to see the specific MUE for that code. This list is also available as a PDF document. Select the Coding Menu on the Toolbar. From the Current Procedural Coding Expert menu, select CPT Codes. Then select the Appendix labeled "Medically Unlikely Edits" from the submenu. Clinical note: A quantity alert is notification that the supply of the code from the manufacturer or vendor may not match the HCPCS code description. In the case of J9190, fluorouracil 500 mg there are multiple dosages available. 122

135 By NDC number one package is 500 mg, the next 1000 mg, another is 2500 mg, and the largest is 5000 mg. If the patient is receiving one of the dosage vials that is more than 500 mg it would be appropriate to report J9190 with a unit value corresponding to the amount of medication given to the patient. The MUE or Medically Unlikely Edits are developed and maintained by the CMS. These edits limit the number of times a procedure code may be reported or the number of units reported on a CMS 1500 paper form or 837P electronic format. Initially the MUE edits were unpublished edits. Currently CMS has released edits of 1-4 units for many, but not all codes. CMS has chosen not to publish edits for some services, even though there are assigned MUE values. As a result there are some codes that CMS will process and edit according to the published MUE and other codes are reviewed according to the unpublished MUE. SNF CB Edits The Skilled Nursing Facility (SNF) Consolidated Billing Edit displays the Major Category and Exclusion/Inclusion information about the code. These codes are for services that are specifically included or excluded from the bundle of services that must be billed by the SNF. Institutional providers continue to bill their F.I. for services that are excluded from consolidated billing and may be separately billed. Select the Coding Menu on the Toolbar. From the Coding Edits menu, click SNF CB Edits. Click the SNF Major Category link to display the codes for the Major Category. Click the code link to go to the Code Section or Code Detail (option set in Preferences). Click the icon from the Code Section or Code Detail. 123

136 Future New, Revised and Deleted Codes On the Toolbar, select the Coding, then Future Codes. Then select New, Revised, or Deleted to display the Future Codes that have been added, changed or deleted in the current year and have future effective dates. The Code screens contain separate tabs for each applicable code set (CPT or HCPCS). Example screen of future new CPT codes: The screen can contain several columns: Code, Description, Icons, Date, or Cross Reference. For New and Revised codes, the code listed in the codes column and the icon images in the icons column are not clickable; they are for informational use only. For Deleted codes, the codes listed in the codes column and in the cross reference column are clickable. The date listed in the date column is the effective date in the future when the code is to be utilized. Note: The information displayed for future codes is subject to last minute changes and also to final approval by the industry. 124

137 Modifier List Search On the Toolbar, select the Coding, then Modifier List. Then select CPT or HCPCS to display the corresponding modifier list for either CPT codes or HCPCS codes. The modifier list screen is displayed. It shows the listed modifiers, their descriptions, usage information, and definition. In the Modifier List screen, codes that link to additional cross code information will be underlined. Click the link to see crosswalk information about that modifier. The linked modifier codes are the Optum modifiers (CMS and OPPS modifiers are not linked). If there is no underline link, then there is no crosswalk information for the modifier. Example screen of CPT Modifiers screen: You can search for information about any modifier. Enter the modifier code or a term to search for in the search box, then click the Search button. After the search is finished you will see a list of all modifiers related to the search criteria that you entered. New Codes This screen shows all new codes, sorted with tabs by code set. From the Coding menu on the Toolbar, select Current Procedural Coding Expert, HCPCS, ICD-9-CM DX, ICD- 9-CM Px, or ICD-10-CM. Then select New Codes. From the Coding menu on the Toolbar, select Current Procedural Coding Expert, HCPCS, ICD-9-CM Vol. 1, ICD-9-CM Vol. 3, or ICD-10-CM. Then select Appendices, and then select New Codes. The screen displays a list of the New Codes, code effective date, description, references and edits. Some icons just provide information about the code and others can be clicked to access other information. Click the colored code links to go to the Code Sections. Deleted Codes When a deleted code is entered in the search prompt, the Deleted Codes screen is displayed. From the Coding menu on the Toolbar, select Current Procedural Coding Expert, HCPCS, ICD-9-CM DX, ICD- 9-CM Px, or ICD-10-CM. Then select Deleted Codes. From the Coding menu on the Toolbar, select Current Procedural Coding Expert, HCPCS, ICD-9-CM Vol. 1, ICD-9-CM Vol. 3, or ICD-10-CM. Then select Appendices, and then select Deleted Codes. 125

138 Deleted codes are maintained for the years 1993 through the current year. The screen displays several tabs (one for each code set type) and a list of codes that are currently deleted from the code set and are no longer in use. It shows the code, the description, the date it was deleted and a cross reference to a newer code that should be used instead of the deleted code. Click the underlined linked code to go to the code section page or detail page for that code. Revised Codes This screen shows all revised codes, sorted with tabs by code set. From the Coding menu on the Toolbar, select Current Procedural Coding Expert, HCPCS, ICD-9-CM DX, ICD- 9-CM Px, or ICD-10-CM. Then select Revised Codes. From the Coding menu on the Toolbar, select Current Procedural Coding Expert, HCPCS, ICD-9-CM Vol. 1, ICD-9-CM Vol. 3, or ICD-10-CM. Then select Appendices, and then select Revised Codes. The screen displays a list of the Revised Codes, code effective date, description, references and edits. Some icons just provide information about the code and others can be clicked to access other information. Click the colored code links to go to the Code Sections. Reinstated Codes This screen shows all reinstated CPT, or HCPCS codes, sorted with tabs by code set. The specific code set tab will be highlighted for whichever menu option you selected. A reinstated code is a code and its informational content that was discontinued by the industry previously and then subsequently brought back into use -- the same code and its same informational content were both brought back into use. Note: a recycled code is a code and its content that were discontinued but then subsequently the code with new procedural content information was brought back into use. A reinstated code is not a recycled code. From the Coding menu on the Toolbar, select Current Procedural Coding Expert, HCPCS. Then select Reinstated Codes. From the Current Procedural Coding Expert menu on the toolbar, select Reinstated Codes. The screen displays a list of the Reinstated Codes, code effective date, description, references and edits. Some icons just provide information about the code and others can be clicked to access other information. Click the colored code links to go to the Code Sections. Resequenced Codes Beginning in 2010, The American Medical Association (AMA) employed a new numbering methodology of resequencing. According to the AMA, there are instances where a new code is needed within an existing grouping of codes and an unused code number is not available. In the instance where the existing codes will not be changed or have minimal changes, the AMA will assign a code that is not in numeric sequence with the related codes. The resequenced codes and descriptions are placed with their related codes out of numeric sequence. In the CPT manual, resequenced codes appear in numeric order, referring users to their resequenced location. A resequenced code is a CPT procedure code that has been reassigned to another sequence, or CPT range set of codes. For example, procedure code 28039, which normally falls outside the official range of (numerically it is less than 28043), and in accordance with the AMA resequencing guidelines, the procedure is reassigned into the range of , but still retains its numerical code From the Coding menu on the Toolbar, select Current Procedural Coding Expert. Then select Resequenced Codes. From the Current Procedural Coding Expert menu on the toolbar, select Resequenced Codes. From the Coding menu on the Toolbar, select Current Procedural Coding Expert. Then select Appendices, and then select Resequenced Codes. 126

139 The screen displays a list of the Resequenced Codes, code effective date, description, references and edits. Some edit icons provide basic information about the code and others can be clicked to access more detailed information. The green pound sign icon indicates that this code is a resequenced code. Click the colored code links to go to the Code Section. 127

140 Color Codes CPT Color Codes To access the CPT Color Code screen: Click the CPT Color Codes link from the Coding Guidance section on the Home Page. Select the Coding menu on the Toolbar, Current Procedural Coding Expert and Color Codes. This screen provides a look-up of all CPT codes with assigned color codes. You can also search within the list for a specific code with the code set. The data in the tabs is the same and doesn't change when you select a different CPT code in the Code Detail or Search Results. It has tabs for New, Revised, Reinstated, Resequenced, Add-on, -51Exempt, and Unlisted. New. The New tab displays all new CPT codes and the descriptions. Revised. The Revised tab displays all revised CPT codes and the descriptions. Reinstated. The Reinstated tab displays all reinstated CPT codes and the descriptions. Resequenced. The Resequenced tab displays all the resequenced CPT codes and the descriptions. Add-on. The Add-on tab displays all CPT Add-on codes. It has three columns. The Code column shows all CPT Add-on codes. The Type column lists whether add-on codes have been defined by Optum or the AMA. The Description column contains the code s description. -51 Exempt. The -51 Exempt tab displays all CPT codes with their descriptions that should not be used with Modifier -51. Unlisted. The tab labeled "Unlisted" shows codes that are not listed in the regular code list. Click the red code number links to go to the appropriate codes in the CPT Code Detail. HCPCS Color Codes To access the HCPCS Color Codes screen, start from the Home Page and click HCPCS Color Codes in the Coding Guidance section. Select the Coding menu on the Toolbar, HCPCS, and Color Codes. If you are in the Code Books screen, click the Color Codes link on the HCPCS tab. You can also search within the list for a specific code with the code set. This screen has links to look up all HCPCS codes and it displays the assigned color codes. It has tabs for New, Revised, Reinstated, Quantity, Medicare and Unlisted. Note: If a tab is not displayed, there are no codes that fit the category. This screen contains blue code number links that go to the appropriate code in the HCPCS Code Detail. New. The New tab displays all new HCPCS codes and their descriptions. Revised. The Revised tab displays all HCPCS codes that have been revised and their descriptions. Reinstated. The Reinstated tab displays all HCPCS codes that have been reinstated and their descriptions. Quantity. The Quantity tab displays all HCPCS codes that have any quantities associated with them. The quantities are displayed and their descriptions. Medicare. The Medicare tab displays all HCPCS codes that are exclusive to Medicare. The Code column displays the HCPCS code. The Coverage column indicates whether the code is used at the contractor s discretion or is not covered. The Description column contains the code s description. Unlisted. The tab labeled "Unlisted" shows codes that are not listed in the regular code list. ICD-9-CM Vol. 1 Color Codes To access the ICD-9-CM Vol. 1 Color Codes screen use any one of the following methods: From the Home Page, click ICD-9-CM Vol. 1 Color Codes from the Coding Guidance section of the Quick Links column. Select Coding on the Toolbar, ICD-9-CM Dx, ICD-9-CM Expert Vol. 1 and Color Codes to access the ICD-9-CM Vol. 1 Color Codes screen. This screen has links to look up all ICD-9-CM Vol. 1 codes and displays assigned color codes. You can also search within the list for a specific code with the code set. 128

141 It has tabs for New, Revised, CC, Age, Sex, and Manifestation. New. The New tab displays all new ICD-9-CM Vol. 1 codes and descriptions. Revised. The Revised tab displays all ICD-9-CM Vol. 1 codes that have been revised and descriptions. CC. The CC tab displays all Complication and Comorbidity codes (diagnoses that affect DRG assignments) and descriptions. Age. The Age tab displays all ICD-9-CM Vol. 1 codes that are age related. The Code column contains the ICD-9-CM code. The Age column has the applicable age category (e.g., Adult, Newborn). The Description column displays the description of the code. Sex. The Sex tab displays all ICD-9-CM Vol. 1 codes that are attributable to either a male or female diagnosis. The Code column displays the ICD-9-CM Vol. 1 code. The Sex column has the gender that is intended for the procedure. The Description column displays the description of the code. Manifestation. The Manifestation tab shows the list of diagnosis codes that are associated with manifestation of some other underlying disease and not the disease itself. They cannot be used as a primary diagnosis codes. The data displayed in these tabs is always the same and does not change if you select another code in the Code Section/Range page or Code Detail page. This screen contains green code number links that go to the appropriate code in the ICD-9-CM Volume 1 Code Section. ICD-9-CM Vol. 3 Color Codes To access the ICD-9-CM Vol. 3 Color Code screen use either one of the following methods: From the Home Page, click ICD-9-CM Vol. 3 Color Codes from the Coding Guidance section. Select the contents menu option from any one of the code sets sub-menus of the Coding Menu to quickly access Code Books. Click the ICD-9-CM Vol. 3 Color Codes link on the ICD-9-CM Vol. 3 tab to link to the Color Code screen. This screen allows you to look up all ICD-9-CM Vol. 3 codes assigned color codes. You can also search within the list for a specific code with the code set. It has tabs for New, Revised, OR, Sex, and Medicare. New. The New tab shows all new ICD-9-CM Vol. 3 codes and their descriptions. Revised. The Revised tab shows all ICD-9-CM Vol. 3 codes that have been revised and their descriptions. OR. The OR tab shows all ICD-9-CM Vol. 3 Operating Room procedures and their descriptions. Sex. The Sex tab shows all ICD-9-CM Vol. 3 codes that are attributable to either a male or female diagnosis. The Code column provides the ICD-9-CM Vol. 1 code. The Type column shows the gender for which the procedure is intended. The Description column gives the code s description. Medicare. The Medicare tab displays the ICD-9-CM Vol. 3 codes that have limited coverage or are not covered by Medicare. The Code column contains the ICD-9-CM Vol. 3 code. The Coverage column indicates whether the code is covered by Medicare. The Description column gives the code s description. The data in these tabs is the same no matter what code has been selected in the Code Detail or Tabular Results. This screen contains blue colored code number links that take you to the appropriate code in the ICD-9-CM Volume 3 Code Section. ICD-10-CM Color Codes To access the ICD-10-CM Color Codes screen use any one of the following methods: From the Home Page, click ICD-10-CM Color Codes from the Coding Guidance section of the Quick Links column. Select Coding on the Toolbar, ICD-10-CM and Color Codes to access the ICD-10-CM Color Codes screen. This screen has links to look up all ICD-10-CM codes and displays assigned color codes. You can also search within the list for a specific code with the code set. It has tabs for New, Revised, CC, Age, Sex, and Manifestation. New. The New tab displays all new ICD-10-CM codes and descriptions. Revised. The Revised tab displays all ICD-10-CM codes that have been revised and descriptions. CC. The CC tab displays all Complication and Comorbidity codes (diagnoses that affect DRG assignments) and descriptions. Age. The Age tab displays all ICD-10-CM codes that are age related. The Code column contains the ICD-10-CM code. The Age column has the applicable age category (e.g., Adult, Newborn). The Description column displays the description of the code. 129

142 Sex. The Sex tab displays all ICD-10-CM codes that are attributable to either a male or female diagnosis. The Code column displays the ICD-10-CM code. The Sex column has the gender that is intended for the procedure. The Description column displays the description of the code. Manifestation. The Manifestation tab shows the list of diagnosis codes that are associated with manifestation of some other underlying disease and not the disease itself. They cannot be used as a primary diagnosis codes. The data displayed in these tabs is always the same and does not change if you select another code in the Code Section/Range page or Code Detail page. This screen contains green code number links that go to the appropriate code in the Code Section. 130

143 Coding Guidelines Menu Select the Coding Guidelines menu on the Toolbar to go to the DRG Reference tools. See the following topics for more information about the selections. DRG Trees Select the Coding Guidelines Menu, DRG Reference. DRG Trees, CMS Grouper Version and one of the MDC categories to display the DRG Tree in the PDF format. DRG Indicators The diagnosis-related group (DRG) system organizes ICD-9-CM diagnosis and procedure codes into a complex, comprehensive system based on a few simple principles. The DRG system enables providers to recover the appropriate payment for inpatient services rendered in an acute care hospital facility. Information in the Facility Online Applications is taken from the official data published by the Centers for Medicare and Medicaid Services (CMS) in the Federal Register. In addition to calculating reimbursement, DRGs help evaluate the quality of care and utilization of services. DRGs are assigned using the principal diagnosis, up to eight additional diagnoses, the principal procedure and up to five additional procedure codes, age, sex, discharge status presence or absence of complications and comorbidities (CCs) and birth weight for neonates. One DRG is assigned to each inpatient stay. The case (inpatient stay) is assigned to one of the 25 major diagnostic categories (MDCs). The MDCs are mutually exclusive groups based on principal diagnosis. Each MDC is organized into one of two sections, surgical or medical. The MDCs are organized by major body system and/or associated with a particular medical specialty. Select the Coding Guidelines Menu, DRG Reference and DRG Indicators. The columns are provided with the following information: MDC Code: Major Diagnostic Category MDC Description: Major Diagnostic Category Description DRG Code: Diagnostic Related Group DRG Description: Diagnostic Related Group Description Medical/Surgical: Major Diagnostic Category Medical or Surgical section GMLOS: Geometric Mean Length of Stay AMLOS: Arithmetic Mean Length of Stay RW: Relative Weight Icons appear in this column to provide information about the DRG. This icon indicates that there could be a more appropriate, higher-paying DRG. This icon indicates a DRG may be paid as a transfer case. This icon indicates a complication and comorbidity. This icon indicates special payment provisions for long-term care hospitals within hospitals and satellites of long-term care hospitals. 131

144 This icon indicates that the DRG is one of the targeted pairs of DRGs identified as a DRG having the potential for upcoding or DRG creep. DRG Pairs Alert Table The ICD-9-CM Codes for Targeted DRGS list identifies ICD-9-CM codes for DRG codes that have the potential for upcoding or DRG creep. These ICD-9-CM codes that link to the targeted DRG codes should be considered as probable targets of an audit. Select the Coding Guidelines Menu, DRG Reference and DRG Pairs Alert Table to go to the ICD-9-CM Codes for Targeted DRGS list. Click a link in the ICD-9-CM column to go to the Code Section or Code Detail. Targeted DRGs The Targeted DRG list identifies DRG codes that have the potential for upcoding or DRG creep. These DRG codes should be considered as probable targets of an audit. Select the Coding Guidelines Menu, DRG Reference and Targeted DRGs to go to the Targeted DRG List. Click an icon in the Link column to go to the Targeted DRG List details. This page displays the Targeted DRGS, an Issue section and a section that contains the Most Common Diagnostic Codes. From the Most Common Diagnostic Codes section, click an ICD-9-CM code link to go to the Coding and Documentation Guidelines for the DRG and ICD-9-CM code. MDC Look-up Major Diagnostic Codes (MDC) are major diagnostic categories which are mutually exclusive groups based on principal diagnosis. The MDC applies to either a surgical section or medical section. The surgical section classifies all surgical conditions based on operating room procedures. The medical section classifies all diagnostic conditions based on diagnosis codes. DRG assignment is based on the following considerations: Principal and secondary diagnosis and procedure codes Sex Age Discharge status Presence or absence of complications and comorbidities (CCs) Birth weight for neonates Select the Coding Guidelines Menu, DRG Reference and the MDC Look-up to access the Major Diagnostic Codes page. The MDC list displays the MDC Code, MDC Description, DRG Codes and Diagnostic Codes columns. Click DRG List from the DRG Codes column to display the applicable DRG codes Descriptions, RW (relative weight) for the MDC code. Click the ICD-9-CM Codes link from the ICD-9-CM Codes column to display the applicable ICD-9-CM codes for the MDC code. MDC References MDC References displays MDC codes and descriptions with the DRG codes and descriptions. Select the Coding Guidelines Menu, DRG Reference menu and MDC References. 132

145 Compliance Menu Select the Compliance menu on the Toolbar to go to the MSP Compliance Tools. From this menu you can go to specific areas. See the following topic for more information about the applicable selections. MSP Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not responsible for paying a health care claim first (primary payment). The private insurance industry generally talks about "Coordination of Benefits" when assigning responsibility for primary and secondary payment) Medicare is the secondary payer for individuals who have health care coverage through another insurance plan or program after the primary payer has met its obligation to pay for services. The MSP categories are: Working Aged, Disability, End Stage Renal Disease (ESRD), Workers' Compensation, Federal Black Lung, Veteran's Administration, No-Fault/Automobile, and Liability. Each category has specific criteria that must be met before the patient is considered to be an MSP beneficiary. Select the Compliance Menu on the Toolbar, MSP (Medicare Secondary Payer). From this menu you can select the following: Guidelines Quick Reference Questionnaire 133

146 Guidelines Select the Compliance Menu on the Toolbar to access the Compliance Tools. Select Guidelines from the MSP menu to view MSP guidelines for government-issued entitlements that may apply and therefore MSP rules apply. The guidelines you can select are the following: MSP Background Information Black Lung Program Group Health Plan (GHP) Coverage Working Aged (this is a subset of GHP) Disability (this is a subset of GHP) End-Stage Renal Deisease (ESRD) Coverage Under and EGHP Automobile Medical and Other Medical No-Fault Insurance Liability Insurance Veterans Affairs Program Worker's Compensation Dual Entitlement Each of these option will display more complete information with regards to the rules and procedures that must be followed when billing these types of conditions under MSP. Quick Reference Select the Compliance Menu on the Toolbar, MSP and Quick Reference. The MSP Quick Reference page displays MSP situations and whether they should be billed with another insurance as primary, billed to Medicare as the primary payer, or billed to Medicare as the secondary payer. Questionnaire Select the Compliance Menu on the Toolbar, MSP and Questionnaire to view the questionnaire provided by CMS for facility use in determining whether MSP rules apply to a given claim. Black Lung Program The MSP rules pertaining to black lung victims was initiated by the Federal Coal Mine Act of The Black Lung Benefits Act established the black lung program under the Department of Labor (DOL). Under these rules, Medicare is the secondary payer for services provided to treat lung disease or other conditions attributable to coal mining. The Department of Labor should be billed if the diagnosis is black lung related. DOL Acceptable Diagnosis List 134

147 The DOL pays for an inpatient stay if the primary diagnosis (the diagnosis that precipitated the inpatient care) is any one of the acute conditions listed. (Black lung, pneumoconiosis, chronic obstructive pulmonary disease (COPD) are not acute conditions.)(source: Rev. 532 /02-88) This option provides a list of acceptable diagnosis that DOL reimburses upon treatment. The letters represent the following categories: Category A: A diagnosis coded category "A" is acceptable to DOL as a primary admitting diagnosis for inpatient services or emergency room care. Category B. A diagnosis coded category "B" is acceptable to DOL as a primary admitting diagnosis for inpatient services or emergency room care only when concurrent diagnoses or the discharge diagnoses/summary indicate pulmonary disease as the primary acute condition. The DOL's List of Approved Procedures This option provides a list of procedures for the type of service that DOL reimburses. The letters represent the following categories: CODE A. A major procedure always covered under Black lung treatment benefits when performed in conjunction with a condition listed on the Acceptable Diagnostic List. CODE B. A major procedure covered under the program only when performed for a condition on the Acceptable Diagnosis List. CODE C. A routine procedure always covered under Black lung treatment benefits when performed in conjunction with a condition listed on the Acceptable Diagnosis List. CODE D. A routine procedure covered when performed for a condition on the Acceptable Diagnosis List or considered concomitant care when treating a patient for an Acceptable Diagnosis List condition as an inpatient. 135

148 Reimbursement Menu EncoderPro EncoderPro for Payers Select the Reimbursement menu on the Toolbar to access the Outpatient Fee Schedule Lookup Tools, and the DRG Calculator Tool. Reimbursement Lookup EncoderPro EncoderPro for Payers Select the Reimbursement Menu and to access the Reimbursement Lookup Tools. Inpatient: The Inpatient menu provides access to: DRGs: Click the DRGs menu option to go to the DRG List. The page displays the DRG codes, Description, MDC, MDC Description, AMLOS length of stay, RW based on your preference and any footnotes. If you have multiple preferences, you can change your preference in User Preferences. LTC DRGs: Click the LTC-DRGs menu option to go to the LTC DRG List (Long Term Care Diagnosis- Related Groups). The page displays the DRG codes, Description, MDC, MDC Description, AMLOS length of stay, RW based on your preference and any applicable footnotes. If you have multiple preferences, you can change your preference in User Preferences. Outpatient: The Outpatient Menu provides access to: Fee Schedules: Select this menu to see DME Payment information and Lab Payment information. OPSI Codes: Click this selection on the Lookup menu to view the Outpatient Payment Status Indicators codes and their descriptions. Federal Register Addendum B: Click this selection to search in the Federal Register Addendum B for the OPSI Code, Description, APC, RW, Pay Rate, National Unadjusted Copay and the Minimum Unadjusted Copay that applies to a CPT Code or HCPCS Code. Packaged Rev Codes: Packaged Revenue Codes when billed under OPPS without HCPCS codes are packaged services and are not eligible for a separate payment. The cost of these services is included in the transitional outpatient payment (TOPS) and outlier calculations. 136

149 DRG Calculator Select the Reimbursement menu on the Toolbar and DRG Calculator. Select the year, enter your Provider Number and click the Calculate button. You can click the "Provider Lookup" link on the screen to search for your provider number. Enter a provider's name or provider's number and click the Search button. You can enter partial name or partial numbers to narrow your search results. Click the Provider Number link to go back to the DRG Calculator with your selected number automatically populated in the "Enter Provider Number" box. If you want to go back to the DRG Calculator without selecting a provider, click the "DRG Calculator" link at the top of the page. Click the Calculate button to display the full DRG calculated results based on hospital-specific DRG calculations for each DRG code based on the operating and capital values. Changes to the DRG data may occur throughout the year and when updates are available you will be able to select other dates from the Effective Data field. You can search for a single DRG payment rate or a series of DRG codes. Type them into the search box separated by commas. Click the Search button. 137

150 Billing Menu Select the Billing menu on the Toolbar to access the Billing Relationships Tools. Rev Codes to CPT/HCPCS The Rev Codes to CPT/HCPCS page provides a search box that allows you to enter a Revenue Code and search for all CPT/HCPCS Codes that may be associated with the Revenue Code. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Cross Codes menu, select Rev Codes to CPT/HCPCS. When you access the Rev Codes to CPT/HCPCS codes, the table displays a list of Revenue Codes. Enter a Revenue Code in the search field, or click a Revenue Code to display the applicable CPT and HCPCS codes, descriptions and any applicable notes. CPT/HCPCS Codes for Revenue Code The CPT/HCPCS Codes for Revenue Code page provides a search box that allows you to enter a Revenue Code. After entering the code and clicking Search, all CPT/HCPCS Codes that may be associated with the Revenue Code are displayed. To access this page: 1. Select the Coding Menu on the Toolbar. 2. From the Cross Codes menu, select Rev Codes to CPT/HCPCS. 3. Click a Revenue Code from the displayed list, or enter a Revenue code and click Search. The CPT/HCPCS Cross Codes for Revenue Code screen will be displayed. When you access the Rev Codes to CPT/HCPCS codes, the table displays the applicable CPT and HCPCS codes, descriptions and any applicable notes. In addition, you can click the link for a CPT or HCPCS code and go to the Code Section. Revenue Codes Requiring CPT/HCPCS Select the Billing menu on the Toolbar, then select Billing Relationships and then select Rev Codes Requiring CPT/HCPCS. This page provides a list of all of the Revenue Codes that require a CPT code or HCPCS code for Medicare outpatient billing (with a link to Revenue Code Detail), the Revenue Code Category, and the Revenue Code Description. Revenue Code Detail Revenue code detail shows the Revenue Code, its description and whether it represents an Accommodation code or an Ancillary Services code; whether CPT/HCPCS reporting is required, relevant FLs; billing tips; and coding tips. The information under Relevant Fields directs you to other FLs that require data for accurate claim completion. The instructions and tips in EncoderPro.com for Payers focus on Medicare claims completion, correction and adjudication since this program has national claims procedures and standards. The instructions encompass both inpatient and outpatient claims submission procedures. Unless otherwise indicated, the billing and coding tips apply to Medicare claims. Because the guidelines for other payers (Medicaid, Blue Cross or commercial insurers) vary significantly at the state and local level, EncoderPro.com for Payers does not address the individual billing and coding requirements of these payers in detail. However, where national specifications as defined in the NUBC UB-04 data specifications manual, have been adopted by Medicaid, Blue Cross, commercial insurers and CHAMPUS, the billing tips and guidelines have been provided and have been identified as such. The EncoderPro.com for Payers is updated on an ongoing basis to reflect current billing and coding procedures and guidelines finalized by Medicare. 138

151 Policy Lookup Menu The Policy Lookup menu option provides access to LCD and NCD guidelines. Select the Policy Lookup menu on the Toolbar. Please Select One or More Options: This tabbed section provides check boxes to select the search criteria below: Enter CPT/HCPCS here: Enter a valid CPT/HCPCS code number to go directly to the Code Section. Enter keyword here: Enter search terms in order to quickly find the code you are looking for. Type up to four key words and the software searches all selected code set databases for a specific match based on the key words entered and the type of search option specified. Enter ICD code here: Enter a valid diagnosis code number to go directly to the Code Section. Enter effective date here: If you have the effective date of the policy you are looking for, you can enter it here or use the calendar icon to search through calendar pages. Select one or more of the following options: Local Coverage Determination (LCD) This selection searches the LCD policies. Medicare Carrier This drop-down box allows you to change the Medicare Carrier selection and the search results are for that carrier. Fiscal Intermediary This drop-down box allows you to change the Fiscal Intermediary for your search results. Include retired policies This check box will include retired policies in the search results. National Coverage Determination (NCD) This selection searches the NCD policies. You can select for either Medicare Part A or for Medicare Part B. 139

152 Policy Search Results Enter your search criteria in the Policy Lookup and click Search. The LCD and NCD policy links are displayed and organized on tabs. Click the tab for your desired policy list. LCD tab. Click the link in the Id column to go to the CMS Medicare Coverage Database. NCD tab. Click the link in the Section column to go to the CMS Medicare Coverage Database. OR Click the icon in the Codes column to go to the Policy Details. Then, click the code links to go to the Code Section, or Code Detail (set in Preferences). Policy Details From the Policy Search Results section after completing your Policy Lookup, click the Codes Icon on the LCD or NCD tab to go to the Policy Details. The details for the policy will be displayed. The policy information, contractor information and related codes (organized by their color codes) are displayed. Click the code links to go to the Code Section, or Code Detail (set in Preferences). 140

153 Code Sections The Code Section page displays an overview of the code results and the neighboring codes after a search. CPT Code Section The CPT Code Section screen displays the section of the CPT Book where the code is located, description of the code, all neighboring codes, any applicable color codes and provides access to information. Other icons that may be displayed are annotations, coder's essential 3-pack (DecisionHealth data), images, modifiers, and special coverage instructions (Pub-100) based on the features and additional add-ons purchased within your product. Note about resequenced codes: Beginning in 2010, The American Medical Association (AMA) has employed a new numbering methodology of resequencing. According to the AMA, there are instances where a new code is needed within an existing grouping of codes and an unused code number is not available. In the instance where the existing codes will not be changed or have minimal changes, the AMA will assign a code that is not in numeric sequence with the related codes. The resequenced codes and descriptions are placed with their related codes out of numeric sequence. In the CPT manual, resequenced codes appear in numeric order, referring users to their resequenced location. Codes that have been resequenced will appear with a green pound sign in the edits column. EncoderPro.com Expert, Professional, and EncoderPro.com for Payers provides access to Crosscodes, CCI edits and Medicare Physician s Fee Schedule. EncoderPro.com Suite and EncoderPro.com for Payers has the Notepad and User Notes features. You can add a code to the Notepad, attach a User Note to the code, or print a Code Detail Summary report. More information about the CPT Code Section: Section Headers The title bar displays the section of the CPT Book where the codes are located. Actions Add a User Note to the code. Add the code on the row to the Notepad. Print a Code Detail Summary Page. Code This column displays the code number. Click the red code number link to go to the Code Detail for the selected code. Description This column displays the code description. 141

154 References This column contains the applicable color codes such as add-on (subsidiary) codes, codes for which Modifier - 51 is exempt, new and revised codes, etc. It also provides icons that link to various other information screens based on the product: The View User Notes Icon links to any User Notes for the code in that row. The Notes Icon links you to any CPT Section Notes for the code in that row. The Annotations Icon links you to any CPT Lay Descriptions for the code in that row. The Modifiers Icon links you to any CPT Modifiers for the code in that row. The Crosscodes Icon links you to the Cross Coder for the code in that row. The CCI Unbundle Edits Icon links you to any CPT CCI Unbundle Edits for the code in that row. The Pub-100 References Icon links you to any Pub-100 References for the code in that row. The CMS Fee Schedule Icon links you to the Medicare Physician Fee Schedule for the code in that row. The Images Icon links to illustrations that provide coders with a thorough understanding of medical terminology and anatomy. The "dh" Icon links to Coder's Essential 3-Pack for the code. Edits The Edits column contains code edits that are applicable for the code. Some icons are informational and some icons are links. Click the icon link to go to detailed information about the edit. You can stop your pointer over the icon to see a description. Previous and Next Section Buttons Clicking the gray arrows goes to the CPT Code Section for the previous or next section of codes. 142

155 HCPCS Code Section The Code Section screen displays the section of the code book where the code is located, the description for the selected code, all neighboring codes, any applicable color codes and access to information such as section notes. Other icons that may be displayed are annotations, coder's essential 3-pack (DecisionHealth data), images, modifiers, and special coverage instructions (Pub-100) based on the features and additional add-ons purchased within your product. For EncoderPro.com Expert, Professional and EncoderPro.com for Payers, access is provided to Crosscodes, CCI edits and Medicare Physician s Fee Schedule. In EncoderPro.com Suite and EncoderPro.com for Payers, you can add a code to the Notepad, attach a User Note to it, or print a Code Summary Detail report. More information about HCPCS Code Section: Section Headers The title bar displays the section of the code book where a code or group of codes is located. Actions Add a User Note to the code. Add the code on that row to the Notepad. Print a Code Detail Summary Page. Code This column contains the code number. Click any of the blue code number links to go to the HCPCS Code Detail. Description This column displays the description of the code. Reference This column displays the applicable color codes such as new codes, revised codes, associated quantities and Medicare exclusive codes. It also provides icons that link to various other information screens based on the product: The User Notes Button links to any User Notes on the code in that row. If an icon is not displayed, a User Note has not been created for the code. The Notes Icon links to any HCPCS Section Notes for the code. The Annotations Icon links to any HCPCS Annotations for the code. The "dh" icon links to Coder's Essential 3-Pack for the code. The Modifiers Icon links to any HCPCS Modifiers for the code. The Crosscodes Icon links to any HCPCS Crosscodes for the code. The CCI Unbundle Edits Icon links to any HCPCS CCI Unbundle Edits for the code. The Pub-100 References Icon links to any Pub-100 References for the code. 143

156 The CMS Fee Schedule Icon links to the Medicare Physician Fee Schedule for the code. Edits The Edits column contains code edits that are applicable for the code. Some icons are informational and some icons are links. Click the icon link to go to detailed information about the edit. You can stop your pointer over the icon to see the description. Previous and Next Section Buttons Click the gray buttons to access the HCPCS Code Section for the previous or next section of codes. 144

157 ICD-9-CM Volume 1 Code Section The Code Section screen displays the section of the code book for the code, the description of the selected code, all neighboring codes, and any applicable color codes. Other icons that may be displayed are annotations, coder's essential 3-pack (DecisionHealth data), images, modifiers, and special coverage instructions (Pub-100) based on the features and additional add-ons purchased within your product. EncoderPro.com Expert, Professional and EncoderPro.com for Payers provides access to DRG crosscodes. EncoderPro.com Suite and EncoderPro.com for Payers provides a feature to add a code to the Notepad, attach a User Note to it, or print a Code Detail Summary report. Section Headers The title bar displays the section of the code book where a code or group of codes is located. Actions Add a User Note to the code, add the code on the row to the notepad, or print a code detail summary report. Code Section This column displays the code number and occasionally a color code along with the description of the code. Clicking any of the green code number links goes to the ICD-9-CM Vol. 1 Code Detail screen. Reference This column provides the applicable color codes such new and revised codes, age diagnosis, Complication and Co-morbidity, etc. It also provides icons that link to various other information screens based on the product: The User Notes Button links to any User Notes for the code in the row. An icon is displayed when there is a User Note attached to the code. The Notes Icon links to any ICD-9-CM Instructional Notes for the code in the row. The Annotations Icon links to any ICD-9-CM Annotations for the code in the row. The DRG Crosscodes Icon links to any DRG Crosscodes for the code in the row. The ICD-10 Mapping Icon links to the ICD-10 Mapping screen. The "dh" Icon links to Coder's Essential 3-Pack for the code. Edits The Edits column contains code edits that are applicable for the code. You can stop your pointer over the icon to see the description. Previous and Next Section Buttons Clicking the gray buttons goes to the ICD-9-CM Volume 1 Code Section for the previous or next section of codes. 145

158 ICD-9-CM Volume 3 Code Section The Code Section screen displays the section of the code book for the code, the description of the selected code, all neighboring codes, and any applicable color codes. Other icons that may be displayed are annotations, coder's essential 3-pack (DecisionHealth data), images, modifiers, and special coverage instructions (Pub-100) based on the features and additional add-ons purchased within your product. EncoderPro.com Suite and EncoderPro.com for Payers provides a feature to add a code to the Notepad, attach a User Note to it, or to print a Code Detail Summary report. Section Headers The title bar displays the section of the code book where a code or group of codes is located. Actions Add a User Note to the code. Add the code on the row to the Notepad. Code Section Displayed in this column is the code number and occasionally a color code along with the code s description. Clicking any of the green code number links goes to the ICD-9-CM Vol. 3 Code Detail screen. Reference This column provides the applicable color codes such new and revised codes, age diagnosis, Complication and Comorbidity, etc. It provides icons that link to various other information screens based on the product: The User Notes Button links to any User Notes on the code in that row. An icon will be displayed if there is a User Note attached to the code. The Notes Icon links you to any ICD-9-CM Instructional Notes on the code in that row. The Annotations Icon links you to any ICD-9-CM Annotations on the code in that row. The Crosscodes Icon links you to any Crosscodes for the code in that row. The "dh" Icon links to Coder's Essential 3-Pack for the code. Edits The Edits column contains code edits that are applicable for the code. You can stop your pointer over the icon to see the description. Previous and Next Section Buttons Clicking the gray buttons goes to the ICD-9-CM Volume 1 Code Section for the previous or next section of codes. 146

159 ICD-10-CM Code Section The Code Section screen displays the section of the code book for the code, the description of the selected code, all neighboring codes, and any applicable color codes. Other icons that may be displayed are annotations, and special instructions based on the features and additional add-ons purchased within your product. Note: ICD-10-CM is still in draft mode. The industry is set to begin using ICD-10-CM in the latter part of EncoderPro.com Suite and EncoderPro.com for Payers provides a feature to add a code to the Notepad, attach a User Note to it, or print a Code Detail Summary report. Section Headers The title bar displays the section of the code book where a code or group of codes is located. Actions Add a User Note to the code., add the code on the row to the notepad, or print a code detail summary report. Code Section This column displays the code number and occasionally a color code along with the description of the code. Clicking any of the purple code number links goes to the ICD-10-CM Code Detail screen. Reference This column provides the applicable color codes such new and revised codes, age diagnosis, Complication and Co-morbidity, etc. It also provides icons that link to various other information screens based on the product: The User Notes Button links to any User Notes for the code in the row. An icon is displayed when there is a User Note attached to the code. The Notes Icon links to any ICD-10-CM Instructional Notes for the code in the row. The ICD-10 Mapping Icon links to the ICD-10 Mapping screen. Edits The Edits column contains code edits that are applicable for the code. You can hover the mouse pointer over the icon to see the description. Previous and Next Section Buttons Clicking the gray buttons goes to the previous or next section of codes. 147

160 Code Detail The Code Detail page displays all available information for a selected code. Click the links on the page to go to related codes and information. Code Detail screens are available for CPT, HCPCS, ICD-9-CM Volume 1, ICD-9-CM Volume 3, and ICD-10-CM codes. Note: ICD-10 is still in draft mode. The industry is set to begin using ICD-10 in the latter part of Note with regards to accuracy of data within EncoderPro applications: Medicare Reference This information is compiled from CMS/ Medicare information. The data is formatted for ease of use. Code Information Code Description - The code and the official description. CPT Codes - The full description as contained in the CPT book printed and copyrighted by the American Medical Association. HCPCS codes - The full description as released by CMS. ICD-9-CM Volume 1 and Volume 3 codes - The full description as approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. ICD-10-CM - The full description as released by CMS. Code History - A brief summary of the historical information about a code. Click the parchment icon to access complete historical information. Lay Description - The specific lay description of the procedure as outlined by our clinical editors. Coding Tips - Information on how the code should be used, related CPT codes, and offers help concerning common billing errors, modifier usage, and anesthesia. Notes - CPT codes - The notes for the section and subsection as contained in the CPT book printed and copyrighted by the American Medical Association. ICD-9-CM Volume 1 and Volume 3 codes: Instructional notes contained in the ICD-9-CM. Code Specific Reference Information - CPT codes - the AMA CPT Assistant references. CPT codes primary procedure codes - identifies appropriate primary procedures to be reported with the add-on code as derived from the instructional notes contained in the CPT book. CPT Changes: An Insider's View - A clinical look at the annual changes to the procedural charge codes. ICD-9-CM codes - the AHA Coding Clinic references. DecisionHealth Pink Sheets, Part B News, and Answer Books - Articles and information for specific practice specialties and Medicare news and answers. See also Coder's Essential 3-Pack. Annotations - ICD-9-CM Volume 1 and Volume 3 codes as contained in the ICD-9-CM. HCPCS codes - information regarding the code. Images - Optum's illustration relating to the specific code where available. Optum Data Color codes - 148

161 CPT color codes - all the icons listed in this section are taken from: the CPT book, information released by CMS, or from the Cooperating Parties for the ICD-9-CM Crosscodes - CPT and HCPCS codes - Tables or lists of appropriate modifiers or diagnosis codes that can be reported with CPT or HCPCS codes as developed and maintained by Optum using CCI, NCD, and other official sources as well as clinical expertise of Optum staff. ICD-9-CM Volume 1 - DRG crosswalk as released by CMS and the Cooperating Parties for the ICD-9-CM NDC crosswalk identifies possible medications that may be prescribed for the diagnosis based upon official sources such as pharmaceutical information and clinical expertise of Optum staff ICD-9-CM Volume 3 DRG crosswalk as released by CMS and the Cooperating Parties for the ICD-9-CM Crosscodes - Tables or lists of appropriate modifiers or diagnosis codes that can be reported with CPT or HCPCS codes as developed and maintained by Optum using CCI, NCD, and other official sources as well as clinical expertise of Optum staff. Also note: occasionally, there may be times when the information contained in different sections of the EncoderPro application may appear to be inconsistent as a result of differences between CPT as published by the American Medical Association and the guidelines released by CMS. The information from each source is presented and is correct. The information above should help to identify the source of the information provided and help to determine the guidelines most appropriate for your practice and used by the payers you contract with. Click the View Range button to go to the code section for the code. Click the left arrow to go to the previous code within the section, or click right arrow to go to the next code within the section. Click the Add to Notepad button to add the code to the EncoderPro notepad. Click the Add to User Notes button to add a customized user note to the code. Click the Print Code Detail Summary button to print a single page summary of the Code Detail page. 149

162 CPT Code Detail The Code Detail page contains all information that is available for a specific code. The Code Detail page displays all available information for a selected code. Click the links on the page to go to related codes and information. Code Detail screens are available for CPT, HCPCS, ICD-9-CM Volume 1, ICD-9-CM Volume 3, and ICD-10-CM codes. Note: ICD-10 is still in draft mode. The industry is set to begin using ICD-10 in the latter part of Note with regards to accuracy of data within EncoderPro applications: Medicare Reference This information is compiled from CMS/ Medicare information. The data is formatted for ease of use. Code Information Code Description - The code and the official description. 150 CPT Codes - The full description as contained in the CPT book printed and copyrighted by the American Medical Association. HCPCS codes - The full description as released by CMS. ICD-9-CM Volume 1 and Volume 3 codes - The full description as approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. ICD-10-CM - The full description as released by CMS. Code History - A brief summary of the historical information about a code. Click the parchment icon to access complete historical information. Lay Description - The specific lay description of the procedure as outlined by our clinical editors. Coding Tips - Information on how the code should be used, related CPT codes, and offers help concerning common billing errors, modifier usage, and anesthesia. Notes - CPT codes - The notes for the section and subsection as contained in the CPT book printed and copyrighted by the American Medical Association. ICD-9-CM Volume 1 and Volume 3 codes: Instructional notes contained in the ICD-9-CM. ICD-10-CM codes: Instructional notes, including section notes, category notes, and chapter notes. Code Specific Reference Information - CPT codes - the AMA CPT Assistant references. CPT codes primary procedure codes - identifies appropriate primary procedures to be reported with the add-on code as derived from the instructional notes contained in the CPT book. ICD-9-CM codes - the AHA Coding Clinic references. DecisionHealth Pink Sheets, Part B News, and Answer Books - Articles and information for specific practice specialties and Medicare news and answers. See also Coder's Essential 3-Pack. Annotations - ICD-9-CM Volume 1 and Volume 3 codes as contained in the ICD-9-CM. ICD-10-CM codes - annotations regarding the code. HCPCS codes - information regarding the code. Images - Optum's illustration relating to the specific code where available. Optum Data Color codes -

163 Color codes - all the icons listed in this section are taken from: the CPT book, information released by CMS, or from the Cooperating Parties for the ICD-9-CM, and ICD-10-CM Crosscodes - User Notes CPT and HCPCS codes - Tables or lists of appropriate modifiers or diagnosis codes that can be reported with CPT or HCPCS codes as developed and maintained by Optum using CCI, NCD, and other official sources as well as clinical expertise of Optum staff. ICD-9-CM Volume 1 - DRG crosswalk as released by CMS and the Cooperating Parties for the ICD-9-CM NDC crosswalk identifies possible medications that may be prescribed for the diagnosis based upon official sources such as pharmaceutical information and clinical expertise of Optum staff ICD-9-CM Volume 3 DRG crosswalk as released by CMS and the Cooperating Parties for the ICD-9-CM Crosscodes - Tables or lists of appropriate modifiers or diagnosis codes that can be reported with CPT or HCPCS codes as developed and maintained by OptumInsight using CCI, NCD, and other official sources as well as clinical expertise of OptumInsight staff. If you have a User Note assigned to the code, it is displayed in this section. View Range Click to go to the CPT Code Section that contains the code range for the code. You can click the forward arrow to go up to the next code or click the backward arrow to go back to the next code. Add to Notepad Click to add your code to the Notepad. Add to User Notes Click to add User Notes. Print Code Detail Summary Report Click to print a Code Detail Summary report. DrugReimbursement.com add-on module The CPT Code Detail screen displays the selected code with the code description and provides links to information that is available for the code. To access the CPT Code Detail, enter your Search terms or code in the search box on the Title Bar. Click the Code link in the Code column in the grid. Medicare Reference Information Code Specific Edits Click the LCD or NCD link to go to the specific policy tab in the Medicare Coverage Policies. Code-Specific Edits displays links for the edits that apply to the code. Click the Pub-100 References link to go to Pub-100 References. The Physician Fee Schedule Information provides a method of Calculating the Medicare Physician Fee Schedule according to Medicare Carrier/Locality. You can change the Medicare Carrier/Locality selection, Conversion Factor or % of Medicare and recalculate the Fee Schedules according to your selections. The CMS Transmittals provides links to the CMS articles. Payment References contains icons and links to payment information. 151

164 The Physician Fee Schedule Information provides a method of Calculating the Medicare Physician Fee Schedule according to Medicare Carrier/Locality. You can change the Medicare Carrier/Locality selection, Conversion Factor or % of Medicare and recalculate the Fee Schedules according to your selections. This screen displays information about CPT codes from the Medicare Physician Fee Schedule. When applicable, this screen provides actual payment information such as Relative Value Units, Global Information, and specific Medicare Rules from the Medicare Physician Fee Schedule. You can change the entry in the Conversion Factor field which will also change the % of Medicare field. If you change the entry in the % of Medicare field, the entry in the Conversion Factor field changes appropriately. See Medicare Rules. Code Information Code Description contains the description that applies to the code. Code History provides important dates and information about the code. Lay Descriptions are non-clinical descriptions of medicine codes. Notes displays any notes that apply to the code. If Section Notes are available for the code, they are displayed in Section Notes. Section Notes are guidelines that provide parenthetical commentary (instructions). Code Specific Reference Information provides links to information about the code. Optum Data This column contains data that applies to your selected code. Click Hide/UnHide arrow to hide the sections on the page. Fee Analyzer Changes to Medicare Physician Fee required by Congress apply to Radiology codes and the Medicare Physician Fee Schedule. 152 OPPS payment is displayed on the Code Detail screen when you select a radiology code to compare the OPPS payment to the MPFS and make your own determination. Reduced payment is displayed on the Code Detail screen when you select a radiology code for codes that are flagged with a Multiple Procedure Reduction identifier. () The code family identifier is displayed in the parenthesis next to Reduced. Medicare Reference This column contains Medicare information and references. The Physician Fee Schedule Information provides a method of Calculating the Medicare Physician Fee Schedule according to Medicare Carrier/Locality. You can change the Medicare Carrier/Locality selection, Conversion Factor or % of Medicare and recalculate the Fee Schedules according to your selections. This screen displays information about CPT codes from the Medicare Physician Fee Schedule. When applicable, this screen provides actual payment information such as Relative Value Units, Global Information, and specific Medicare Rules from the Medicare Physician Fee Schedule. You can change the entry in the Conversion Factor field which will also change the % of Medicare field. If you change the entry in the % of Medicare field, the entry in the Conversion Factor field changes appropriately. See Medicare Rules. If you have one or more fee schedules loaded (see Add User Fee Schedule) the Update Fee section is displayed in the Medicare Reference section. You can select your fee schedule and click the Update Fee button to update your user fee with the Medicare Physician Fee if it is greater than zero. Code Information This column contains information about your selected code. It displays the Code and Description.

165 User Notes If you have a User Note assigned to the code, it is displayed in this section. Optum Data This column contains data that applies to your selected code. Anesthesia Base Units are displayed in this column. Lay Descriptions The lay descriptions are non-clinical descriptions that are available for many CPT surgery and medicine codes. Lay Descriptions can be viewed in the Code Detail. Coding Tips The Coding Tips section provides information on how the code should be used, related CPT codes, and offers help concerning common billing errors, modifier usage, and anesthesia. Coding Tips can be viewed in the Code Detail. 153

166 HCPCS Code Detail The Code Detail page contains all information that is available for a specific code. Medicare Reference This column contains Medicare information and references. Click the links to go to Code-Specific Edits and Pub-100 References. The Physician Fee Schedule Information section displays the Medicare Physician Fee Schedule. The CMS Transmittals provides links to the CMS articles. Code Information This column contains information about your selected code. It displays the Code and Description. If the code has Annotations and Lay Descriptions, they are displayed in this section. Optum Data This column contains data that applies to your selected code. Color Codes and Cross Codes are displayed in this column. User Notes If you have a User Note assigned to the code, it is displayed in this section. View Range Click to go to the HCPCS Code Section that contains the code range for the code. You can click the forward arrow to go up to the next code or click the backward arrow to go back to the next code. Add to Notepad Click the 'Add to Notpad' button to add your code to the Notepad. Add to User Notes Click the 'Add to User Notes' button to add User Notes. Print Code Detail Summary Report Click the 'Print Code Detail Summary' button to print a Code Detail Summary report. DrugReimbursement.com add-on module The HCPCS Code Detail screen displays the selected code with the code description and provides links to information that is available for the code. To access the HCPCS Code Detail, enter your Search terms or code in the search box on the Title Bar. Click the Code link in the Code column in the grid. Medicare Reference Information Code Specific Edits Click the LCD or NCD link to go to the specific policy tab in the Medicare Coverage Policies. Code-Specific Edits displays links for the edits that apply to the code. The CMS Transmittals provides links to the CMS articles. The Physician Fee Schedule Information provides a method of Calculating the Medicare Physician Fee Schedule according to Medicare Carrier/Locality. You can change the Medicare Carrier/Locality selection, Conversion Factor or % of Medicare and recalculate the Fee Schedules according to your selections. Payment References contains icons and links to payment information. The Physician Fee Schedule Information provides a method of Calculating the Medicare Physician Fee Schedule according to Medicare Carrier/Locality. You can change the Medicare Carrier/Locality selection, Conversion Factor or % of Medicare and recalculate the Fee Schedules according to your selections. 154

167 This screen displays information about CPT codes from the Medicare Physician Fee Schedule. When applicable, this screen provides actual payment information such as Relative Value Units, Global Information, and specific Medicare Rules from the Medicare Physician Fee Schedule. You can change the entry in the Conversion Factor field which will also change the % of Medicare field. If you change the entry in the % of Medicare field, the entry in the Conversion Factor field changes appropriately. See Medicare Rules. Code Information Code Description contains the description that applies to the code. Code History provides important dates and information about the code. Lay Descriptions are non-clinical descriptions of medicine codes. Notes displays any notes that apply to the code. If Section Notes are available for the code, they are displayed in Section Notes. Section Notes are guidelines that provide parenthetical commentary (instructions). Code Specific Reference Information provides links to information about the code. Optum Data This column contains data that applies to your selected code. Click Hide/UnHide arrow to show or hide the sections on the page. Fee Analyzer Medicare Reference This column contains Medicare information and references that applies to the selected code. Code Information This column contains information about your selected code. It displays the Code and Description. User Notes If you have a User Note assigned to the code, it is displayed in this section. Optum Data This column contains data that applies to your selected code. 155

168 ICD-9-CM Vol. 1 Code Detail Code Information This column contains information about your selected code. It displays the Code and Description. If the code has any Annotations and Lay Descriptions, they are displayed in this section. Optum Data This column contains data that applies to your selected code. If the code has Color Codes, they are displayed in this section. Crosscodes are also available. There is also a section for ICD-10 mapping, if the code is mappable to ICD-10-CM diagnosis codes. User Notes If you have a User Note assigned to the code, it is displayed in this section. View Range Click the 'View Range' button to go to the ICD-9-CM Volume 1 Code Section that contains the code range for the code. You can click the forward arrow to go up to the next code or click the backward arrow to go back to the next code. Add to Notepad Click the 'Add to Notepad' button to add your code to the Notepad. Add to User Notes Click the 'Add to User Notes' button to add User Notes. Print Code Detail Summary Report Click the 'Print Code Detail Summary' button to print a Code Detail Summary report. DrugReimbursement.com add-on module The Code Detail displays the code number, description and various links that contain further information about the code. Use the code Search Results to go to the desired code. Click the code link in the Code column to go to the I9 Codes list. Click the code link to go to the Code Detail. 156

169 ICD-9-CM Vol. 3 Code Detail The Code Detail page contains all information that is available for a specific code. Code Information This column contains information about your selected code. It displays the Code and Description. If the code has any Annotations, they are displayed in this section. Optum Data This column contains data that applies to your selected code. If the code has Color Codes, they are displayed in this section. User Notes If you have a User Note assigned to the code, it is displayed in this section. View Range Click the 'View Range' button to go to the ICD-9-CM Volume 1 Code Section that contains the code range for the code. You can click the forward arrow to go up to the next code or click the backward arrow to go back to the next code. Add to Notepad Click the 'Add to Notepad' button to add your code to the Notepad. Add to User Notes Click 'Add to User Notes' button to add User Notes. Print Code Detail Summary Report Click the 'Print Code Detail Summary' button to print a Code Detail Summary report. DrugReimbursement.com add-on module The Code Detail displays the code number, description and various links that contain further information about the code. Use the code Search Results to go to the desired code. Click the code link in the Code column to go to the I9 Codes list. Click the code link to go to the Code Detail. 157

170 ICD-10-CM Code Detail Code Information This column contains information about your selected code. It displays the Code and Description. If the code has any Instructional Notes, Annotations and Lay Descriptions, they are displayed in this section. Optum Data This column contains data that applies to your selected code. If the code has Color Codes, they are displayed in this section. Crosscodes are also available. There is also a section for ICD-10 mapping, if the code is mappable to ICD-10-CM diagnosis codes. User Notes If you have a User Note assigned to the code, it is displayed in this section. View Range Click the 'View Range' button to go to the ICD-10-CM Code Section that contains the code range for the code. You can click the forward arrow to go up to the next code or click the backward arrow to go back to the next code. Add to Notepad Click the 'Add to Notepad' button to add your code to the Notepad. Add to User Notes Click the 'Add to User Notes' button to add User Notes. Print Code Detail Summary Report Click the 'Print Code Detail Summary' button to print a Code Detail Summary report. Annotations Annotations and Lay Descriptions provide explanations of medical terminology and descriptions for specific diseases that pertain to the code selected. They provide more information about medical and surgical supplies, durable medical equipment, drugs and certain professional services. Annotations and Lay Descriptions can be viewed in the Code Detail. 158

171 Code History The Code History displays summary of the history of a code. It is displayed in the Code Information section on the Code Detail screen. Click the parchment icon (scroll and feather icon) to display the complete history for the code. Complete Code History: In the Complete Code History screen, the historical information is listed with most recent changes at the top of the list and goes downward to the oldest change. To read the changes in chronological order, start from the bottom of the list (information when the code was first implemented) and work your way up to the top of the list for the most recent revision of the code. In the case where a code was previously discontinued and then subsequently reinstated, unless otherwise noted, the information displayed in the discontinued code area will be the same information that the code was reinstated with. For example if code J7611 was discontinued effective 12/31/07 (no longer used as of 1/1/08) with a description of Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 1 mg, and then subsequently reinstated on 4/1/08. The previous description information would also apply to the reinstatement of the code. 159

172 Code Detail Summary Report Print Report The Code Detail Summary Report allows you to print a summary page for the details of a selected code or multiple codes. It shows the code, a brief description, an illustration, and other cross coding information. If you have the HAC module, the report will display the information for the currently selected time period. This report is available for CPT codes, HCPCS codes, ICD-9 codes and ICD-10-CM codes. Access the Code Detail Summary report by clicking the printer icon on the Code Section page, or clicking on the button labeled Print Code Detail Summary in the Code Detail page. After clicking the print button in either of these two screens, the Print Report screen will be displayed. In this screen you can indicate which details you would like to be included on the Code Detail Summary report printout. Print Report Preferences Screen Print Code Detail Summary Code: In this field, type the code(s) to be included on the report. The corresponding radio button and field show the code(s) being printed. If desired you can change the code being printed by entering a new valid code here. Additionally, you can enter multiple types of codes. For example you can enter 3 CPT, 5 Diagnosis, and 2 HCPCS codes. The codes must be entered as a comma separated list.when entering information in the Code field, there is a limit of 10 codes that can be entered. If an invalid code is entered, then an error message will be displayed indicating that a valid code must be entered. (Note: The radio button is checked by default since it is currently the only option.) The Global Days check box - The global period is the number of days during which all necessary services normally furnished by a physician (before, during, and after the procedure) are included in the reimbursement for the procedure performed, also known as the "Follow-up" period. Select this check box to show the global days for the specified code. Since global days are not applicable to diagnosis codes, this setting is ignored for diagnosis codes reports. The Print Medicare Physician Fee Schedule - Locality: drop down is defaulted from your default setup. However, if desired, you can change the locality information by clicking on the drop down arrows and selecting the desired locality from the displayed list. The information printed on the report will be specific to the location entered in this box. 160

173 The Print LCD Part B - Medicare Carrier/MAC: drop down is also defaulted from your default setup. And if desired, you can change the locality information by clicking on the drop down arrows and selecting the desired locality from the displayed list. LCD policy information will be printed for the selection in this box. You can choose to print the codes only or include the descriptions with the codes as well. Please note: In some cases the list of supported and unsupported diagnostic codes can be quite large. The remaining print options contain a series of check boxes where all, multiple, or none of the check boxes can be selected. The defaulted answers are from the previous time you used this feature. The Cross Code information allows you to list the codes from the other code sets that "match" up or cross over with the code on the report. For example if printing this for a CPT code, the other ICD9, HCPCS, and Anesthesia codes will be listed. You can choose to list just the codes only or to include the code description as well on the report. The codes and descriptions will all be listed in up to three columns on the report. Please note the following disclaimers when referring to cross code information on the printed report: The CPT anesthesia codes listed may be used to report the anesthesiology services when the surgeon reports the correlating CPT procedure codes. In some cases, not every possible code is listed and the CPT book should be referenced for other valid codes. ICD-9-CM diagnostic codes listed are common diagnoses or reasons the procedure or service may be necessary. In some cases, not every possible code is listed and the ICD-9-CM book should be referenced for other valid codes. ICD-9-CM Volume 3 procedure codes listed may be used to report the correlating CPT procedure codes. In some cases, not every possible code is listed and the ICD-9-CM Volume 3 book should be referenced for other valid codes. The CCI information allow you to list the correct coding initiative billing relationships between the codes shown. You can include component codes, mutually exclusive and/or greater procedure codes. When this option is chosen, the codes that accept modifiers will be listed on the report in bold text. The Color Code information, Section Notes/Annotations, Personal User Notes, Global Notes, and Include Page Breaks between multiple codes, check boxes allow you to include these on the report as desired. If you select a check box and there is no information to be printed, "Not Applicable" will be shown on the printed report. Click the Print button to generate the report in the form of a PDF file, or click Cancel to go back without printing the report. Click the back arrow within the browser to return to return to the EncoderPro application when finished with the report printout. 161

174 This is a sample of what a print out looks like. 162

175 ICD-10 Basic Mapping The U.S. Department of Health and Human Services (HHS) has announced that starting in October of 2014, ICD-10 codes will replace ICD-9 codes as the HIPAA adopted code set for use in coding diagnoses in physicians offices and other outpatient settings for diagnoses. Because of this mandate, EncoderPro has implemented a basic mapping tool that will allow you to see which ICD-10 codes map to the current ICD-9 codes, so that you can be prepared for when ICD-10 codes are required. Basic mapping is available for ICD-9-CM Vol. 1 to ICD-10-CM and for ICD-9-CM Vol. 3 to ICD-10-PCS codes. Additionally, you can purchase an add-on module that will allow you access the more advanced mapping features available in EncoderPro. This add-on module is called Map Manager. Access this screen by clicking the green "10" icon on the Code Section page for the selected ICD-9 code or by clicking the link in the Code Detail page for the selected ICD-9 code. If the mapping is not available for a code you will see the red "10" icon indicating that the mapping is not currently available. As more codes become available (as 2014 approaches), you will be able to see more information. The ICD-10 mapping screen allows you to find corresponding ICD-10 codes for selected ICD-9 codes. This screen helps you to know which of the newly proposed ICD-10 codes are most similar for billing purposes to those ICD-9 codes that you currently use for billing. It shows a list of related codes for both simple and complex mapping relationships. Example of the CM code mapping screen in EncodePro Expert for ICD-9-CM Vol. 1 diagnosis code : Example of the PCS code mapping screen in EncoderPro Expert for ICD-9-CM Vol.3 procedural code 28.7: 163

176 There are several columns with information about the relationships of the ICD-10 codes to the ICD-9 codes. Columns displayed and their order will depend on the type of mapping being shown. Coding Tips: This column indicates whether the code has single mapping or complex/combo mapping available. Blank means that simple mapping is only available. A puzzle icon will be displayed when there is complex/combo mapping. Click the icon to display the code alternative combination mapping scenarios that are possible for the corresponding code. A star icon indicates that this code is the preferred code for billing purposes. Note: This is merely a suggestion, it is not a rule that this code is the correct choice. The actual services provided or your billing practice may dictate that a different code may/should be used. The GEM map icon indicates that this code is acceptable to be used according to the US government standards. The Optum map icon indicates the suggested code to be use according the clinical technical experts at Optum. Code Alt: This column shows all of the alternative ICD-10 codes that are related to the current ICD-9 code. Click the column header or double arrows to reorder the column in ascending or descending order. For PCS mapping click the blue arrow next to the ICD-10 code to expand a tree structure to display more specific ICD-10 codes based on the root of the code. For CM codes you can click the link to go to the Code Section/Range page or the Code Detail page. Description: This column shows a description for the ICD-10 codes. This column is displayed for CM type codes. Root Operation/Body System Description: This column shows the code description based on Root Operation or on Body System depending on the PCS code being displayed on the row. This column is displayed for PCS type codes. Code Information: This column displays the applicable data for the code alternative. If the note is large, an expand icon is available. Click the icon to expand the selection to display all the available code information. Click the icon again to hide the text. This column is displayed for CM type codes. Qty: This column show the quantity of "children" codes of the root operation code on this row. Click the blue arrow icon in the 'Code Alt' column to see all the codes corresponding the number in this column. This column is displayed for PCS type codes. 164

177 Instructional Notes: This column displays icons to further explain the applicable note information from the ICD-10-CM book for the code alternative. Hover your mouse pointer over each icon to display the notes for each icon. Green Paper icon: Show the section notes for the entire section of the book to which the code applies. Red Paper icon: Show the category notes for the category that the code pertains to. Yellow Paper icon: Show the chapter notes for the chapter for that code. Backward mapping to ICD-9: This column show a list of other related ICD-9 codes that are mappable backward from the corresponding ICD-10 code. Hover the mouse pointer over the code to view the code description or you can click the code link to display the code section or detail page for the ICD-9 code. If there are more than 50 codes for backward mapping, click the expand icon to display them all. Click the icon again to "hide" them. There are links at the bottom of the screen that provides access to instructional presentations about the proper use of ICD-10 codes. More advanced mapping features and custom mapping options are available in the I-10 Map Manager add-on module. More information about code alternative combinations: The ICD-9-CM Codes to ICD-10 Codes do not always have a direct mapping, one-to-one. If the result for the ICD-10 Code Alternative is a combination of codes, groups of codes are displayed when you choose your ICD- 10 code. Click on one of the icons in the Combo column to display the Code Alternative Combinations section. The Code Alternatives to be billed together column displays the combinations of codes. Each combination of codes that should be billed together are shown within the same row the list. 165

178 Notepad Click the Notepad Button on the Toolbar to open the Notepad screen. The Notepad presents codes in two major groupings. A code is displayed in either the Diagnosis Codes table or the Procedure, Service and/or Supply Codes table. The Notepad functionality is used to temporarily store codes that can be copied to the Windows Clipboard. The advantage of using the Notepad is you can perform several searches and then send all the codes to the clipboard at one time. The Select All column allows you to select all, some, or none of the codes within the table. Click the checkbox in the column header to select all codes or uncheck it to deselect all codes. You can also select or deselect individual codes by clicking the corresponding checkbox for the desired code. The columns in this screen can each be sorted. Highlighted arrows show the column that was used to sort the table along with highlighted ascending or descending arrows. The columns that can be sorted are: Code, Description, Mod1, Mod2, Fee, Work RVU, PE RVU, MPRVU, Total RVU, Fee Type, and Global Days. The fees are displayed if the Fee Type has been set to Facility or Non-Facility. Otherwise, if N/A is selected, N/A is displayed. See Editing Codes in the Notepad. Note: The Mod1, Mod2, Fee, Work RVU, PE RVU, MPRVU, Total RVU, Fee Type, and Global Days columns, as well as fee information, are not available in EncoderPro Standard edition or MedicareReimbursmentPro.com. Notepad Fields and Buttons Notepad Buttons: The Add button is used for Adding Codes to the Notepad. The Delete button is used for Deleting Codes from the Notepad. When you click this button the selected codes will be deleted. A confirmation message will be displayed. Click OK or Cancel. The Copy/Export button is used for Exporting selected codes to the desired location. You can copy/export to Excel, the Windows Clipboard, or to Compliance Editor. You can also indicate which information to export; Code, Code and Description, or All code information including RVU and fee information if available. Note: The Compliance Editor option is only available for EncoderPro Expert and EncoderPro for Payers. In the top section of the screen are: The Edit icon is used for Editing Codes in the Notepad. The Copy icon is used for Copying Codes to the Notepad. 166

179 Editing Codes in the Notepad Click the pencil icon in the Edit column for the corresponding code in the Notepad screen. The Edit Notepad screen is displayed. Add a modifier and change the fee schedule information. NOTE: The Fee Type, Conversion Factor, and % of Medicare fields are not available in EncoderPro.com Standard or MedicareReimbursementPro.com. To Append a Modifier to a Code in the Notepad: CPT and HCPCS modifiers that are specific to a code selected in the Notepad are available in the Modifier 1 and Modifier 2 drop-down lists. Select the proper modifiers and click the Save button. Medicare Physician Fee Schedule (not available in Standard or MedicareReimbursmentPro.com): You can change the Conversion Factor or % of Medicare and the fee will be displayed in the Fee column in Notepad, however, you must have the Fee Type selected as Facility or Non-Facility. If you have N/A selected you will not get the fee in Notepad. Deleting Codes from the Notepad To Delete a Row from the Notepad, check the box(es) for the corresponding code(s) and click the Delete button. Copying Codes in the Notepad To duplicate a row in the Notepad, click the Copy button in the right column of the Notepad screen. Adding Codes to the Notepad You can add codes to the Notepad within the Notepad dialog box and from the Code Sections. Add a Code to the Notepad from within the Notepad: 1. Click the Add button. 2. Type the code or multiple codes separated with commas. 3. Click Save. Add a Code to the Notepad from the Code Sections: 1. Click the Add to Notepad Button in the Actions column. 2. Fill in the appropriate fields in the Edit Notepad screen and click Save. 167

180 Codes to Compliance Edit After you select codes in the Notepad screen and click the Copy/Export button with the Compliance Editor radio button option, your codes are displayed on the Codes to Compliance Edit screen. Select the Check (#1,#2,#3,#4,#5) from the drop down box to indicate which Compliance Editor tab that should receive your codes from the Notepad. The default is Check #1. You can select the primary and secondary diagnosis codes if they were already in Notepad. Note: Exporting these codes into a Compliance Editor tab will overwrite any codes that you may have already entered previously into that tab of Compliance Editor. Click Export to Compliance Editor to go to Compliance Edit where you can run the edits for the codes. Exporting Codes from the Notepad You can export code information from the Notepad for use in a windows text editor, Excel spreadsheet, or Compliance Editor. Check the box next to the code(s) you wish to export and then click the Copy/Export button, with either the Excel option, the Clipboard option, or the Compliance Editor option selected. Depending on which Export: radio button is selected will determine how much of the code information is exported. Locations: Excel: Select this option to export the code information for use in a spreadsheet Clipboard: Select this option to export the code information to the Windows Clipboard, to be used in another third party application. Compliance Editor: Select this option to export the codes to the Compliance Edit. In the Select All column, place a check in the box for each code you want to add to the Compliance Edit. This option is only available for EncoderPro Expert and EncoderPro for Payers. Export: Code: Export just the code to the desired location. Code/Description: export just your codes and descriptions to the desired location. All Information: export all fields that contain data to the desired location. Note: When exporting codes to Compliance Editor, the Export radio buttons will be grayed out since this doesn't apply to Compliance Editor. The information will be copied to the windows clipboard and you can then open up the desired third party application and paste it into it. 168

181 Compliance Edit You can run a compliance edit to display coding conflicts affecting the Diagnosis, CPT and HCPCS codes. You can enter patient data to enhance the compliance edit. The rules for compliancy are based on non-facility rules (professional HCFA 1500 claims). Compliancy for facility claims (institutional UB04 claims) is not yet available. Claims edits rules for ICD-10-CM and ICD-10-PCS codes are in the process of being refined by the industry and insurance payers. The complete set of ICD-10 codes is to be implemented after October Click on the Toolbar. Compliance Edit Screen Enter a Claim Identifier. This is a free form text field for any kind of text entered. It can be left blank. Enter a Claim Date of Service. The date entered here will also be used in the claim lines individual dates of service as well. If necessary, you can change the date of service on the individual service lines in the lower section. Please note that although CCI edit checking may be available for up to two years, it is important to remember that certain timely filing guidelines are in effect depending upon the payer. Enter the patient s date of birth (or select from the calendar) for specific edits that relate to the patient's age. Enter the patient s gender for the specific compliance edits that check for gender conflicts. Click the check box to make the currently selected gender, the default selection. Each of the 5 Check tabs can have its own default set. (This is useful for specialty type practices such as women's health clinics.) Enter a Provider Specialty. Some edits are dependant on the specialty of the provider. If this is left blank then those edits will not be utilized. Select the Region and Medicare Carrier. The Medicare Carrier list shows the Medicare information that is used for the Medical Necessity edits. If none is selected then a basic "generic" set of edit rules will be used. Add codes to the Claim Lines in the CPT and/or HCPCS Codes field. For multiple codes, enter a comma separated list of codes. An example is provided below the CPT and HCPCS Codes field. After entering code(s), click Add. Each code displays on a separate claim line below. Non-Facility or Facility fees are available when you select the radio button. The default is set to Non-Facility. Enter primary or secondary diagnosis codes into the text boxes (optional). If you want to change or remove the diagnosis code, click the pencil icon next to the code to put the field text box into edit mode. 169

182 You can also look up cross coded diagnosis codes for the CPT code on this line item by clicking on the cross coder button. Click the LCD pill icon to look up LCD policy information associated with the CPT and diagnosis codes on this line item. Click the red triangle icon to copy the diagnosis code down to the other line items of the claim. Press the Enter key or click away from the box to save the codes. Highlight the code and press the Delete key to remove a diagnosis code. Enter one or two modifiers if desired, or click the magnifying glass to select from a look up list. Only valid modifiers are shown in the list. Click Run Check # (1,2,3,4,5). Or if you need to make a change and wish to start over click Clear Check # (1,2,3,4,5). Certain fields are "sticky" in that they remember the previously entered information from previous run checks. These fields are: Region, Medicare Carrier, Fee Type (radio button), Medicare/Commercial radio button, Date of Service, Claim Date of Service, Gender, and Provider Specialty. Compliance Edit Screen The number of lines in the Claim Lines section is based on the number of codes entered. When you click the Add button, a validation process determines whether you entered any deleted or invalid HCPCS/CPT/Diagnosis Codes. Deleted codes are underlined and black in the Code column. Click the deleted code to go to Deleted Codes and determine which code to use. Invalid codes are black in the Code column. Hover the mouse pointer over the code to see the Invalid Code tool tip. Columns that can be sorted have sort arrows. Click the arrows to sort in ascending or descending order. Fee Type allows you to see Facility or Non-Facility fees. The default is set to Non-Facility fees. If you change the Fee Type after the fees are on the Claim Lines, all fees will be changed to the new selection. The edit results are based on non-facility fee (professional) rules, regardless of which fee type option is selected. The fee type selection simply changes the data that is displayed in the "Fee", "Total RVU", and "Work RVU" columns. The amount as listed in the column will be displayed in red text if affected by the facility vs. non-facility fee scenario. The selection of the fee type displayed does not affect actual claim edit results on the procedure code. A disclaimer message will also be displayed regarding your use of EncoderPro and the facility/non-facility amounts displayed. 170

183 Click this link for Disclaimer Message Example: Run Check #(1,2,3,4,5) button starts the Compliance Edit function based on the information supplied on the screen. The Compliance Check runs in the background so you can start another Check #2, Check #3, etc by selecting another tab. Compliance Edit Screen After the Compliance Edit checks for rules and edits and if any conflicts exist, icons appear in the Edit Conflicts column. Hover the mouse pointer over the icon to display the Edit Conflict. Each edit message will have its own mnemonic icon with a tool tip message briefly explaining the reason for the edit. The mnemonic icon for each edit is displayed along with the line number for the edit conflict. When an edit is encountered then the appropriate edit icon will be shown. When a claim line is "clean" and has no edit error then the green "OK" icon will be shown indicating that the service line is satisfactory for submission to processing. The Edit Conflicts section displays the Claim Line in the Line column with the Edit Type, Edit Conflict and Description. Click an icon in the Edit Conflicts column to display the Edit Conflicts section. Edit Conflicts 171

184 displays the Edit Type, Edit Conflict and Description. Any HCPCS/CPT codes in this section are links to the Code Detail or Code Section (set in Preferences). When you change the claim information in a field that requires an edit recheck of the claim, the Edit Conflicts section will be dismissed indicating that a recheck is necessary. However when you change a field that does not require rechecking the claim edit then the Edit Conflicts section will remain on the screen; clicking Run Check simply refocuses the screen on the existing Edit Conflicts. The fields that DO require a recheck are the following: Claim Date of Service, Line Item Date of Service, Medicare/Commercial radio button, Modifier, CPT and/or HCPCS Codes (including import functions), Diagnosis fields, Medicare Carrier, Region, Gender, and Delete line. Note: Changing the fee type does NOT require a recheck, since fee type is not taken into account with the edit check process. Non-facility fee rules are used in the edit check process. Click the Optum Coding Answers link to access answer to common coding questions. If you do not have a subscription, you will be directed to the Optum website where you can purchase it. You can go to Preferences and set up your login and access your Coding Answers without logging in again. Click Import PEP to add the codes to the Compliance Edit from the Patient Encounter Form. Click Import Notepad to add the codes to the Compliance Edit from the Notepad. Click Import Claims Batch to run the Compliance Edit on an entire batch of claims at once using the Claims Batch Editor. Edit Conflicts This section of the screen displays a report of the codes that have edit conflicts. It appears when edit conflicts are found after you click the Run Check button on the Compliance Edit screen, or in the Repair Toolkit Screen. The Edit Conflicts section reports all edit conflicts for the claim lines. The Line column lists each code by line number that is affected by an edit conflict. The Icon column lists each icon mnemonic code for each line that is affected by an edit conflict. The Edit Type column displays either Review or Caution. Review means it should re-coded. Caution is a warning that the use of the code may be appropriate but has been questioned. The Edit Conflict column displays the name of the edit conflict. The Description column provides more information about the conflict. After the Compliance Edit checks for rules and edits and if any conflicts exist, icons appear in the Edit Conflicts column. Hover the mouse pointer over the icon to display the Edit Conflict. Each edit message will have its own mnemonic icon with a tool tip message briefly explaining the reason for the edit. The mnemonic icon for each edit is displayed along with the line number for the edit conflict. When an edit is encountered then the appropriate edit icon will be shown. When a claim line is "clean" and has no edit error then the green "OK" icon will be shown [ ]indicating that the service line is satisfactory for submission to processing. The Edit Conflicts section displays the Claim Line in the Line column with the Edit Type, Edit Conflict and Description. Click an icon in the Edit Conflicts column to display the Edit Conflicts section. Edit Conflicts 172

185 displays the Edit Type, Edit Conflict and Description. Any HCPCS/CPT codes in this section are links to the Code Detail or Code Section (set in Preferences). Please note that although CCI edit checking may be available for up to two years, it is important to remember that certain timely filing guidelines are in effect depending upon the payer. 173

186 Claims Edits List - Commercial Flag Status Description ACW Caution Anesthesia Crosswalk When a surgical CPT procedure code is billed by an anesthesiologist to report the anesthesia Claims Manager for that procedure, ClaimsManager crosses the surgical procedure code to the appropriate anesthesia CPT code prior to analysis. This edit identifies instances where a surgical procedure code was crosswalked to the CPT code describing anesthesia Claims Manager for that procedure. This crosswalk occurs for claims by any provider identified in the provider database as specialty 05 (Anesthesiology) or 43 (Certified Registered Nurse Anesthetist, Anesthesia Assistant). This flag should always be set for profiling since it describes a process, not an error. The default action for this edit is Caution. ANE Review Anesthesia By Non-Anesthesiologist This flag is driven by provider specialties 05 and 43 and is intended to identify improper use of anesthesia codes for postoperative pain management, local anesthesia, or sedation not requiring monitoring by an anesthesiologist. ASD Review Anesthesia Secondary Procedure For a given operative session, only one anesthesia code should be billed, even when multiple surgical procedures are performed. In such cases, it is important to bill the anesthesia service with the highest value. This flag identifies when more than one anesthesia service has been billed, and invalidates the flagged line from further editing. BDS Review Missing or Invalid Date of Service The beginning or ending Date of Service is invalid. BRR Caution Anesthesia Crosswalk By Report The system was unable to crosswalk this surgical code to an anesthesia code. The surgical CPT code is a "By Report" procedure. Review the documentation. CAG Review Injection Procedure w/o Cardiac Catheterization CPT codes identify injection procedures performed during cardiac catheterization. Whenever these codes appear, the claim is searched to verify that a cardiac catheterization was also billed. If a corresponding cardiac catheterization is not found, ClaimsManager flags this and recommends reporting of the injection using the codes in the Vascular Procedures section of CPT ( ) instead of the listed injection code. It is also possible, though less likely, that the cardiac catheterization has been left off the claim and should be added rather than replacing the injection code. CCI Review Injection Procedure w/o Cardiac Catheterization CPT codes identify injection procedures performed during cardiac catheterization. Whenever these codes appear, the claim is searched to verify that a cardiac catheterization was also billed. If a corresponding cardiac catheterization is not found, ClaimsManager flags this and recommends reporting of the injection using the codes in the Vascular Procedures section of CPT ( ) instead of the listed injection code. It is also possible, though less likely, that the cardiac catheterization has been left off the claim and should be added rather than replacing the injection code. CCR Review Cardiac Catheterization w/o Rad Supervision An injection procedure for cardiac catheterization has been billed without the radiological supervision procedure. CDL Review Deleted Procedure Code Procedure code has been deleted. CPT Review Missing or Invalid Procedure Code Procedure code is invalid or missing. CSX Review Procedure Not Typical for Sex of Patient 174

187 Procedure code is not typically performed for gender of patient. DAP Review Deny Add on Procedure Indicates the submitted Add On procedure code needs to be denied because the primary procedure code submitted with the Add On Code was denied. DLP Review Duplicate Line by Provider The line item may be a duplicate of another line item performed by the same provider. (without the appropriate overrides.) GFP Review Global Follow-up by Provider This flag identifies an evaluation and management (E/M) code that: was billed during the global followup period of an earlier procedure has the same primary diagnosis as any one diagnosis for the earlier Procedure was performed by the same physician. No modifier overrides this flag so we recommend that the line be deleted from your claim before submitting it to your payer. This flag applies to non-medicare claims. The mfp mnemonic flags the same scenario for Medicare claims. The GFP flag invalidates the line for further editing. GSP Review Post-Op Surgery by Provider This flag identifies a procedure code that: was billed without an appropriate modifier during the global follow-up period of an earlier procedure has the same primary diagnosis as any one diagnosis for the earlier procedure was performed by the same physician The flag description indicates that modifier -58, -76, -78, or -79 is required. This flag applies to non-medicare claims. The msp mnemonic flags the same scenario for Medicare claims. IAG Review Diagnosis Not Typical for Patient Age Diagnosis Code is not typical for age of this patient ICD Review ICD-9 CM Code Cannot be Found in Database Diagnosis code is not listed as a valid code in the ICD-9 database. ICM Review Missing Diagnosis Code The primary diagnosis is missing. ICR Caution Anesthesia Crosswalk Individual Consideration Procedure code requires crosswalking to one of several appropriate anesthesia codes before pricing. Review the documentation for correct code. IDL Review Deleted ICD9-CM Code Diagnosis code has been deleted. IDX Review Non Specific Diagnosis Code Diagnosis code is a non-specific diagnosis code and requires a fourth and/or fifth digit to provide the proper specificity. IMC Review Inappropriate Modifier Combination Identifies modifiers that cannot be used together on the same claim line. IMO Review Invalid Modifier This edit identifies a line containing a modifier that cannot be found in the table of valid CPT, Medicare, or user-defined modifiers. INJ Review Injection Administration w/o Supply 175

188 When an injection is performed in an office setting, the claim is searched for the presence of CPT code or a HCPCS Level II J code to verify that the arterial injection has been reported. If no such code is found, the flag is set and recommends adding this billable item to the claim. ISX Review Diagnosis Not Typical for Patient s Gender Diagnosis code is not typical for patient gender. LNM Review No initial lab procedure to repeat Lab procedure billed with a 59 or 91 modifier. No other lab billed on the same date of service. LPR Review Repeat lab procedure Lab procedure code has been billed more than once for the date of service without a repeat modifier (59 or 91). M26 Review Modifier 26 Required This flag identifies line items that do not contain a modifier -26 for a procedure with a PC/TC split when the procedure was performed in a hospital inpatient or outpatient place of service. When a procedure that has both a professional and technical component is performed in an inpatient or hospital outpatient setting, the physician should bill only the professional component because the technical component is typically billed by the facility. To identify the professional component, the physician should apply modifier -26 or -PC following the CPT code, or use Q as the type of service indicator. The list of procedures with PC/ TC splits is not always consistent with the Medicare list and use of this flag is not recommended for analysis of Medicare claims. Other flag address PC/TC issues for Medicare claims. MFD Review Typical Daily Frequency Exceeded Line item may be a duplicate of one on another claim or the typical allowed daily frequency for this procedure is exceeded. M51 Review Modifier 51 required This flag identifies line items that do not contain a modifier 51 for multiple procedures. However, this edit works in conjunction with the N51 and NOT flag the procedure with the highest RVU nor will this edit flag subsidiary codes that should not billed with a 51 in the first place. MOD Review Modifier Not Appropriate Modifier is inappropriate with listed CPT code. N51 Review Modifier 51 Not Allowed on Primary Procedure This flag identifies line items where modifier 51 is appended to either the only procedure code billed on one claim or the primary procedure NPD Review Not a Primary Diagnosis Diagnosis Code describes an external cause, underlying disease, or unacceptable and should never be listed as the primary diagnosis for a procedure. PCM Review Invalid Professional Component Modifier Modifier 26 or PC is invalid with the procedure code billed. PRO Review Prolonged Service without E&M Procedure Prolonged service procedure has been billed without a corresponding E&M procedure. PRS Review Missing or Invalid Provider Specialty Provider s specialty is missing or invalid. PSX Review Missing Patient Gender 176

189 The gender for this patient is either empty or an invalid. RDL Review Repeat Radiology Radiology procedure code has been billed more than once for the date of service without a repeat modifier (76,77 or 59). REB Review Re-bundle to Appropriate Procedure Code When two or more billed Claims Manager are more appropriately reported using a single code, the lines is playing these CPT codes are flagged. In the flag description, the code to which these Claims Manager rebundle is displayed. An REB flag is set for each line of service involved in the rebundle process. This means, for example, that a single coding mistake involving rebundling of three Claims Manager into one service is reported as three REB flags. The TRA flag and the REB flag describe two steps in the rebundle process. The REB flag invalidates the line for further editing. RNM Review Inappropriate use of Repeat Modifier Radiology procedure billed with a 76, 77 or 59 modifier. The same radiology code has not been billed on the same date of service. S51 Review Subsidiary code with modifier 51 Subsidiary code was billed with a modifier 51. These codes are usually exempt from modifier 51 guidelines. SAS Review Typically no Surgical Assistant Required Procedure Code typically requires no Surgical Assistant. SUB Review Add On Code w/o Primary Procedure Subsidiary or Add on code was billed without the primary procedure code. Use msb for Medicare subsidiary codes. TRA Review Transfer to Appropriate CPT Transfers to a more appropriate CPT code when applicable. This flag works in conjunction with the REB flag. UED Review Coding Relationship Error, Deny This flag identifies a procedure that has an appropriate relationship with another procedure on the same claim. The line flagged identifies the procedure that would be denied if both were submitted. The UED flag invalidates the line for further editing. Use mun and muo for Medicare unbundling. UES Review Coding Relationship Error, Secondary This flag identifies a procedure that has an inappropriate relationship with another procedure on the same claim. The line flagged identifies the procedure that would be denied if both were submitted. In practice, this flag is identical to UED. Differences in the types of unbundling relationships between CPT codes require two flags to provide the appropriate result and flag description. The UES flag invalidates the line for further editing. Use mun and muo for Medicare unbundling. UID Review Incidental Procedure, Deny This flag identifies a minor procedure that is performed during the same session as a related major procedure (for example, meatotomy performed during the same session as a cystourethroscopy with biopsy). These procedures are considered incidental and are included in the payment for the major procedure and are denied if billed separately. The UID flag invalidates the line for further editing.. Use mun and muo for Medicare unbundling. UIS Review Incidental Procedure, Secondary 177

190 This flag identifies a minor procedure that is performed during the same session as a related major procedure (for example, removal of a foreign body in the ear at the time of a surgical ear exploration). The foreign body removal is considered included in the payment for the major procedure and is denied if billed separately. In practice, this flag is identical to UID. Differences in the types of incidental relationships between CPT codes require two flags to provide the appropriate result and flag description. The UIS flag invalidates the line for further editing. Use mun and muo for Medicare unbundling. UNL Caution CPT Code Unlisted This flag identifies CPT-4 codes that are used for procedures or Claims Manager that have no CPT code that adequately describes them (for example, Unlisted pulmonary service or procedure). Documentation is required to describe the unlisted service. UOE Review Unbundled E&M Procedure Evaluation and management (E/M) Claims Manager cannot be billed on the same day as surgical procedures, with the exception of some minor diagnostic procedures. They are considered to be included in the payment for the procedure. The exception is when the E/M service is for an unrelated condition (i.e., a significant, separately identifiable E/M service ) or when the E/M service results in the initial decision to perform the surgery. These conditions should be identified by using modifiers -25 or - 57 respectively. The list of procedures for which an E/M service can be billed on the same date is derived from two sources. For private payers, it is derived from Optum's Claims Edit System database. For Medicare payers, it is derived from CMS s Correct Coding Initiative (CCI). The UOE flag invalidates the line for further editing. Use mem for Medicare E&M unbundling. UUD Review Unbundled Procedure, Deny This flag identifies a procedure that is considered an essential part of another procedure performed on the same date, such as intermediate repair performed with an exploratory laparotomy. The line flagged identifies the procedure that would be denied if both were submitted. The UUD flag invalidates the line for further editing. Use mun and muo for Medicare unbundling. UUS Review Unbundled Procedure, Secondary This flag identifies a procedure that is considered an essential part of another procedure performed on the same date, such as introduction of needle or catheter billed with administration of chemotherapy. The line flagged identifies the procedure that would be denied if both were submitted. In practice, this flag is identical to UUD. Differences in the types of unbundling relationships between CPT codes require two flags to provide the appropriate result and flag description. The UUS flag invalidates the line for further editing. Use mun and muo for Medicare unbundling. VEN Review Venipuncture Not Billed Procedure code which requires a venipuncture was billed without the corresponding venipuncture code. 178

191 Claims Edits List - Medicare Flag Status Description ACW Caution Anesthesia Crosswalk The surgical procedure code has been crosswalked to an anesthesia procedure code for analysis of the claim. ANE Review Anesthesia By Non-Anesthesiologist A Procedure was billed by a provider not listed as an Anesthesiologist or a Nurse Anesthetist (Specialty type of 05 or 43). Review provider file and documentation to verify appropriateness. ASD Review Anesthesia Secondary Procedure Only allow the anesthesia code with the highest base unit value per operative session. BAG Review Procedure Not Typical for Patient Sex The gender billed on the claim does not meet the policy requirements per LCD Part A guidelines. BAG Review Inappropriate Age for LCD Part B The age billed on the claim does not meet the policy requirements per LCD Part B guidelines. BCD Review Missing or Invalid Dx for Code to code The diagnosis code required for the procedure to procedure relationship is either missing from the claim line or has been disabled. BCM Review Missing or Invalid Mod for C2C in LCD B The modifier code required for the procedure to procedure relationship is either missing from the claim line/history line. BCP Review Missing or Invalid Additional Procedure The procedure code billed requires an additional procedure to be billed per LCD Part B guidelines. BDS Review Missing or Invalid Date of Service The beginning or ending Date of Service is invalid. BFR Review LCD Part B Typical Frequency Exceeded The maximum allowed frequency for the procedure has been exceeded per LCD Part B guidelines. BPO Review Missing required LCD Place of Service The place of service code billed on the claim does not meet the policy requirements per LCD Part B guidelines. BRR Review Anesthesia Crosswalk By Report The system was unable to crosswalk this surgical code to an anesthesia code. The surgical CPT code is a "By Report" procedure. Review the documentation. BSX Review Procedure Not Typical for Patient Sex The gender billed on the claim does not meet the policy requirements per LCD Part B guidelines. CAG Review Procedure Not Typical for Age of Patient Procedure code is not typical for the age of the patient. CCI Review Injection Procedure w/o Cardiac Catheterization An injection procedure for cardiac catheterization has been billed without the primary cardiac 179

192 catheterization procedure. CCR Review Cardiac Catheterization w/o Rad Supervision An injection procedure for cardiac catheterization has been billed without the radiological supervision procedure. CDL Review Deleted Procedure Code Procedure code has been deleted. CPT Review Missing or Invalid Procedure Code Procedure code is invalid or missing. CSX Review Procedure Not Typical for Sex of Patient Procedure code is not typically performed for gender of patient. DLP Review Duplicate Line by Provider The line item may be a duplicate of another line item performed by the same provider. without the appropriate overrides IAG Review Diagnosis Not Typical for Patient Age Diagnosis Code is not typical for age of this patient ICD Review ICD-9 CM Code Cannot be Found in Database Diagnosis code is not listed as a valid code in the ICD-9 database. ICM Review Missing Diagnosis Code The primary diagnosis is missing. ICR Caution Anesthesia Crosswalk Individual Consideration Procedure code requires crosswalking to one of several appropriate anesthesia codes before pricing. Review the documentation for correct code. IDL Review Deleted ICD9-CM Code Diagnosis code has been deleted. IDX Review Non Specific Diagnosis Code Diagnosis code is a non-specific diagnosis code and requires a fourth and/or fifth digit to provide the proper specificity. IMC Review Inappropriate Modifier Combination Identifies modifiers that cannot be used together on the same claim line. IMO Review Invalid Modifier This edit identifies a line containing a modifier that cannot be found in the table of valid CPT, Medicare, or user-defined modifiers. INJ Review Injection Administration w/o Supply Injection administration procedure has been bill without the drug or supply administered. ISX Review Diagnosis Not Typical for Patient s Gender Diagnosis code is not typical for patient gender. LBI Review Missing required LCD Part B diagnosis 180

193 None of the diagnosis billed on the claim line supports medical necessity as specified by the LCD guidelines. LBM Review Missing LCD Part B modifier The modifier required for this policy is missing or disabled. LBN Review LCD Part B diagnosis is not in the Primary Position A diagnosis code on the claim meets medical necessity, but the diagnosis was not billed in the primary position as specified in the LCD Part B policy. LBP Review Missing or invalid sequence of LCD Part B primary diagnosis The primary diagnosis billed on the claim is not an LCD specified diagnosis code or the primary diagnosis code is missing. LBS Review Missing or invalid sequence of LCD Part B secondary diagnosis The secondary diagnosis billed on the claim is not an LCD specified diagnosis code or the secondary diagnosis code is missing. LBT Review Missing or invalid sequence of LCD Part B tertiary diagnosis The tertiary diagnosis billed on the claim is not an LCD specified diagnosis code or the tertiary diagnosis code is missing. M26 Caution Modifier 26 Required This flag identifies line items that do not contain a modifier -26 for a procedure with a PC/TC split when the procedure was performed in a hospital inpatient or outpatient place of service. When a procedure that has both a professional and technical component is performed in an inpatient or hospital outpatient setting, the physician should bill only the professional component because the technical component is typically billed by the facility. To identify the professional component, the physician should apply modifier -26 or -PC following the CPT code, or use Q as the type of service indicator. The list of procedures with PC/ TC splits is not always consistent with the Medicare list and use of this flag is not recommended for analysis of Medicare claims. Other flag address PC/TC issues for Medicare claims. M51 Review Modifier 51 Required This flag identifies line items that do not contain modifier 51 for multiple procedures. However, this edit works in conjunction with the N51 and will NOT flag the procedure with the highest RVU nor will this edit flag subsidiary codes that should not be billed with a modifier 51. map Review Deny Add On Procedure Indicates the submitted Add On procedure code needs to be denied because the primary procedure code submitted with the Add On Code was denied. mas Review Assistant Surgeon not Permitted No payment allowed for surgical assistant. mb2 Review Bilateral Payment Adjustment is not Applicable This flag is an advisory edit that does not identify a coding error. Instead, it notifies you of procedures for which the typical payment adjustments are not applicable. The default action for this flag is Caution. This flag allows you to monitor or spot check claims to verify that appropriate Medicare payment rules are being followed. There are four possible ways in which bilateral procedures are reimbursed. Please see User s guide for details. mbc Review Bundled Code Payment is not considered. Procedure code has no RVU s assigned. mbi Review Bundled Item or Service This flag identifies items or Claims Manager that are covered as incident to a physician service. These items or Claims Manager are bundled into the payment for that physician service if provided on the same date and will not be separately reimbursed. An example is an elastic bandage furnished by a 181

194 physician incident to a physician service such as treatment of an ankle sprain. mco Review Co-surgeons not Permitted Medicare has identified CPT codes for which no reimbursement may be made for co-surgeons. When one of these codes is billed with a modifier - 62, the line is flagged by this flag. This does not include those procedures for which co-surgery is reimbursed if documentation is submitted to establish medical necessity; these CPT codes are flagged with the documentation flag md2. md1 Review Document Assistant at Surgery Surgical assistant payment may be allowed if documentation supports medical necessity. md2 Review Document Co-surgeons Co-surgery payment may be allowed if documentation supports medical necessity. md3 Review Document Team Surgery Team surgery payment may be allowed if documentation supports medical necessity. mdp Review Post-op Unrelated Service by Provider E&M procedure with a different diagnosis, without an appropriate modifier, is within the global period of another procedure performed by the same provider. mdt Review Diagnostic Test in Hospital Setting Procedure code requires a modifier -26 when billing for the professional component in an inpatient or outpatient hospital setting. mem Review Surgical Procedure with E&M E&M code has been billed by the same provider on the same day or previous day as a surgical procedure. Modifier 25 or 57 is required. mfp Review Follow-up by Provider This flag identifies an evaluation and management (E/M) code that; Was billed during the global follow-up period of an earlier procedure Has the same primary diagnosis as any one diagnosis for the earlier procedure Was performed by the same physician. No modifier overrides this flag so we recommend that the line be deleted from your claim before submitting it to your payer. This flag applies to Medicare claims. The GFP edit flags the same scenario for non-medicare claims. The global period for this edit is defined by CMS s Physician Fee Schedule. mgt Review Global Test Only Modifier 26 or TC is not appropriate to be billed with a stand-alone diagnostic test. mim Review Inappropriate Modifier Procedure has been billed with a modifier considered irrelevant by Medicare. See User s Guide for detail min Review Injection Service Injections service is bundled into any other Claims Manager payable under the fee schedule. mlp Review Laboratory Physician Interpretation Laboratory code for which separate payment may be made. Modifier TC is not applicable. mns Review Non-covered Service Claims Manager that are not covered by Medicare and the patient may be billed. 182

195 mnv Review Not Valid for Medicare Purposes Procedure code is not valid for Medicare purposes, an alternate procedure code should be used. MOD Review Modifier Not Appropriate Modifier is inappropriate with listed CPT code. mog Review Medicare Outside Global Period This flag indicated that the procedure code submitted with (post operative follow-up visit, included in global service) is outside the global follow-up period and a separately billable E/M code can be billed instead of mpc Review Professional Component Only A stand-alone code for the professional component of a diagnostic service has been billed. Modifier 26 or TC is not applicable. mpi Review Physician Interpretation code This flag identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for a hospital inpatient. No billing of the technical component is recognized because payment for the underlying clinical laboratory test is made to the hospital. mps Review Physician Service Code Professional/technical component split does not apply to certain procedure codes. Modifier 26 or TC is not applicable. mpt Review Physical Therapy Service Physical therapy Claims Manager are not reimbursed to a physician in an inpatient or outpatient hospital setting. msb Review Add on Code w/o Primary Procedure Subsidiary or Add on code was billed without the primary procedure code. msp Review Post-op Surgery by Provider Surgical procedure Code is within the global period of another procedure performed by the same physician. It should not be billed without modifier -58 for Staged, -76 for Repeat, -78 for Complication, or -79 for Unrelated. mts Review Team Surgeons not Permitted No payment allowed for team surgeons. mun Review Unbundled Code Medicare Unbundling rules will search out in history for Comprehensive, Component, and Mutually Exclusive codes. The mun flag will be issued when the current claim line unbundles to another line on the current claim or to a claim line in history. The mun flag is similar to the muh flag. However, it is raised when a component of the primary procedure is billed either on the same claim or on a later claim for the same patient. The mun flag invalidates the line from further editing. muo Review Unbundled Code Modifier Override Procedure code unbundles to another procedure code on the same claim for which an appropriate modifier override is allowed. mup Review Unrelated Surgery by Provider This flag identifies a procedure code that has been billed, without the appropriate modifier, during the global follow-up period of an earlier procedure, and was performed by a physician in the same department, but with a different diagnosis. The flag description indicates that modifier -79 is required. However, the system is unable to make an absolute determination of the relationship between procedures. So that the appropriate modifiers can be applied once the reviewer makes the final 183

196 determination, the following modifiers have been included to suppress the mup flag: -58, -76, -78, or This flag applies to Medicare claims. The GUP edit flags the same scenario for non-medicare claims. The global period for this flag is defined by CMS s Physician Fee Schedule mvm Review Ventilator Management Ventilator management codes are not allowed for the same date of service as E&M Claims Manager. mvp Review Medicare Venipuncture Procedure code which requires a venipuncture was billed without the corresponding venipuncture code. N51 Review Modifier 51 Not Allowed on Primary Procedure This flag identifies line items where modifier 51 is appended to either the only procedure code billed on the claim or to the primary procedure. NPD Review Not a Primary Diagnosis Diagnosis Code describes an external cause, underlying disease, or unacceptable and should never be listed as the primary diagnosis for a procedure. PAT Review Missing Patient ID The Patient ID is blank or cannot be located. No further analysis could be performed. PAY Review Missing or Invalid Payer ID The Payer ID is blank or cannot be located. No further analysis could be performed. PCM Review Invalid Professional Component Modifier Modifier 26 or PC is invalid with the procedure code billed. PRO Review Prolonged Service without E&M Procedure Prolonged service procedure has been billed without a corresponding E&M procedure. PRS Review Missing or Invalid Provider Specialty Provider s specialty is missing or invalid. PSX Review Missing Patient Gender The gender for this patient is either empty or an invalid. RNM Review Inappropriate use of Repeat Modifier Radiology procedure billed with a 76, 77 or 59 modifier. The same radiology code has not been billed on the same date of service. UNL Caution CPT Code Unlisted Procedure code is an unlisted procedure for which there is no applicable CPT procedure code. Documentation may be required. 184

197 User Data - Outpatient Forms Click the Print ABN button from the Compliance Edit screen. Enter the following information, if desired (optional): Patient Information: Patient's Name, Health Insurance Claim (HIC) Number, Estimated Cost Form Header: Select Logo Form Footer: Clinic Name, Clinic Address, Clinic Tel. Number Click Print ABN to go to the form. Then, click the Print icon on the browser to print the ABN form. Note: If you print your ABN form from a Compliance Edit Check # that contains codes, the ABN form will contain the codes. If you print from a blank Compliance Edit Check #, the ABN will be a blank form. 185

198 User Notes User Notes are custom notes that are created by you or an Administrator. You can attach user notes to selected codes. They can be viewed by all users in your organization, however, you can edit only the notes that you entered if you are not an Administrator. You can add one note to multiple codes. You can also add multiple notes to any given code. If you are an administrator you can mark the User Notes as Global User Notes that allow all users to view the notes within your company. User Notes columns: The columns can be sorted. Click the arrows to sort ascending or descending. Stop your pointer over the arrows to display which sort is available. The Title column shows the title the author gave to the user note. Click on the title to view the entire note. The Code column displays all codes that have a User Note. Click the colored code link to go to the Code Section. The Note column displays the text you added to the code. The Modify Date column shows the date and time the User Note was added or modified. Copy to Clipboard Select the Copy to Clipboard button and the User Notes are copied to the Windows Clipboard where you can copy them into other Windows applications. A message displays to inform you that the notes have been copied to the Windows Clipboard and can now be pasted into another Windows application. 186

199 Add User Notes To add User Notes, click the Add User Notes Analyzer grid. icon in the Actions column of a Code Section or the Fee Give your User Note a Title and type text in the Note field. Click Save. Adding Notes If you are an Administrator, click the Global Note for Entire Company checkbox to make a User Note viewable by all users in your company. Otherwise, the note will be your personal note. Add the title and note text. If you want to associate the note with other codes, add those codes in the Codes Assigned to User Note field. If you are adding multiple codes, note that you separate them by commas. View User Notes Click the User Notes Button from the Toolbar. Click the View User Notes Icon in the References column in a Code Section that already has a User Note. Click the User Notes icon next to your code in the grid from the Home Page. This icon is displayed for all rows in the grid that have User Notes. Edit User Notes Click the User Notes icon from the Toolbar and the icon in the Edit column for the User Note. Make your changes and click Save. Modifying Notes You can edit a User Note by clicking the Edit button at the right of the User Note. This allows you to change the title or note, or add more codes to the same note. 187

200 Delete User Notes Click the User Notes icon from the Toolbar and the Delete icon. A verification box appears confirming you want to permanently delete the note. Click OK. Search User Notes Enter text in the Search User Notes field and click Search, to find a specific note that contains the text. 188

201 Medicare Reference Medical Necessity Edits LCD Medical Necessity Edits See also NCD Medical Necessity Edits LCD Medical Necessity Edits displays CPT Codes and ICD-9-CM Codes that are medically necessary for a selected CPT code and Medicare carrier. In EncoderPro Expert, EncoderPro Professional and EncoderPro for Payers, the code is a link in the "Id" column. Click the code to access the policy. On the CPT Code Section screen or HCPCS Code Section screen, click the LCD icon located in the Reference column or click the link to the Medical Necessity Edits from the CPT Code Detail or HCPCS Code Detail. The icon displays if there are any LCD Edits for that code and any carrier. If the Medicare Carrier/Locality that was set in the LCD Medical Necessity Edits section has LCD edits, the policies are listed on the LCD screen. If there are no edits for the selected carrier, this message is displayed: There are no policies that match the search criteria. If you would like to check another medicare carrier or fiscal intermediary, please select one and search again. Or select All Carriers or All Fiscal Intermediaries from the pull down box. These wider search criteria are the first entry in the list. Use the drop-down list to select another Medicare Carrier/Locality and view the LCD data for the selected code if it is available. The selection list contains only the Medicare Carriers with LCD data. Make default carrier checkbox can be selected to set the Medicare Carrier/Locality as your default carrier. Click the icon in the Code column to access the code list box. It displays CPT codes and ICD-9-CM codes that are Medical Necessity edits for the selected CPT code and Medicare Carrier. Click the red code number links for CPT codes and green code number links for ICD-9-CM codes to go to the code in the Code Section. Click the code link in the " Id" column to display the policy. The LCD Information screen displays CPT/HCPCS Codes and ICD-9-CM codes that are Medical Necessity edits for the selected code. It contains red CPT/HCPCS code number links and green ICD-9 code number links that go to the selected code in the appropriate Code Section. Local Coverage Determinations (LCD): LCD policies are administrative and educational tools to assist providers, physicians, and suppliers in submitting correct claims for payment. Local policies outline how contractors review claims to ensure that they meet Medicare coverage requirements. CMS requires that local policies be consistent with national guidance (although they can be more detailed or specific), and be developed with scientific evidence and clinical practice. 189

202 Under the Medicare program, the government pays only for "medically necessary" services. The Medicare carriers and intermediaries have significant authority, through their medical directors, to define what is "medically necessary." LCD policies can include incorrect or incomplete information as they relate to a specific region, carrier, or procedure. They can vary widely. EncoderPro.com reviews procedure and diagnosis codes against edits for active Part B LCD policies for all carriers and regions to ensure that providers billing Medicare can receive proper reimbursement. These LCD edits are designed to give information as to which diagnoses are considered "medically necessary" and are covered by Medicare. If a relationship exists to support medical necessity, then there is no LCD Edit Conflict. If a relationship does not exist in the LCD data for a certain CPT code and Dx code combination, then there is an LCD Edit Conflict. This conflict is shown as an alert and it could be due to several different reasons. At times a Medicare carrier does not list a particular diagnosis with a procedure code that it may match clinically (and meet valid cross-coding requirements). This may be due to the fact that they require submission of a different diagnosis for the procedure to be covered. They may not accept a diagnosis just because it may clinically seem valid for the procedure. EncoderPro.com Expert and Professional alerts providers to this type of conflict and others. The provider should rely on their history of billing and reimbursement with their carrier to override any potential LCD Edit Conflicts if they choose to do so. The Medicare program requires that a proposed LCD be published for comment before it is instituted. Proposed LCD policies are published by carrier and intermediary in infrequent bulletins. Sometimes proposed LCD policies are flawed and need revision. Often, providers get stuck with an LCD that may inappropriately restrict Medicare coverage for services due to their very unrefined nature. LCD policies become effective 30 days from the date of publication. The following general Medicare guidelines apply to all published LCD policies: Medically Necessary and Reasonable Title XVIII of the Social Security Act, Section 1862 (a)(1)(a) states "...no payment may be made under Part A or Part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." Medicare limits coverage of many procedures to certain ICD-9-CM diagnosis codes. Please be aware that it is not enough to link the procedure code to a payable ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid, but in addition, the procedure must be medically reasonable and necessary and representative of the patient s condition. Medicare may require documentation of medical necessity on a pre-payment and/or post-payment basis or comprehensive medical review basis. Please note that the ICD-9-CM codes must be coded to the highest level of specificity, coding to the fourth or fifth digit. This is a requirement for all claims. Documentation Documentation supporting the medical necessity of the service should be legible, maintained in the patient s medical record, and must be made available to Medicare upon request. Reimbursement All of the coverage criteria listed for an individual Local Medical Review Policy must be met. National Policy In the event that a national policy is established for any of these local medical policies, the national policy takes precedence over the local policy. Focused Medical Review Medicare continues to monitor the utilization of Local Medical Policies through the Focused Medical Review (FMR) process. NCD Medical Necessity Edits See also LCD Medical Necessity Edits. NCD Medical Necessity Edits displays HCPCS/CPT Codes and ICD-9-CM Codes that are allowed for a selected CPT code based on Medicare's National Coverage Determinations (NCD). 190

203 The NCD icon is present if there is an NCD Edit for the selected code. On the CPT Code Section screen or HCPCS Code Section screen, click the NCD icon located in the Reference column or click the link to the Medical Necessity Edits for a code from the CPT Code Detail or HCPCS Code Detail. NCD Information (EncoderPro.com Expert and EncoderPro.com for Payers only) Click the code link in the Section column to display the policy. The NCD Information screen displays CPT/HCPCS Codes and ICD-9-CM codes that are Medical Necessity edits for the selected code. It contains red CPT/HCPCS code number links and green ICD-9 code number links that go to the selected code in the appropriate Code Section. The NCD for a diagnostic laboratory test is a national policy statement granting, limiting or excluding Medicare coverage for that test. It states CMS policy with respect to the circumstances under which the test(s) are considered reasonable and necessary, that they are not screening or otherwise not covered for Medicare purposes. Such a policy applies nationwide. An NCD is neither a practice parameter nor a statement of the accepted standards of medical practice. Words such as "may be indicated" or "may be considered medically necessary" are used for this reason. Where a policy gives a general description and then lists examples, the list of examples is not meant to be all inclusive, but merely to provide guidance. Medically Necessary and Reasonable Title XVIII of the Social Security Act, Section 1862 (a)(1)(a) states "...no payment may be made under Part A or Part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." Medicare limits coverage of many procedures to certain ICD-9-CM diagnosis codes. Please be aware that it is not enough to link the procedure code to a payable ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid, but in addition, the procedure must be medically reasonable and necessary and representative of the patient s condition. Medicare may require documentation of medical necessity on a pre-payment and/or post-payment basis or comprehensive medical review basis. Please note that the ICD-9-CM codes must be coded to the highest level of specificity, coding to the fourth or fifth digit. This is a requirement for all claims. Documentation Documentation supporting the medical necessity of the service should be legible, maintained in the patient s medical record, and must be made available to Medicare upon request. National Policy In the event that a national policy is established for any local medical policies, the national policy takes precedence over the local policy. 191

204 Code-Specific Edits CPT Edits and Info CPT Section Notes This screen displays CPT guidelines that provides access to: Section Notes, Instructions (parenthetical commentary), References to AMA CPT Assistant publication information, Pink Sheets specialty newsletters, Medicare Part B News, and Answer Books, Section Guidelines, and Insider's View. Depending on the code selected this screen also can include information about primary procedure codes that are appropriate for use with CPT add-on codes and also clinical examples for CPT Evaluation & Management Codes. To access this screen: Click the Section Notes icon to the right of the code in the CPT Code Section or view section notes at the bottom of the CPT Code Detail. Click the red code link on the Instructions tab, to go back to that code in the CPT Code Section. There are several tabs which contain different types of information that relate to the code. The References tab provides CPT Assistant reference that directs you to issues of the CPT Assistant that discusses the selected CPT code. CPT Assistant is a quarterly publication of the American Medical Association. The Primary Px tab shows the primary procedure codes that are appropriate for use with the selected add-on code. The tab contains colored number links that go to the appropriate code in the CPT Code Section. The Clinical Examples tab is visible only for E/M codes. It displays clinical examples from Appendix D of the CPT Book. As described in CPT 2003, clinical examples of the CPT codes for E/M services are intended to be an important element of the coding system. The clinical examples, when used with the E/M descriptors contained in the full text of the CPT Book, provide a comprehensive and powerful new tool for physicians to report the services provided to patients. The Pink Sheets tab shows information regarding specialty newsletters. You can look up news specific to the specialty associated with the use of the selected coded. The Part B News tab shows news and information specifically related to Medicare Part B for the associated code. The Answer Books tab shows answers to common questions for the related code. The Section Notes tab shows notes that pertain to code sections within the procedural code book. The Insider's View tab provides access to the publication CPT Changes: An Insider's View. It is available as a searchable database for specific code changes. AMA CPT Assistant References The AMA CPT Assistant References screen appears as the References tab on the CPT Section Notes screen. This tab displays references to issues from the American Medical Association s CPT Assistant, the official publication for the AMA guidelines. It references CPT Assistant editions and page numbers where the selected code has been discussed. The year is listed, the quarter and the page number of the reference. If you purchased the CPT Assistant Add-on module, you can click the article title link in the Title column to display the article. If you have the CPT Assistant Add-on module, click an article link from the Title column to go to the CPT Assistant Detail. 192

205 Clinical Examples This screen appears as a tab in the CPT Section Notes. More information about Clinical Examples: It is visible only for E/M codes. It shows clinical examples from the Appendix of the CPT Book. Clinical examples of the CPT codes for E/M services are intended to be an important element of the coding system. The clinical examples, when used with the E/M descriptors contained in the full text of the CPT Book, provide a comprehensive and powerful new tool for physicians to report the services provided to their patients. The clinical examples that are provided are limited to Office or Other Outpatient Services, Hospital Inpatient Services, Consultations, Critical Care, Prolonged Services, and Care Plan Oversight. These examples do not encompass the entire scope of medical practice. Inclusion or exclusion of any particular specialty group does not infer any judgment of importance or lack thereof; nor does it limit the applicability of the example to any particular specialty. It is important to note that these are only examples. A particular patient encounter, depending on the specific circumstances, must be judged by the services provided by the physician for that particular patient. Simply because the patient s complaints, symptoms, or diagnoses match those of a particular clinical example, does not automatically assign that patient encounter to that particular level of service. The three key components (history, examination, and medical decision making) must be met and documented in the medical record to report a particular level of service. Pink Sheets The Pink Sheets screen appears as the Pink Sheets tab on the Section Notes screen. In this list is a compilation of Pink Sheet specialty newsletters. The year and date of the issue is listed, as well as the subtype (specialty) and title of the article. If you have purchased the Coder's Essential 3-Pack Add-on module, you can click the article title link in the Title column to display the article details. Part B News The Part B News screen appears as the Part B News tab on the Section Notes screen. In this list is a compilation of Medicare Part B News items. The year and date of the issue are listed, as well as the type of article and title of article. If you have purchased the Coder's Essential 3-Pack Add-on module, you can click the article title link in the Title column to display the article details. Answer Books The Answer Books screen appears as the Answer Books tab on the Section Notes screen. In this list is a compilation of Answer Books items. The year and issue date are listed, along with the type of article and title of the article. If you have purchased the Coder's Essential 3-Pack Add-on module, you can click the article title link in the Title column to display the article details. AMA Section Guidelines The AMA Section Guidelines screen appears as the Section Guidelines tab on the Section Notes screen. You can access this screen through the section notes icon in the code section/range page or through the link on the code detail page. The Section Guidelines screen includes both the primary guidelines for the entire code section group, and also guidelines for each sub-section of the code group specific to each code. Click the expand icon to see more information as desired. CPT Changes: An Insider's View References The CPT Changes: An Insider's View References screen appears as the Insider's View tab on the CPT Section Notes screen. This tab displays references to annual publications of CPT changes. It references chapters and sections where the selected code has been discussed. The year is listed, the chapter and the section of the reference. If you 193

206 purchased the CPT Changes: An Insider's View Add-on module, you can click the section title link in the Section column to display the detail information. CPT Annotations Annotations provide explanations of medical terminology and descriptions for specific diseases that pertain to the code selected. Annotations provide more information about medical and surgical supplies, durable medical equipment, drugs and certain professional services. CPT Lay Descriptions and Coding Tips The lay descriptions are non-clinical descriptions that are available for many CPT surgery and medicine codes. The lightbulb icon is also used for Coding Tips and Annotations. Click the Annotations/Lay Descriptions icon to the right of the code in the CPT Code Section. Lay Descriptions and Coding Tips are available middle section under Code Information in the CPT Code Detail. CPT Modifiers Click the Modifier icon in the Reference column for the code in the CPT Code Section or click the modifier link in the CPT Code Detail to go to lists of CPT modifiers with the descriptions that are displayed on separate tabs for Optum modifiers, OPPS modifiers and CMS modifiers. Cross Coder Optum modifiers are modifiers that are evaluated by clinical technical editors and seen as clinically appropriate for billing with the associated procedure code. CMS modifiers are modifiers that are approved for billing to medicare or other Centers for Medicare and Medicaid Services (CMS). These are not evaluated by Optum clinical technical editors. OPPS modifiers are modifiers that are billed for outpatient payment systems. The Cross Coder screen displays corresponding crosscodes for CPT codes in all code sets. Click the Crosscodes Icon in the Reference column for the code in the CPT Code Section or click the Crosscodes link in the CPT Code Detail. You can view ICD-9-CM, and ICD-10-CM crosscodes. When it is applicable, this dialog box also displays HCPCS codes, ASA, Reverse ASA to CPT Crosswalk, dental codes, CPT anesthesia codes, medicine codes, radiology codes and lab codes that are crossed to the selected CPT surgical code. When crosscodes are available, they appear on the applicable tabs with linked codes. Click the link to go to the code in the Code Section or the Code Detail. Clicking the expand icon allows you to see legal disclaimer information about those particular cross codes. The anesthesia base units are available in the Anesthesia Codes and ASA tabs. Hover the mouse over an anesthesia code and a tooltip will be displayed with the base unit information. A few codes are too broad and would crosswalk to an unmanageable large list of codes. If your code is too broad, the following message will be displayed: "The application of this code is too broad to adequately present valid Crosscodes." CPT CCI Unbundle Edits 194

207 This screen displays Medicare s Correct Coding Initiative unbundle edits for the selected CPT code. It displays codes that should not be billed with the selected CPT code and the reason for the unbundle edit, as defined by the Medicare Correct Coding Initiative. To access this screen, click the CCI icon to the right of the code in the CPT Code Section. Links are provided to the CCI unbundle edits from the CPT Code Detail. Download National Correct Coding policy narratives now is a link to access the policy. To download the National Correct Coding policy narratives, click the corresponding link. You can type a code in Find code and click Find. If the code can be billed with your original code, a message is displayed, These codes may be billed together. If the code has an unbundle edit, the code is displayed in the table. You can also check multiple codes for correct coding billing relationships by typing codes into each of the ten (or more) boxes and then click the Check button to verify the CCI correctness for those codes. Customize the display results by selecting the radio buttons and check boxes as desired. The results will be display in the CCI Results screen. CPT CCI Unbundle Edits Tabs: The following tabs are displayed on this screen for the code selected: Column 2 tab: If the selected code is a Column 1 code, the Column 2 list contains the codes conflicting with the Column 1 code. Column 1 tab: If the selected code is a Column 2 code, the Column 1 list contains the codes conflicting with the Column 2 code. Columns: The Action column contains the Add to User Notes Button and the Add to Notepad Button. The Code column in all three tabs contains code number links that go to the appropriate code in the CPT Code Section. These codes represent codes that cannot bundle with the original CPT code selected in the Code Detail. Total Fee column displays the National Non-facility Fee Total if the Non-Facility radio button is selected, or it displays the National Facility Total if the Facility radio button is selected. Work RVU column displays the work relative value units. PE RVU column displays the practice expense component of physician services RVUs. Malpractice RVU column displays the RVUs assigned to the malpractice insurance component for a specific service. Total RVU column displays the Relative Value Units used to calculate the Medicare payment for each code The Reason column provides the reason this edit is not allowed. The Modifier column indicates whether the use of a modifier is allowed to differentiate between the services provided. Click the magnifying glass to open a list of modifiers for the code. If a modifier is allowed, an appropriate modifier must be used with the code that represents a component procedure and/or the code that represents the greater procedure. The modifier adds specificity about the services being billed which helps to differentiate between the services represented by the different codes. Assuming the modifier is used correctly and appropriately, this specificity provides the basis for a separate payment for the services. Generally, the modifiers which are most likely to add specific or further information to the billed codes are: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, 58, 59, 78 and 79. Primary or Secondary column displays which code within the relationship is designated as the primary code and which code is designated as the secondary code. Click the OCE Edits link to go to the OCE Edits page. Note: Click the CCI Edits link on the OCE CCI Unbundles Edits page to go back to the CCI Unbundles page. 195

208 Columns The Action column contains the Add to User Notes Button and the Add to Notepad Button. The Code column in all three tabs contains code number links that go to the appropriate code in the CPT Code Section. These codes represent codes that cannot bundle with the original CPT code selected in the Code Detail. Total Fee column displays the National Non-facility Fee Total if the Non-Facility radio button is selected, or it displays the National Facility Total if the Facility radio button is selected. Work RVU column displays the work relative value units. PE RVU column displays the practice expense component of physician services RVUs. Malpractice RVU column displays the RVUs assigned to the malpractice insurance component for a specific service. Total RVU column displays the Relative Value Units used to calculate the Medicare payment for each code. The Reason column provides the reason this edit is not allowed. The Modifier column indicates whether the use of a modifier is allowed to differentiate between the services provided. Click the magnifying glass icon to open a list of modifiers for the code. If a modifier is allowed, an appropriate modifier must be used with the code that represents a component procedure and/or the code that represents the greater procedure. The modifier adds specificity about the services being billed which helps to differentiate between the services represented by the different codes. Assuming the modifier is used correctly and appropriately, this specificity provides the basis for a separate payment for the services. Generally, the modifiers which are most likely to add specific or further information to the billed codes are: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, 58, 59, 78 and 79. Primary or Secondary column displays which code within the relationship is designated as the primary code and which code is designated as the secondary code. CCI Results The results on this screen are according to the industry recognized CCI guidelines. You can enter up to fifteen procedure codes and check them against each other for correctness in billing relationships. Type up to fifteen CPT or HCPCS codes in the CCI Quick Check fields on the home screen and click the Check button. Or if you need to check more than 15 codes, click the More button and type up to 50 codes. Or you can perform a CCI check from the CCI Unbundles screen, by clicking the CCI icon for a procedure code and then typing up to fifteen codes in the fields provided. Or if you need to check more than 15 codes, click the More button and type up to 50 codes. Click the Check button to run the CCI edit check process. Click the Reset button to clear the screen and not perform a CCI check. After clicking the Check button, the system will check those codes for correct coding relationships and display the results on the CCI Results screen. If an invalid code is entered into the list of codes, there will be NO negative relationship of that invalid code to the valid codes entered, therefore, nothing will show. The results displayed will be dependent on the display options selected as part of the quick check process. Select the radio buttons to customize the view of the results below. Non-Facility RVU - select this button to display the results for professional services. Facility RVU - select this button to display the results for hospital facility services. CCI Conflict View - this view displays only the codes that have conflict with one another in billing relationships. CCI Code View - this view displays ALL codes, regardless if there is a conflict or not in billing relationships. 196

209 You can also customize the results by checking the boxes to view unbundling, mutually exclusive conflicts, greater procedure conflicts and MPFS & Modifier information. The columns of information that are shown when a valid relationship is shown, are the following: Note: Not all columns will be displayed. Those that are shown will depend on the CCI Check parameters selected. The Code column in the tabs contains code number links that go to the appropriate code in the CPT Code Section. These codes represent codes that have an edit relationship with the original CPT code selected. Total Fee column displays the National Non-facility Fee Total if the Non-Facility radio button is selected, or it displays the National Facility Total if the Facility radio button is selected. Work RVU column displays the work relative value units. PE RVU column displays the practice expense component of physician services RVUs. Malpractice RVU column displays the malpractice RVUs assigned to the malpractice insurance component for a specific service. Total RVU column displays the Relative Value Units used to calculate the Medicare payment for each code Reason (NTIS) column displays the reason for the CCI edit according to National Technical Information Service (NTIS). The Modifier column indicates whether the use of a modifier is allowed to differentiate between the services provided. If a modifier is allowed, an appropriate modifier must be used with the code that represents a component procedure and/or the code that represents the greater procedure. The modifier adds specificity about the services being billed which helps to differentiate between the services represented by the different codes. Assuming the modifier is used correctly and appropriately, this specificity provides the basis for a separate payment for the services. Generally, the modifiers which are most likely to add specific or further information to the billed codes are: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, 58, 59, 78 and 79. From CMS: "Although the Column 2 code is often a component of a more comprehensive Column 1 code, this relationship is not true for many edits. In the latter type of edit the code pair edit simply represents two codes that should not be reported together, unless an appropriate modifier is used. " Primary or Secondary column indicates the code billing relationship in connection with the other codes within the CCI check. Primary indicates that the code should be the primary billing code. Secondary indicates that the code should be the secondary billing code. Please note that although CCI edit checking may be available for up to two years, it is important to remember that certain timely filing guidelines are in effect depending upon the payer. I-OCE Edits The I-OCE Edits displays outpatient Medicare code edits with the descriptions and explanations. The table shows the edit number and description, the Edit Result/Claim Disposition, and the Provider Action/Response that needs to be taken. To access this page: Select the Coding Menu on the Toolbar, Coding Edits and the I-OCE Edits option. NOTE: For DrugReimbursement.com add on module, see Integrated OCE Edits. OCE Device Edits When a code is billed and it has a device edit, a HCPCS device code must be reported on the same claim. Click the Integrated OCE Edits icon from the Code Section or the Code Detail. This detail page shows the applicable APC Assignment, Status Indicator, Payment Indicator, information and applicable Edits. 197

210 Click the Detail page. from the Code Section or click the Integrated OCE Edits link on any applicable Code LCD Medical Necessity Edits See also NCD Medical Necessity Edits LCD Medical Necessity Edits displays CPT Codes and ICD-9-CM Codes that are medically necessary for a selected CPT code and Medicare carrier. In EncoderPro Expert, EncoderPro Professional and EncoderPro for Payers, the code is a link in the "Id" column. Click the code to access the policy. On the CPT Code Section screen or HCPCS Code Section screen, click the LCD icon located in the Reference column or click the link to the Medical Necessity Edits from the CPT Code Detail or HCPCS Code Detail. The icon displays if there are any LCD Edits for that code and any carrier. If the Medicare Carrier/Locality that was set in the LCD Medical Necessity Edits section has LCD edits, the policies are listed on the LCD screen. If there are no edits for the selected carrier, this message is displayed: 198 There are no policies that match the search criteria. If you would like to check another medicare carrier or fiscal intermediary, please select one and search again. Or select All Carriers or All Fiscal Intermediaries from the pull down box. These wider search criteria are the first entry in the list. Use the drop-down list to select another Medicare Carrier/Locality and view the LCD data for the selected code if it is available. The selection list contains only the Medicare Carriers with LCD data. Make default carrier checkbox can be selected to set the Medicare Carrier/Locality as your default carrier. Click the icon in the Code column to access the code list box. It displays CPT codes and ICD-9-CM codes that are Medical Necessity edits for the selected CPT code and Medicare Carrier. Click the red code number links for CPT codes and green code number links for ICD-9-CM codes to go to the code in the Code Section. Click the code link in the " Id" column to display the policy. The LCD Information screen displays CPT/HCPCS Codes and ICD-9-CM codes that are Medical Necessity edits for the selected code. It contains red CPT/HCPCS code number links and green ICD-9 code number links that go to the selected code in the appropriate Code Section. Local Coverage Determinations (LCD): LCD policies are administrative and educational tools to assist providers, physicians, and suppliers in submitting correct claims for payment. Local policies outline how contractors review claims to ensure that they meet Medicare coverage requirements. CMS requires that local policies be consistent with national guidance (although they can be more detailed or specific), and be developed with scientific evidence and clinical practice.

211 Under the Medicare program, the government pays only for "medically necessary" services. The Medicare carriers and intermediaries have significant authority, through their medical directors, to define what is "medically necessary." LCD policies can include incorrect or incomplete information as they relate to a specific region, carrier, or procedure. They can vary widely. EncoderPro.com reviews procedure and diagnosis codes against edits for active Part B LCD policies for all carriers and regions to ensure that providers billing Medicare can receive proper reimbursement. These LCD edits are designed to give information as to which diagnoses are considered "medically necessary" and are covered by Medicare. If a relationship exists to support medical necessity, then there is no LCD Edit Conflict. If a relationship does not exist in the LCD data for a certain CPT code and Dx code combination, then there is an LCD Edit Conflict. This conflict is shown as an alert and it could be due to several different reasons. At times a Medicare carrier does not list a particular diagnosis with a procedure code that it may match clinically (and meet valid cross-coding requirements). This may be due to the fact that they require submission of a different diagnosis for the procedure to be covered. They may not accept a diagnosis just because it may clinically seem valid for the procedure. EncoderPro.com Expert and Professional alerts providers to this type of conflict and others. The provider should rely on their history of billing and reimbursement with their carrier to override any potential LCD Edit Conflicts if they choose to do so. The Medicare program requires that a proposed LCD be published for comment before it is instituted. Proposed LCD policies are published by carrier and intermediary in infrequent bulletins. Sometimes proposed LCD policies are flawed and need revision. Often, providers get stuck with an LCD that may inappropriately restrict Medicare coverage for services due to their very unrefined nature. LCD policies become effective 30 days from the date of publication. The following general Medicare guidelines apply to all published LCD policies: Medically Necessary and Reasonable Title XVIII of the Social Security Act, Section 1862 (a)(1)(a) states "...no payment may be made under Part A or Part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." Medicare limits coverage of many procedures to certain ICD-9-CM diagnosis codes. Please be aware that it is not enough to link the procedure code to a payable ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid, but in addition, the procedure must be medically reasonable and necessary and representative of the patient s condition. Medicare may require documentation of medical necessity on a pre-payment and/or post-payment basis or comprehensive medical review basis. Please note that the ICD-9-CM codes must be coded to the highest level of specificity, coding to the fourth or fifth digit. This is a requirement for all claims. Documentation Documentation supporting the medical necessity of the service should be legible, maintained in the patient s medical record, and must be made available to Medicare upon request. Reimbursement All of the coverage criteria listed for an individual Local Medical Review Policy must be met. National Policy In the event that a national policy is established for any of these local medical policies, the national policy takes precedence over the local policy. Focused Medical Review Medicare continues to monitor the utilization of Local Medical Policies through the Focused Medical Review (FMR) process. 199

212 Surgical Procedure Codes Click the icon from the Code Section for the applicable code to go to the surgical component associated with the radiology code. Revenue Code for Code Click the Revenue Codes icon from the Code Detail or Code Section to display the code and a list of revenue codes that can be billed with the code. The list shows the Revenue Code, Code Description, Type of Bill Facility Code, Type of Bill Description, and Note. 200

213 HCPCS Edits and Info HCPCS Section Notes This screen provides a view of notes in the code book that pertain to the selected HCPCS code. These notes appear at the beginning of certain sections in the HCPCS book. HCPCS section notes include ambulance origin modifiers, destination modifiers and PET scan modifiers. To access this screen, click the Section Notes icon to the right of the code in the HCPCS Code Section or go to the section notes at the bottom of the HCPCS Code Detail. AHA Coding Clinic for HCPCS References This screen appears as a tab with the HCPCS Section Notes. The References tab provides references to issues of the American Hospital Association s Coding Clinic, the official publication for the HCPCS guidelines. It references Coding Clinic editions and page numbers where the selected code has been discussed. If you have the AHA Coding Clinic HCPCS Add-on module, click an article link from the Title column to go to the AHA Coding Clinic for HCPCS Detai l. HCPCS Annotations In this screen, annotations are displayed from the HCPCS Level II Expert that pertain to the code selected. Annotations provide more information about medical and surgical supplies, durable medical equipment, drugs, and certain professional services. To access this screen, click the Annotations icon to the right of the code in the HCPCS Code Section or view annotations in the HCPCS Code Detail. HCPCS Lay Descriptions The lay descriptions are non-clinical descriptions that are available for many HCPCS codes. Click the Annotations icon to the right of the code in the HCPCS Code Section and the Lay Descriptions tab. Lay Descriptions are available in the Lay Description section under Code Information in the HCPCS Code Detail. HCPCS Modifiers Click the Modifier icon in the Reference column for the code in the HCPCS Code Section or click the modifier link in the HCPCS Code Detail to go to lists of HCPCS modifiers with the descriptions that are displayed on separate tabs for Optum modifiers, CMS-Ambulatory modifiers, OPPS modifiers and CMS modifiers. Optum modifiers are modifiers that are evaluated by clinical technical editors and seen as clinically appropriate for billing with the associated procedure code. CMS modifiers are modifiers that are approved for billing to medicare or other Centers for Medicare and Medicaid Services (CMS). These are not evaluated by Optum's clinical technical editors. OPPS modifiers are modifiers that are billed for outpatient payment systems. Modifiers that include ambulance origin, destination modifiers, and PET scan modifiers are listed in the HCPCS Section Notes. HCPCS CCI Unbundle Edits 201

214 This screen displays HCPCS codes that have unbundle edits based on Medicare s Correct Coding Initiative (CCI). It shows codes that should not be billed with the selected HCPCS code and the reason for the unbundle edit as defined by the Medicare Correct Coding Initiative. To access this screen, click the CCI icon to the right of the code in the HCPCS Code Section. Links are provided to the CCI unbundle edits from the HCPCS Code Detail. Download National Correct Coding policy narratives now is a link to access the policy. To download the National Correct Coding policy narratives, click the corresponding link. You can type a code in Find code and click Find. If the code can be billed with your original code, a message is displayed, These codes may be billed together. If the code has an unbundle edit, the code is displayed in the table. You can also check multiple codes for correct coding billing relationships by typing codes into each of the ten (or more) boxes and then click the Check button to verify the CCI correctness for those codes. Customize the display results by selecting the radio buttons and check boxes as desired. The results will be display in the CCI Results screen. HCPCS CCI Unbundle Edits tabs: At least one of the following three tabs is displayed on this screen depending on the code selected: CCI Component tab. If the selected CPT code is a comprehensive procedure, a list of codes is provided that represent the components of the comprehensive procedure. CCI Mutually Exclusive tab. The codes listed in this tab represent procedures that cannot be performed during the same operative session. CCI Greater Px tab. This tab displays the greater procedure (or comprehensive) codes for the component code that could be considered an edit. It provides the complete CCI relationships, regardless of what code is selected. EncoderPro.com Action column contains the Add to User Notes Button and the Add to Notepad Button. Code column in all three tabs contains code number links that go to the appropriate code in the Code Section. These codes represent codes that cannot bundle with the original HCPCS code. Total Fee column displays the National Non-facility Fee Total if the Non-Facility radio button is selected, or it displays the National Facility Total if the Facility radio button is selected. Work RVU column displays the work relative value units. PE RVU column displays the practice expense component of physician services RVUs. Malpractice RVU column displays the RVUs assigned to the malpractice insurance component for a specific service. Total RVU column displays the Relative Value Units used to calculate the Medicare payment for each code Reason column provides the reason this edit is not allowed. Modifier column indicates whether the use of a modifier is allowed to differentiate between the services provided. Click the magnifying glass icon to see a list of modifiers for the code. If a modifier is allowed, an appropriate modifier must be used with the code that represents a component procedure and/or the code that represents the greater procedure. The modifier adds specificity about the services being billed which helps to differentiate between the services represented by the different codes. Assuming the modifier is used correctly and appropriately, this specificity provides the basis for a separate payment for the services. Generally, the modifiers which are most likely to add specific or further information to the billed codes are: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, 58, 59, 78 and 79. EncoderPro.com for Payers Click the OCE Edits link to go to the OCE Edits page. Note: Click the CCI Edits link on the OCE CCI Unbundles Edits page to go back to the CCI Unbundles page. 202

215 Columns The Action column contains the Add to User Notes Button and the Add to Notepad Button. The Code column in all three tabs contains code number links that go to the appropriate code in the Code Section. These codes represent codes that cannot bundle with the original HCPCS code. Total Fee column displays the National Non-facility Fee Total if the Non-Facility radio button is selected, or it displays the National Facility Total if the Facility radio button is selected. Work RVU column displays the work relative value units. PE RVU column displays the practice expense component of physician services RVUs. Malpractice RVU column displays the RVUs assigned to the malpractice insurance component for a specific service. Total RVU column displays the Relative Value Units used to calculate the Medicare payment for each code. The Reason column provides the reason this edit is not allowed. The Modifier column indicates whether the use of a modifier is allowed to differentiate between the services provided. Click the magnifying glass icon to see a list of modifiers for the code. If a modifier is allowed, an appropriate modifier must be used with the code that represents a component procedure and/or the code that represents the greater procedure. The modifier adds specificity about the services being billed which helps to differentiate between the services represented by the different codes. Assuming the modifier is used correctly and appropriately, this specificity provides the basis for a separate payment for the services. Generally, the modifiers which are most likely to add specific or further information to the billed codes are: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, 58, 59, 78 and 79. CCI Results The results on this screen are according to the industry recognized CCI guidelines. You can enter up to fifteen procedure codes and check them against each other for correctness in billing relationships. Type up to fifteen CPT or HCPCS codes in the CCI Quick Check fields on the home screen and click the Check button. Or if you need to check more than 15 codes, click the More button and type up to 50 codes. Or you can perform a CCI check from the CCI Unbundles screen, by clicking the CCI icon for a procedure code and then typing up to fifteen codes in the fields provided. Or if you need to check more than 15 codes, click the More button and type up to 50 codes. Click the Check button to run the CCI edit check process. Click the Reset button to clear the screen and not perform a CCI check. After clicking the Check button, the system will check those codes for correct coding relationships and display the results on the CCI Results screen. If an invalid code is entered into the list of codes, there will be NO negative relationship of that invalid code to the valid codes entered, therefore, nothing will show. The results displayed will be dependent on the display options selected as part of the quick check process. Select the radio buttons to customize the view of the results below. Non-Facility RVU - select this button to display the results for professional services. Facility RVU - select this button to display the results for hospital facility services. CCI Conflict View - this view displays only the codes that have conflict with one another in billing relationships. CCI Code View - this view displays ALL codes, regardless if there is a conflict or not in billing relationships. You can also customize the results by checking the boxes to view unbundling, mutually exclusive conflicts, greater procedure conflicts and MPFS & Modifier information. The columns of information that are shown when a valid relationship is shown, are the following: Note: Not all columns will be displayed. Those that are shown will depend on the CCI Check parameters selected. 203

216 The Code column in the tabs contains code number links that go to the appropriate code in the CPT Code Section. These codes represent codes that have an edit relationship with the original CPT code selected. Total Fee column displays the National Non-facility Fee Total if the Non-Facility radio button is selected, or it displays the National Facility Total if the Facility radio button is selected. Work RVU column displays the work relative value units. PE RVU column displays the practice expense component of physician services RVUs. Malpractice RVU column displays the malpractice RVUs assigned to the malpractice insurance component for a specific service. Total RVU column displays the Relative Value Units used to calculate the Medicare payment for each code Reason (NTIS) column displays the reason for the CCI edit according to National Technical Information Service (NTIS). The Modifier column indicates whether the use of a modifier is allowed to differentiate between the services provided. If a modifier is allowed, an appropriate modifier must be used with the code that represents a component procedure and/or the code that represents the greater procedure. The modifier adds specificity about the services being billed which helps to differentiate between the services represented by the different codes. Assuming the modifier is used correctly and appropriately, this specificity provides the basis for a separate payment for the services. Generally, the modifiers which are most likely to add specific or further information to the billed codes are: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, 58, 59, 78 and 79. From CMS: "Although the Column 2 code is often a component of a more comprehensive Column 1 code, this relationship is not true for many edits. In the latter type of edit the code pair edit simply represents two codes that should not be reported together, unless an appropriate modifier is used. " Primary or Secondary column indicates the code billing relationship in connection with the other codes within the CCI check. Primary indicates that the code should be the primary billing code. Secondary indicates that the code should be the secondary billing code. Please note that although CCI edit checking may be available for up to two years, it is important to remember that certain timely filing guidelines are in effect depending upon the payer. 204

217 Cross Coder The Cross Coder screen links HCPCS procedure codes to ICD-9 CM and ICD-10-CM, CPT procedure codes, anesthesia codes, ASA, and dental codes. Click the tabs to display the appropriate codes. Click the Crosscodes Icon in the Reference column for the code in the HCPCS Code Section or click the crosscodes link in the HCPCS Code Detail. Clicking the expand icon allows you to see legal disclaimer information about those particular cross codes. All screens contain linked code numbers to go to the appropriate code in the Code Section. The anesthesia base units are available in the Anesthesia Codes and ASA tabs. Hover the mouse over an anesthesia code and a tooltip will be displayed with the base unit information. 205

218 Outpatient Calculator The reimbursement information is based on how the outpatient service is reimbursed under OPPS. The calculation used to determine the Medicare Reimbursement is displayed in the Calculation field. Click the icon from the Code Section or the Code Detail. Enter a CPT code or HCPCS code in the CPT/HCPCS Code search box. You can use the hospital default that is displayed, choose another hospital name (set up by the administrator) or other User Preference from the Preference drop-down box. (You can go to User Preferences to make changes to your User Preference.) Click the check box "Use the non-reporting hospital reduced rate" to see the results of the calculation based on the reduced hospital rate as indicated by the preferences. The results will be shown in red text, along with the regular rate in the reimbursement information table. Click Search to retrieve and display payment information for the code. Example of Reimbursement Information search results: APC Codes: Individual APC Codes Individual APC codes are displayed in the Reimbursement Information section. Each code is assigned an individual OPSI code and APC code for standard processing. Packaged APC Codes Packaged Codes are displayed in the Reimbursement Information section. If the entered codes (OPSI Q1 or Q2) are packaged, the amounts will be $0.00. Composite APC Groups If the code has a single APC code and pairs with another code that is part of a Composite APC group, the codes will be displayed with their single APC in the Reimbursement Information section and their Composite APC Group in the CAPC Information section. The Composite APC data in the Outpatient Calculator is not provided at the claim level. The user must determine whether the Composite criteria is met and if the Composite APC payment applies. The Criteria column is provided to display the criteria. Click an APC code from the list to display the APC Code Detail. Click the code links in the Code column to go to the Code Section or Code Detail (set in Preferences). Please Note: The Outpatient Calculator uses your CURRENT Wage Index selected preference in history quarters. If you select any History Quarter, create a User Preference for each History Quarter! 206

219 How to Set Wage Index Preference for History Quarters When you select a history quarter and go to the Outpatient Calculator, this message is displayed in the information box: "The Outpatient Calculator is using your CURRENT Wage Index selected preference regardless of the historical quarter you have chosen. To calculate based on a historical wage index value, you must create another preference and set a custom wage index." You can synch your Wage Index amounts with the history quarter by creating new Preferences. 1. Select your history quarter first. 2. Go to User Preferences and Add a new Preference for the history quarter. 3. Find the historical wage index (WI) amount in the drop down list. (Example: WI for Memphis TN-MS-AR Urban 01/01/2012). 4. Give your new Preference a Set Name that clearly labels the Preference. (Example: First Qtr 2012 Memphis TN-MS-AR) 5. In the Custom Wage Index box, type the Wage Index. (Example: ). When the Custom Wage Index is entered, it is always used in the calculation instead of the Wage Index selection from the drop down list. Revenue Code for Code Click the Revenue Codes icon from the Code Detail or Code Section to display the code and a list of revenue codes that can be billed with the code. The list shows the Revenue Code, Code Description, Type of Bill Facility Code, Type of Bill Description, and Note. 207

220 ICD-9-CM Vol. 1 Edits and Info ICD-9-CM Instructional Notes This screen can be used to view notes from the code book that pertain to the selected code and to view references to AHA Coding Clinic ICD-9-CM issues. To access this screen, click the Instructional Notes icon to the right of the code in the ICD-9-CM Volume 1 Code Section. Instructional notes further define terms, clarify information, and provide fifth-digit information. They also contain includes and excludes notes that pertain to the selected code. AHA Coding Clinic for ICD-9-CM References This screen appears as a tab with the ICD-9-CM Volume 1 Instructional Notes. The References tab provides references to issues of the American Hospital Association s Coding Clinic, the official publication for the ICD-9-CM guidelines. It references Coding Clinic editions and page numbers where the selected code has been discussed. If you have the AHA Coding Clinic I-9 Add-on module, click an article link from the Title column to go to the AHA Coding Clinic for ICD-9-CM Detail. ICD-9-CM Annotations In this screen, you can view the annotations that pertain to the selected code. Annotations provide explanations of medical terminology and descriptions for specific diseases or conditions. To access this screen, click the Annotations icon to the right of the code in the ICD-9-CM Volume 1 Code Section or ICD-9-CM Volume 3 Code Section. This screen contains colored number links that go to the appropriate code in the Code Sections. ICD-9 Vol. 1 Lay Descriptions The lay descriptions are nonclinical descriptions that are available for many ICD-9 Vol. 1 codes. Click the Annotations icon to the right of the code in the ICD-9-CM Volume 1 Code Section and the Lay Descriptions tab. Lay Descriptions are available in the Lay Description section under Code Information in the ICD-9-CM Vol. 1 Code Detail. 208

221 ICD-9-CM Vol. 3 Edits and Info ICD-9 Vol. 3 to CPT This screen has a view of CPT surgical codes that correspond to the selected ICD-9-CM Vol. 3 surgery code. Access this screen by clicking on the Crosscodes icon to the right of the code in the ICD-9-CM Volume 3 Code Section. This screen contains red code number links that go to the appropriate code in the Code Section. 209

222 ICD-10-CM Edits and Info ICD-10-CM Instructional Notes This screen can be used to view instructional notes from the code book that pertain to the selected code. To access this screen, click the Instructional Notes icon to the right of the code in the ICD-10-CM Code Section. Instructional notes further define terms, clarify information, and additional digit information. They also contain includes and excludes notes that pertain to the selected code. This page has tabs to show information for Section Notes, Category Notes, and Chapter Notes. Section Notes are information that pertain to the code itself as well as the entire section of codes within the section of the book for that code. Category Notes are information that pertain to the code itself as well as just the category for that code. Chapter Notes are information for the specific chapter in the book for that code. Note: If there is no available Note information, then a message will display "No Notes were found." 210

223 Pub-100 References To access this screen, click the icon from the CPT Code Section or HCPCS Code Section. Internet Only Manuals (Pub-100 References) for a code can be accessed using the link from the CPT Code Detail or HCPCS Code Detail. Pub-100-References are the special coverage instructions for CPT and HCPCS codes that came from the following Medicare References: Coverage Issues Manual (CIM) and Medicare Carriers Manual (MCM). CMS Transmittals Click the icon from the Code Section screen to go to the CMS Transmittals List. Then, click the icon in the File column to go to the CMS website and a.pdf file of the CMS Transmittal that references the CPT or HCPCS code. Payment References APC Group LTC DRG Group DRG Payment Outpatient Calculator Ambulatory Payment Classification Group icon provides access to the payment schedule for the outpatient service. The LTC DRG icon provides access to a list of Long Term Care DRG codes associated with the code. The DRG Payment icon provides access to the DRG code and payment information. The Outpatient Calculator icon provides access to the search page where you can enter a CPT/HCPCS code to display available reimbursement information. You can change your Preference in the selection box. The Code Description, OPSI Code, OPSI Description, Medicare Fee Schedule Carrier, Payment Status, Calculation, Medicare Reimbursement Patient Adjusted Copay and any Comments are displayed if they apply to the code. Ambulance Fee Schedule Outpatient Rehab Fee Schedule The Ambulance Fee Schedule icon provides access to the Outpatient Calculator and the reimbursement information. The Outpatient Rehab Fee Schedule icon provides access to the Outpatient Calculator and the reimbursement information. PEN Fee Schedule The PEN Fee Schedule icon provides access to the Outpatient Calculator and the reimbursement information. Mammography Fee Schedule The Mammography Fee Schedule icon provides access to the Outpatient Calculator and the reimbursement information. ESRD Fee Schedule The ESRD Fee Schedule icon provides access to the Outpatient Calculator and the reimbursement information. DMEPOS Fee Schedule Clinical Diagnostic Laboratory Fee Schedule Medicare Fee Schedule The DMEPOS Fee Schedule icon provides access to the Outpatient Calculator and the reimbursement information. The Clinical Diagnostic Laboratory Fee Schedule icon provides access to the Outpatient Calculator and the reimbursement information. The Medicare Fee Schedule icon provides access to the Outpatient Calculator and the reimbursement information. 211

224 APC Group The APC Codes page displays the HCPCS/CPT code, OPSI code Description, Relative Weight, Pay Rate, National Adjusted Copay, and Minimum Adjusted Copay for the code as well as all neighboring codes. The information is based on how the outpatient service is reimbursed under OPPS. Codes that apply to Composite APCs will have two tabs -- APC and Composite APC. The APC tab has the information for a single APC code. The Composite APC tab has the information for a code that is paid through composite APC codes. For codes that do not have Composite APCs, only the APC tab will be displayed. Click the icon from the Code Section or the Code Detail. 212

225 ASC Payment Indicators CPT and HCPCS codes from the Federal Register Addendum AA and Federal Register Addendum BB have associated ASC Payment Indicators used to determine the payment amount for covered services. Medicare Payment Indicators: A2 - Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight D5 - Deleted/discontinued code; no payment made F4 - Corneal tissue acquisition; hepatitis B vaccine; paid at reasonable cost G2 - Non office-based surgical procedure added to ASC list in CY 2008 or later; payment based on OPPS relative payment weight H2 - Brachytherapy source paid separately when provided integral to a surgical procedure on ASC list; payment based on contractor rate H7 - Brachytherapy source paid separately when provided integral to a surgical procedure on ASC list; payment contractor-priced H8 - Device-intensive procedure on ASC list in CY 2007; paid at adjusted rate J7 - OPPS pass-through device paid separately when provided integral to a surgical procedure on ASC list; payment contractorpriced J8 - Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate K2 - Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate K7 - Unclassified drugs and biologicals; payment contractor-priced L1 - Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate payment made. L6 - New Technology Intraocular Lens (NTIOL); special payment N1 - Packaged procedure/item; no separate payment made P2 - Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight P3 - Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs R2 - Office-based surgical procedure added to ASC list in CY 2008 or later without MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight Z2 - Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS relative payment weight Z3 - Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on MPFS nonfacility PE RVUs Other Payment Indicators: C5 - OPPS inpatient-only procedure E5 - Surgical procedures excluded from payment in an ASC. Not covered by Medicare IC - Not covered by Medicare in any payment system IO - Surgical procedure no on ASC allowable list IP - OPPS impatient-only procedure U5 - Unlisted surgical procedures excluded from payment in an ASC X5 - Surgical Procedures Excluded from Payment in an ASC. Determined to pose a significant safety risk or are expected to require an overnight stay when performed in ASCs Optum Payment Indicators: ID - Drug, biological, radiopharmaceutical, DME equipment or supply not billable by an ASC. These include DME billable only by an enrolled supplier to the DME MAC and drugs and supplies billable by other providers and suppliers, such as ESRD facilities. IL - Laboratory service not Medicare allowable in an ASC. IM - Not allowable on a Medicare ASC claim. These codes represent physican and nonphysician pracitioner professional services or services billable only by another type of entity. Physician and nonphysician pracitioner professional services must be billed on a separate claim from the ASC services. IN - Nonsurgical procedure not Medicare allowable in an ASC. IS - Prosthetics and orthotics separately payable under the DMEPOS fee schedule 213

226 IT - Traditionally packaged item. Payment is bundled into the ASC payment for the procedure. IW - CLIA waived tests are not separately reportable and are considered bundled into the ASC facility payment. If not a CLIA waived test, then not Medicare allowable in an ASC. IX - Code is not reportable to Medicare. IZ - NTIOL not yet assigned. May be assigned in th future. OC - For Medicare claims, report other code in place of this code. Endoscopic Multiple Procedure Reduction Guidelines When two or more procedures in the same family are billed for the same patient, for the same day, and for the same physician then a reduction in reimbursement applies. Endoscopic Multiple Procedure Reduction applies when this procedure code is billed with another endoscopy code within the same code family. The yellow flag icon appears when the rules and guidelines for multiple procedure reduction apply for endoscopic procedures. When the yellow flag icon is clicked in either the Code Section page or the Code Detail page, further explanation will be displayed for the selected code. DRG Crosswalk This screen provides corresponding Diagnostic Related Group (DRG) codes and Medicare reimbursement calculation information for ICD-9-CM codes. To access this screen: 214 Click the DRG icon for the code in the ICD-9-CM Volume 1 Code Section or ICD-9-CM Volume 3 Code Section. Or, click the icon from the Code Detail. More about DRG Crosscodes: DRG Code and Description. DRG codes are derived from groups of ICD-9-CM codes that report inpatient services to Medicare, Medicaid, and some private payers. DRG codes standardize payment by illness and treatment, allowing reimbursement to be predicted prospectively before care is provided. DRG codes are defined as either medical or surgical. Major Diagnostic Category (MDC). Each DRG falls into an MDC category. This classification of diagnoses, typically grouped by the anatomic system, is the basis for the DRG prospective payment system. GMLOS, AMLOS, and RW. The geometric mean length of stay (GMLOS), arithmetic length of stay (AMLOS), and relative weight (RW) are used for the Medicare reimbursement calculation for a particular DRG. The length of stay is averaged for the given DRG and GMLOS is weighted to allow for outliers and other factors that skew data and potentially change reimbursement. The RW is a comparative, assigned weight to indicate relative resource consumption associated with the given DRG. The higher the relative weight equals the greater reimbursement. The relative weight is multiplied by a facility s conversion factor to produce the dollar amount to be paid to the facility. DRG Codes Click the code link from the DRG column in the DRG Crosswalk to go to the DRG codes and descriptions. Note that the Footnote entry from the DRG Crosswalk screen is also included above the list of codes for the specific DRG shown. Then, if desired, click the code link to go to the Code Section or Code Detail (set in Preferences). LTC DRG Group Long Term Care Diagnosis-Related Groups (LTC-DRGs) are based on the principal diagnosis, up to eight additional (secondary) diagnoses, up to six procedures performed during the stay, age, sex and discharge status. LTCs are assigned to patients with an extended length of stay, high levels of acuity and a host of complications.

227 Click the icon from the Code Section or the Code Detail to go to the LTC DRG List. DRG codes and Footnotes are displayed. ASP Part B Payment (DrugReimbursement.com Add-on Module) The ASP Part B Payment information is displayed when it is applicable. Click the icon from the Code Detail or Code Section to go to the ASP Part B Payment screen. 215

228 Physician Fee Schedule Information Medicare Physician Fee Schedule This screen displays information about CPT codes from the Medicare Physician Fee Schedule. When applicable, this screen provides actual payment information such as Relative Value Units, Global Information, and specific Medicare Rules from the Medicare Physician Fee Schedule. Note: This screen also provides a method of Calculating the Medicare Physician Fee Schedule according to Medicare Carrier/Localities. You can change the Medicare Carrier/Locality selection, Conversion Factor or % of Medicare and recalculate the Fee Schedules according to your selections. This functionality does not exist in the EncoderPro.com Professional edition. If this feature interests you, please contact us today for an upgrade. Click the Medicare Physician Fee Schedule icon for the code from the CPT Code Section or from the CPT Code Detail. Medicare Fee Calculation This feature provides area-specific payment information. You can change your Medicare Carrier/Locality selection. You can change the Conversion Factor or the % of Medicare and click Calculate to change the displayed payments. The application displays the Conversion Factor for the current year. The payment area displays the calculated Medicare payment information for the selected Medicare Carrier/Locality. Calculated fees are shown for Facility and Non-Facility. Where modifiers apply, fees are shown for Global values, Modifier -26 (Professional Component), and Modifier -TC (Technical Component). NOTE: Changes to the Medicare Physician Fee required by Congress apply to Radiology codes (provided by Medicare) that will only be reimbursed at the lower rate of either the MPFS or the OPPS amount. A subset of these Radiology codes has been flagged with a Multiple Procedure Reduction identifier. When a code has been flagged with the MPR identifier, this fee is calculated by taking the total Medicare Physician Fee, then multiplying that value by.50. This total is compared to the total calculated OPPS fee and the lower fee will be reimbursed. The actual calculation for the Medicare Physician Fee has changed to include the Budget Neutrality (BN) component. On the Code Detail screen, an additional row, labeled OPPS is displayed with the MPFS amount so you can make your own determination. On the Code Detail screen, an additional row, labeled Reduced is displayed for codes that are flagged with a Multiple Procedure Reduction identifier. The identifier is displayed in parenthesis. Medicare Physician Fee Schedule Payment Formulas Column Descriptions National: The National Payment Amount. The total unadjusted RVU's for facility or non-facility multiplied by the national conversion factor. Global (locality) [with dollar amounts]: The work, practice expense and malpractice RVUs adjusted by the locality geographical price cost indices (GPCI) and multiplied by the national conversion factor Global (locality) [with RVU's]: The work, practice expense and malpractice RVUs adjusted by the locality geographical price cost indices (GPCI) 26: Modifier 26 local payment value, based on your Medicare Carrier/Locality selection above, which is used to designate professional services. The 26 modifier is used to identify the portion of the total procedure that must be performed by the physician. In the Medicare Physician Fee Schedule (MPFS) the reimbursement for the physician portion of the total procedure. The professional component includes examination of the patient, when indicated, performance and supervision of the procedure, interpretation and written report of the examination and consultation with referring physicians. TC: Modifier TC local payment, based on your Medicare Carrier/Locality selection above, which is used to designate the technical value of providing the service. The TC modifier is used to identify the technical portion of a total procedure including the equipment, technologist, supplies, and overhead. In the Medicare Physician Fee Schedule (MPFS) the reimbursement for the technical portion of the total procedure. The technical 216

229 component includes personnel, materials, space, equipment and other allocated facility overhead normally included in providing the service. Global Split: The Global Split is the portion of the global surgical procedure that has been determined to represent the preoperative, intraoperative, and postoperative portions of the total fee. The preoperative portion is reported with modifier 56, the intraoperative portion with modifier 54, and the postoperative portion with modifier 55. RVUs - Nonfacility This section displays relative value units (RVUs) for procedures performed in a physician s office, patient s home, or any other facility or institution, such as a residential care setting, that is not a hospital, SNF or ASC. The RVUs are broken out into the components of physician work (Work RVU), practice expense (PE RVU) and malpractice relative value units. The total RVU is also supplied. The conversion factor is displayed in this section as well. RVUs - Facility This section displays relative value units (RVUs) for procedures performed in a hospital, skilled nursing facility, or an ambulatory surgery center. The RVUs are broken out into the components of physician work (Work RVU), practice expense (PE RVU), and malpractice relative value units. The total RVU is also supplied. The conversion factor is displayed in this section as well. Global Information This section displays global period information for the selected CPT code. The global period is the time following surgery during which routine care by the physician is considered postoperative and included in the surgical fee. Office visits or other routine care related to the original surgery cannot be separately reported if they occur during the global period. Global periods are sometimes referred to as "follow-up days" or FUDs. The Global Split section displays a breakdown of how Medicare expects the value of an encounter to be split if different components of the encounter are performed by different physicians. The percentages are displayed that would be paid to physicians for preoperative, intraoperative, and postoperative services, if these services were performed separately. Medicare Rules This section lists the Medicare edits that are applicable to the selected CPT code. EncoderPro displays the data and information from the Medicare Physician Fee Schedule (MPFS) exactly as it is provided by the Centers for Medicare and Medicaid Services (CMS). CMS chooses to include values for many codes that they do not consider appropriate for reimbursement. Some of those include the values for consultations as well as many other non-covered services. EncoderPro does not edit those values out because many private payers utilize the MPFS for reimbursement. The Medicare Administrative Contractor (MAC) will not have a payment value in the state specific file for a codes that is not covered by CMS. However, that does not necessarily indicate that CMS will not have a value in the MPFS. The data provided in EncoderPro is a reference tool and includes all the data from CMS without censor. This includes all RVUs and payment indicators under the heading "Medicare Rules." Bundled Code: Payment for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient)" 217

230 MPFS Column Descriptions This area shows the calculations for the Medicare Physician Fee Schedule. The explanation for each column is below. National: The National Payment Amount. The total unadjusted RVU's for facility or non-facility multiplied by the national conversion factor. Global (locality) [with dollar amounts]: The work, practice expense and malpractice RVUs adjusted by the locality geographical price cost indices (GPCI) and multiplied by the national conversion factor. Global (locality) [with RVU's]: The work, practice expense and malpractice RVUs adjusted by the locality geographical price cost indices (GPCI). 26: Modifier 26 local payment value, based on your Medicare Carrier/Locality selection above, which is used to designate professional services. The 26 modifier is used to identify the portion of the total procedure that must be performed by the physician. In the Medicare Physician Fee Schedule (MPFS) the reimbursement for the physician portion of the total procedure. The professional component includes examination of the patient, when indicated, performance and supervision of the procedure, interpretation and written report of the examination and consultation with referring physicians. TC: Modifier TC local payment, based on your Medicare Carrier/Locality selection above, which is used to designate the technical value of providing the service. The TC modifier is used to identify the technical portion of a total procedure including the equipment, technologist, supplies, and overhead. In the Medicare Physician Fee Schedule (MPFS) the reimbursement for the technical portion of the total procedure. The technical component includes personnel, materials, space, equipment and other allocated facility overhead normally included in providing the service. Global Split: The Global Split is the portion of the global surgical procedure that has been determined to represent the preoperative, intraoperative, and postoperative portions of the total fee. The preoperative portion is reported with modifier 56, the intraoperative portion with modifier 54, and the postoperative portion with modifier

231 Medicare Physician Fee Schedule Payment Formulas This page shows the Medicare Physician Fee Schedule Payment Formulas and Definitions. NOTE: Budget Neutrality Adjuster is rounded to two decimals. Non-Facility Pricing Amount [(Work RVU * Work GPCI) + (Transitioned Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor Facility Pricing Amount [(Work RVU * Work GPCI) + (Transitioned Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor OPPS Non-Facility Payment Amount [(Work RVU * Work GPCI) + (OPPS Non-Facility PE RVU * PE GPCI) + (OPPS MP RVU * MP GPCI)] * Conversion Factor OPPS Facility Payment Amount [(Work RVU * Work GPCI) + (OPPS Facility PE RVU * PE GPCI) + (OPPS MP RVU * MP GPCI)] * Conversion Factor Definitions: Conversion Factor: National multiplier that converts the geographically adjusted relative value units into Medicare fee schedule dollar amounts that applies to all services paid under the Medicare physician fee schedule. Facility: The sum of the work, practice expense, and malpractice RVUs when the service is performed in a facility setting. Generally, a facility may be defined as an inpatient or outpatient hospital setting, emergency room, skilled nursing facilities or ambulatory surgical centers (ASCs). Global Period (Days): The number of days in the global period for which services directly related to the procedure are included. Also known as "Follow-up period/days" Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable. Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10 day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during the 10-day postoperative period generally not payable. Major surgery with a 1-day preoperative period and 90-day postoperative period included in the fee schedule amount. Maternity codes; usual global period does not apply. GPCI Work: This reflects the adjustment by locality using the Geographic Practice Cost Indices. Intraoperative %: Percentage for intraoperative portion (those services usual and necessary for the completion of the surgical procedure) of global package, including postoperative work in the hospital. Malpractice RVU: Malpractice insurance identifies the relative risk or professional liability associated with the service represented in numeric scale. Non-Facility: The sum of the work, practice expense, and malpractice RVUs when the service is performed in a non-facility setting. Examples of non-facility settings include the physician office or patient's home. 219

232 OPPS: Payment for the technical component (TC) portion of a radiology service will be limited to the lesser of the Medicare Physician Fee Schedule (MPFS) amount or the Outpatient Prospective Payment System (OPPS) amount. PE RVU: Practice expense (PE) the cost of the physical location (rent), staff, supplies, equipment, and other overhead associated with the service represented in numeric scale. Postoperative %: Percentage for services provided as follow-up care to the surgical procedure that is provided after discharge from the hospital. Preoperative %: Percentage for preoperative portion of global package. This includes preoperative visits after the decision is made to operate and begins with the day before surgery for major procedures and the day of surgery for minor procedures Total RVU: The sum of physician work, practice expense (non-facility or facility), and malpractice insurance reflect the total value of the service or the total relative value units (RVUs). Work RVU: Physician work including the cost of the physician s time and skill represented in numeric scale. 220

233 Add-on Subscriptions Coding and Information AHA Coding Clinic for ICD-9-CM (AHA Coding Clinic I-9 Add-on subscription) The Administrator can activate this option if you have an available AHA Coding Clinic I-9 Add-on subscription. Select AHA Coding Clinic I-9 from the Add-ons menu on the Toolbar. This allows you to search through the library of articles for a specific topic or piece of information, such as a certain diagnosis code, just by entering certain search criteria and clicking Find. Please Note: If you subscribe to Historical Application Content (HAC) and it is not set to "Current" then this feature is hidden from the menu. Or in other words, this feature is only available if HAC is set to the current quarter. Search Criteria: To find specific articles, enter the desired search criteria as follows: Select one of the two available radio buttons. 1) Find Text Within Article, or 2) Find Related Article By Code. Find Text Within Article Enter the desired ICD-9-CM information in the check box fields. These fields validate for correct code entry. Enter keyword(s) to be used in the title search and/or in the body text search. Forms of the entered keywords or partial words are allowed as well. Note: the search process is not case sensitive. You can also indicate which part of the article is to be searched, either the title only, the body text only, or the title and the body text. Be aware that if searching the body text, the search process can take some time to find the results. Find Related Article By Code You can enter a code and the search will look for articles related to that code whether or not that code(s) is actually contained within the article. After indicating the search criteria to be used click the Find button The system will then search the applicable articles for the information as requested. If you need to change the search criteria for your search, click the Reset Criteria button. This will erase the current entries and reset the page to the default search criteria. After the search is executed, the found articles are listed from most recent at the top of the list to oldest at the bottom of the list. 221

234 Article Index: Your search results displays a list of the articles. Click an article link in the Title column to go to AHA Coding Clinic for ICD-9-CM Detail. AHA Coding Clinic for ICD-9-CM Detail (AHA Coding Clinic I-9 Add-on subscription) If you have the AHA Coding Clinic I-9 Add-on subscription, you can access the AHA Coding Clinic for ICD-9- CM Detail page using the following: 1. Select AHA Coding Clinic I-9 from Add-ons menu on the Toolbar and click an article link from the Title column in the Article Index section. If no articles are displayed in the Article Index list, perform a search. 2. Or, click the ICD-9-CM Instructional Notes icon from the ICD-9-CM Volume 1 Code Section page, click the References tab and click an article link from the Title column. Article Detail screen: The Article Detail screen is similar to the following image. 222

235 AHA Coding Clinic for HCPCS (AHA Coding Clinic HCPCS Add-on subscription) The Administrator can activate this option if you have an available AHA Coding Clinic HCPCS Add-on subscription. Select AHA Coding Clinic HCPCS from the Add-ons menu on the Toolbar. This allows you to search through the library of articles for a specific topic or piece of information, such as a certain HCPCS code, just by entering certain search criteria and clicking Find. Please Note: If you subscribe to Historical Application Content (HAC) and it is not set to "Current" then this feature is hidden from the menu. Or in other words, this feature is only available if HAC is set to the current quarter. Search Criteria: To find specific articles, enter the desired search criteria as follows: Select one of the two available radio buttons. 1) Find Text Within Article, or 2) Find Related Article By Code. Find Text Within Article Enter the desired HCPCS and/or modifier information in the check box fields. These fields validate for correct code entry. Enter keyword(s) to be used in the title search and/or in the body text search. Forms of the entered keywords or partial words are allowed as well. Note: the search process is not case sensitive. You can also indicate which part of the article is to be searched, either the title only, the body text only, or the title and the body text. Be aware that if searching the body text, the search process can take some time to find the results. Find Related Article By Code You can enter a code and the search will look for articles related to that code whether or not that code(s) is actually contained within the article. After indicating the search criteria to be used click the Find button The system will then search the applicable articles for the information as requested. If you need to change the search criteria for your search, click the Reset Criteria button. This will erase the current entries and reset the page to the default search criteria. After the search is executed, the found articles are listed from most recent at the top of the list to oldest at the bottom of the list. Article Index: Your search results displays a list of the articles. 223

236 Click an article link in the Title column to go to AHA Coding Clinic for HCPCS Detail. AHA Coding Clinic for HCPCS Detail (AHA Coding Clinic HCPCS Add-on subscription) If you have the AHA Coding Clinic HCPCS Add-on subscription, you can access the AHA Coding Clinic for HCPCS Detail page using the following: 1. Select AHA Coding Clinic HCPCS from the Add-ons menu on the Toolbar and click an article link from the Title column in the Article Index section. 2. Or, click the HCPCS Section Notes icon from the HCPCS Code Section, click the References tab and click an article link from the Title column. Article Detail screen: The Article Detail screen is similar to the following image. ASA Crosswalk and RVU Guide (ASA Crosswalk Add-on subscription) The Administrator can activate this option if you have an available ASA Add-on subscription. Select ASA from the Add-ons menu on the Toolbar., or select the cross codes button in the Code Section page or the cross codes link in the Code Detail page. This allows you to see a list of Anesthesia Codes as they relate to other procedural codes. This list comes from the American Society of Anesthesiologists. Click the ASA tab in the Cross Coder screen to see the list of codes, the description, and the base units for each ASA code. Click the code to go to the appropriate code in the Code Detail or Code Section screen. 224

237 CPT Assistant (CPT Assistant Add-on subscription) The Administrator can activate this option if you have an available CPT Assistant Add-on subscription. Select CPT Assistant from the Add-ons Menu on the Toolbar. This allows you to search through the library of articles for a specific topic or piece of information, such as a certain procedure code, just by entering certain search criteria and clicking Find. Please Note: If you subscribe to Historical Application Content (HAC) and it is not set to "Current" then this feature is hidden from the menu. Or in other words, this feature is only available if HAC is set to the current quarter. Search Criteria: To find specific articles, enter the desired search criteria as follows: Select one of the two available radio buttons. 1) Find Text Within Article, or 2) Find Related Article By Code. Find Text Within Article Select the desired time period to search from the drop down list. The available time periods are: ALL, Current Month, Current Quarter, Previous Quarter, Previous 2 Quarters, and 1 Year. Enter the desired CPT and/or modifier information in the check box fields. These fields validate for correct code entry. Enter keyword(s) to be used in the title search and/or in the body text search. Forms of the entered keywords or partial words are allowed as well. Note: the search process is not case sensitive. You can also indicate which part of the article is to be searched, either the title only, the body text only, or the title and the body text. Be aware that if searching the body text the search process can take some time to find the results. Find Related Article By Code You can enter a code and the search will look for articles related to that code whether or not that code(s) is actually contained within the article. After indicating the search criteria to be used click the Find button The system will then search the applicable articles within the time period for the information as requested. If an article doesn't have a date or time period associated with it then it will also be included within the search results for the current year. If you need to change the search criteria for your search, click the Reset Criteria button. This will erase the current entries and reset the page to the default search criteria. After the search is executed, the found articles are listed from most recent at the top of the list to oldest at the bottom of the list. Article Index: 225

238 After a search has been completed, the Article Index section displays a list of the CPT Assistant articles. Click the page numbers or arrows to go forward and backward through the articles. Click an article link from the Title column to go to the CPT Assistant Detail. CPT Assistant Detail (CPT Assistant Add-on subscription) If you have a CPT Assistant Add-on subscription, you can access the CPT Assistant Detail page using the following: 1. Select CPT Assistant from the Add-ons Menu on the Toolbar and click the article link from the Title column in the Article Index section. If no articles are displayed in the Article Index list, perform a search. 2. Or, click the CPT Section Notes icon from the CPT Code Section page, click the References tab and click the article link from the Title column. Article Detail screen: The Article Detail screen is similar to the following image. It shows the contents of the selected article. 226

239 CPT Changes: An Insider's View (CPT Changes: An Insider's View Add-on subscription) The Administrator can activate this option if you have an available CPT Assistant Add-on subscription. Select CPT Changes Insider's View from the Add-ons Menu on the Toolbar. The CPT Changes: An Insider's View screen is displayed that allows you to search through the library of articles for a specific topic or piece of information, such as a certain procedure code, just by entering certain search criteria and clicking Find. Please Note: If you subscribe to Historical Application Content (HAC) and it is not set to "Current" then this feature is hidden from the menu. Or in other words, this feature is only available if HAC is set to the current quarter. Search Criteria: To find specific articles, enter the desired search criteria as follows: Select one of the two available radio buttons. 1) Find Text Within Article, or 2) Find Related Article By Code. Find Text Within Sections Select the desired time period to search from the drop down list. The available time periods are listed by year, or you can select ALL for a search over all the years.. Enter the desired CPT and/or modifier information in the check box fields. These fields validate for correct code entry. Enter the desired keyword(s) to search. Up to four keywords can be used in the title search and/or in the body text search. Forms of the entered keywords or partial words are allowed as well. Note: the search process is not case sensitive. You can also indicate which part of the article is to be searched, either the section title only, the section body text only, or the section title and body text. Be aware that if searching the body text the search process can take some time to find the results. Find Related Article By Code You can enter a code and the search will look for sections related to that code whether or not that code(s) is actually contained within the article. After indicating the search criteria to be used click the Find button The system will then search within the time period for the information as requested. 227

240 If you need to change the search criteria for your search, click the Reset Criteria button. This will erase the current entries and reset the page to the default search criteria. After the search is executed, the applicable chapter and sections are listed from most recent at the top of the list to oldest at the bottom of the list. Article Index: After a search has been completed, the CPT Changes Index section displays a list of the search results. Click the page numbers or arrows to go forward and backward through the articles. Click a link from the Section column to go to the Detail screen. CPT Changes: An Insider's View Detail (CPT Changes: An Insider's View Add-on subscription) If you have the CPT Changes: An Insider's View Add-on subscription, you can access the CPT Changes: An Insider's View detail page using the following: 1. Select CPT Changes: An Insider's View from the Add-ons Menu on the Toolbar and click the article link from the Section column in the Index list. If no information is displayed in the Index list, perform a search. 2. Or, click the CPT Section Notes icon from the CPT Code Section page, click the Insider's View tab and click the link from the Section column. Detail screen: The Detail screen is similar to the following image. It shows the contents of the selected information. 228

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242 Article Detail (Coder's Essential 3-Pack Add-on subscription) If you have a Coder's Essential 3-Pack Add-on subscription, you can access the Article Detail page using the following: 1. Select Coder's Essential 3-Pack from the Add-ons Menu on the Toolbar. and click the article link from the Title column in the Article Index section. If no articles are displayed in the Article Index list, perform a search. You can search for Pink Sheets, Part B News, and Answer Book information. 2. Or, click the Section Notes icon from the Code Section page, then click the Pink Sheets, or Part B News, or Answer Book tab and click the article link from the Title column. Article Detail screen: The Article Detail screen is similar to the following image. It shows the contents of the selected article. 230

243 Stedman's Dictionary (Stedman's Medical Dictionary Add-on subscription) The Administrator can activate this option if you have an available Stedman's Medical Dictionary Add-on subscription. Select Stedman's Medical Dictionary from the Add-ons menu on the Toolbar. Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Index Terms: Click the term to display the Stedman's Medical Dictionary description. Click the page numbers or arrows to go forward and backward through the dictionary. 231

244 Coders' Dictionary (Coders' Dictionary Add-on subscription) The Administrator can activate this option if you have an available Coders' Dictionary Add-on subscription. Select Coders' Dictionary from the Add-ons menu on the Toolbar. Dictionary terms will also display as underlined links in the Code Information column of the Code Detail page. Search: To find a term, type the first few letters of the term or the complete term in the text-box. Click Find. Terms: The Coders' Dictionary displays an alphabetical list of terms, definitions, codes and synonyms. Click the code number link to go to the appropriate Code Section. Click the page numbers or arrows to go forward and backward through the dictionary. 232

245 Coder's Essential 3-Pack Coder's Essential 3-Pack (Coder's Essential 3-Pack Add-on subscription) The Administrator can activate this option if you have an available Coder's Essential 3-Pack Add-on subscription. Select Coder's Essential 3-Pack from the Add-ons Menu on the Toolbar, or you can click the "dh" icon in the Code Section Range Page or link in the Code Detail page. This allows you to search through the Pink Sheets, Part B News, or Answer Books libraries of articles for a specific topic or a piece of information, such as a certain procedure code or diagnosis code, just by entering certain search criteria and clicking Find. Note: If you subscribe to Historical Application Content (HAC) and it is not set to "Current" then this feature is hidden from the menu. Or in other words, this feature is only available if HAC is set to the current quarter. Search Criteria: To find specific articles, enter the desired search criteria as follows: Select either the Pink Sheets, or Part B News, or Answer Book radio button. Then select one of the two available search criteria radio buttons. 1) Find Text Within Article, or 2) Find Related Article By Code. Find Text Within Article: Enter the desired diagnosis or procedure code and/or modifier information in the check box fields. These fields validate for correct code entry. Enter keyword(s) to be used in the title search and/or in the body text search. Forms of the entered keywords or partial words are allowed as well. Note: the search process is not case sensitive. You can also indicate which part of the article is to be searched, either the title only, the body text only, or the title and the body text. Be aware that if searching the body text the search process can take some time to find the results. 233

246 Find Related Article By Code: You can enter a code and the search will look for articles related to that code whether or not that code(s) is actually contained within the article. After indicating the search criteria to be used click the Find button The system will then search the applicable articles within the time period for the information as requested. If an article doesn't have a date or time period associated with it then it will also be included within the search results for the current year. If you need to change the search criteria for your search, click the Reset Criteria button. This will erase the current entries and reset the page to the default search criteria. After the search is executed, the found articles are listed from most recent at the top of the list to oldest at the bottom of the list. Article Index: After a search has been completed, the Article Index section displays a list of the related articles. Click the page numbers or arrows to go forward and backward through the articles. Click an article link from the Title column to go to the Article Detail Pink Sheets The Pink Sheets screen appears as the Pink Sheets tab on the Section Notes screen. In this list is a compilation of Pink Sheet specialty newsletters. The year and date of the issue is listed, as well as the subtype (specialty) and title of the article. If you have purchased the Coder's Essential 3-Pack Add-on module, you can click the article title link in the Title column to display the article details. Part B News The Part B News screen appears as the Part B News tab on the Section Notes screen. In this list is a compilation of Medicare Part B News items. The year and date of the issue are listed, as well as the type of article and title of article. If you have purchased the Coder's Essential 3-Pack Add-on module, you can click the article title link in the Title column to display the article details. Answer Books The Answer Books screen appears as the Answer Books tab on the Section Notes screen. In this list is a compilation of Answer Books items. The year and issue date are listed, along with the type of article and title of the article. If you have purchased the Coder's Essential 3-Pack Add-on module, you can click the article title link in the Title column to display the article details. 234

247 HCPCS Dental Codes HCPCS Dental Codes The HCPCS dental codes are available after an additional purchase. Dental codes are subject to royalty fee payments to the American Dental Association, therefore additional purchase is required. The American Dental Association has implemented a policy that requires additional royalty payments in order to access the dental codes, commonly known as the "HCPCS D Codes". Because of this policy by the ADA, HCPCS Dental Codes have been removed from the EncoderPro applications. In order to gain access to these codes, you can purchase the add-on module that will cover the cost of the royalty fees that are due to the American Dental Association. After purchasing the add-on module, a new icon is available in the user preferences that will allow you to activate the dental codes. Click the pencil icon to edit the preferences and activate the dental codes add-on module. User Preference screen: (as displayed in EncoderPro Expert - other applications will be similar) Edit user subscription screen:(as displayed in EncoderPro Expert - other applications will be similar) Within the Edit User Subscription screen, click the box next to Dental Code to put a check mark into the box in order to activate the dental codes add-on, then click the Save button. Log off of EncoderPro and then log back on again in order to see the dental codes add-on. 235

248 After activating the dental codes subscription, the dental codes are found all throughout the application. Toolbar Code Sets drop down list Home Screen Code Books section. The Dental Codes section is subdivided into smaller sections. Coding Menu, Dental Codes Coding Menu, HCPCS menu, HCPCS Expert, D Codes - Dental Procedures Dental Codes are included in normal code logic functionality. Code trees displayed from the main Search User Defined Code List from multiple codes in the main Search. Dental Code Detail Dental Code Section/Range. The Dental Codes section is subdivided into smaller sections. Dental code links in the Section Notes Dental Codes tab in the Code Books screen Dental Cross Codes tab Dental code links in the Index 236

249 Historical Application Content (Historical Application Content Add-on subscription) Note: This Add-on is not available for MedicareReimbursementPro.com. If you are interested in this Add-on, you can upgrade your subscription to EncoderPro.com. The Administrator can activate this option if you have an available Historical Application Content Add-on subscription. This Historical Application Content feature includes the past quarters of data for, at the minimum, the previous two years (eight quarters) up to the current quarter. The default quarter is the current quarter. Over time, historical application content will become available for up to 5 years. If you purchased DrugReimbursement.com Add-on Module, the Historical Application Content includes coding, billing and reimbursement information for FDA-approved drug codes. Select the Historical Application Content quarter from the Toolbar. You must log out of the application and then log back in for the quarter change to become effective. Some features are not applicable to the Historical Application Content: If you purchased FeeAnalyzer.com Add-on Module, the Fee data is for the current quarter only. PDF files that are available through menu options are for the present quarter only. LCD and NCD policy links, Notepad, Preferences, Subscriptions, Users, Color Legend, application functionality, User's Manual and this Help file are for the current quarter only. The Menu options throughout the application that are applicable to the current quarter have the message displayed, (Current Quarter Only). Patient Encounter Plus/Superbill add-on subscription. If you have purchased CPT Assistant and AHA Coding Clinic add-on subscriptions, the search functions available therein are for the current quarter only. Additional features that apply to the Historical Application Content: The Code Description in the Notepad and User Notes displays the description applicable during the quarter selected in the Historical Application Content. The Compliance Edit uses the selected quarter in the Historical Application Content for the Analysis Period and Edit Conflicts. The Patient Information is displayed according to the selected quarter. 237

250 Add-on Modules Claims Batch Editor Claims Batch List Claims Batch Editor & Repair Toolkit is an add-on module available for purchase. The Claims Batch List shows the list of batch files available for compliance edit checking in batch mode. Click the double arrow at top of any column to sort the list in ascending or descending order according to that column. How to access this screen: Click the Import Claims Batch button on the Compliance Edit screen. Or select Claims Batch Editor from the Add-ons menu. Using Claims Batch Editor Add New Batch: Click the Add New Batch button to add a new batch of claims to the list to be processed for errors. You must first have created the claims batch data file in a standard electronic claims format (a standard ANSI or 5010 Professional or a NSF 2.0/3.0) prior to importing the batch into the Compliance Editor. To create the batch data file consult your practice management system. When you click this button the Add Claims Batch screen is displayed where you can indicate which batch you wish to add to the list. A maximum of ten batches per add-on are allowed in the list. If you try to add a new batch of claims to the list when there are already the maximum amounts of batches in the list, then a warning message will display. 238

251 Sample warning message: Refresh Screen: Click the Refresh Screen button to have the claims, priority, and status columns update and display the most current progress. Run: Click the Run button to run the Claims Manager rule set against the claims within the corresponding batch. After the process is complete, an edit report will be available showing the claims errors that need attention prior to submission for payment. Sample Edit Report with errors 239

252 Sample Edit Report with no errors. Repair (available with Repair Toolkit module): Click the Repair button to fix errors on specific claims and rerun the edit rule set to verify correct coding before claims submission. This will take you to the Claims List screen. After you have completed this process, a variance report will be available showing the changes made to the claims within the batch. 240

253 Sample Variance Report with repairs shown. Batch Name: Displays the name of the batch for the uploaded claims data file. File Name: Displays the actual file name for the uploaded claims data file. Hover the mouse over the file name to see the full file name if necessary. Claims: Displays the number of claims in the claims data file. The first number indicates how many claims have been checked for errors during the initial compliance check process. The second number indicates the total number of claims in the batch. Priority: If you have multiple files queued up for compliance checking, a number will be displayed indicating the priority of the claims within the batch as related to other files also in queue for compliance checking. Upload Date: Displays the date that the batch file was uploaded to the claims batch list. Analysis Date: Displays the date that the batch file was analyzed by the claims manger. It will be blank until the Run button is clicked and then the date of analysis will be shown. Status: Shows the current status of the batch. Hover the mouse pointer over the symbol to display the tool tip message. The following status symbols are available: = uploaded from the practice management system -- "Batch Format Validated." = in queue/process -- "Queued for Compliance Check." = file failure -- "Compliance Check Aborted. Please Contact Support. " = success -- "Compliance Check Completed. Report Ready." 241

254 Reports: Click the red printer icon to access the claims edit report. The red printer icon will be displayed after a batch has completed the compliance check. The edit report shows a list of edits on the claims that need attention before successful billing can occur. Sample Edit Report with errors Sample Edit Report with no errors. 242

255 Click the green printer icon to access the variance report. The green printer icon will be displayed after a batch has completed the compliance check. The variance report shows claims information before and after changes have been made to claims. This report is available with Repair Toolkit. Sample Variance Report with some repairs shown. This report shows the differences between the claims before any changes were made and after any changes were made. You can then use this report as an aid to fix your claims in your practice management system prior to submitting them to the billing entity. Delete: Click the delete icon to remove the batch from the list. A windows dialog message will display for you to confirm or cancel your request to delete the batch from the list. After a batch has been deleted, if you again desire to process it for errors you would need to re-upload the batch from the practice management system to put it back into the list. 243

256 Add Claims Batch The Add Claims Batch screen allows you to add a claims batch data file to the list of claims batches to be processed for errors. How to access this screen: Click the Add New Batch button in the Claims Batch List screen. Adding a New Batch File Name: Enter the name of the file to be imported from the practice management system into the claims batch list. Enter the full path name, which includes the drive letter (eg. C:\). Click the Browse... button to use the windows file system dialog box to "drill down" to the location of your data file. The file must be a standard ANSI or 5010 Professional or NSF 2.0/3.0 electronic claims file layout to be imported properly. Professional claims are those that correspond to a paper HCFA 1500 form. Institutional claims data (UB04 claims) is not supported. 244

257 Batch Name: Enter a free form text name for your batch file. This is so you can more easily recognize the batch when it is displayed in the claims batch list. For example: "Carol's Medicare Batch 01/17/12", or "Commercial Claims for ABC Insurance Company", etc. If you do not want to enter a batch name you can choose to leave the file name as the batch name, or click the check box labeled Use File Name as Batch Name to override any free form text batch name. Rule Set Select the radio button corresponding to the rule set you wish the claims within the batch to be subjected to. Commercial: The generic rule set for commercial insurance companies will be applied to the batch. You can use this for other companies as well such and Blue Cross type companies, state Medicaid programs, etc. Medicare: The rule set for Medicare will be applied to the batch. You can further define the region of Medicare by selecting a state in the corresponding drop down box. Click on the Upload button to upload the selected claims batch data file. Or click the cancel button to abort the process and not upload a file. Note: that in order to minimize processing time, the claims file batch size is limited to a maximum of 750 claims. If you have a batch with greater than 750 claims, you may need to break the batch up into smaller groups of claims in your practice management system before uploading the file for processing. Claims List The Claims List shows the list of claims within a specific batch. How to access this screen: Click the Repair button next to the batch on the Claims Batch List screen. The Claims List screen will be displayed with the claims all listed within the batch. The screen lists the number of claims at a time within the batch as indicated in the user preferences for the "list max page items", if there are more claims than the number of the max items setting then the list continues onto subsequent pages. See the indicators in the lower right corner as to how many total claims are in the batch and how many pages are available for display. Filter: The claims that are displayed in the list can be filtered by selecting from a drop down box. If you come back to the same batch that has already been loaded previously, and not completed, then the filter that was last used will be shown when you return to the batch in this screen at a later time. The available choices are: ALL -- List all claims within the batch. Both good claims and bad claims. 245

258 EDITS -- List only those claims that have an error. This is the default filter when you enter this screen with a new batch loaded. Acceptable -- List only those claims that have completed review and have been deemed as "Acceptable" by you. Needs Review -- List only those claims that have the "Needs Review" status. Clean -- List only those claims that have "Clean" (OK) status. Flagged -- List only the claims that have the check box marked for further review. Not Flagged -- List only the claims that do not have the check box marked. In the event that an interruption occurs while reviewing a claim (such as a power outage, or prematurely exiting the screen in the browser, etc) it can be possible that a claim is left in a state that is has not yet had the Run Check happen to it. This type of claim will be displayed at the top of the list for each of the filters. When this type of claim is loaded into the Repair Toolkit screen, the Run Check button will be the only navigation button available. See Repair Toolkit screen for more information. Print: The Print button is available to get a quick printout of the list of claims. The printout will look just like the filtered listed claims on the Claims List screen. Sample Printout: The name of the batch and the file name for the list of claims that you are viewing will be shown at the top of the list of claims. Click the double arrow at top of any column to sort the list in ascending or descending order according to that column. Claim ID: The default sort is by the claim ID number in the first column. The claim identifier comes from the practice management system's assigned claim number or control number. Click the claim ID number to load it into the Repair Toolkit screen to work with and fix. After a claim has been clicked the color of the underline link changes, letting you know that you have worked with this claim. Claim Date of Service: This column shows the date of service of the claim. Claim Amount: This column shows the total dollar amount of the claim. # of Edits: This column shows the number of edits that were found within the claims. 246

259 Review Status: This column shows the current review status of the claim. There are four different options: Needs Review, Acceptable, Clean, Analyzing Needs Review - This status indicates that the claim has edits and has not yet been indicated as acceptable. This is the default status for claims that have an edit message. In rare circumstances, it can also mean that the claim was being analyzed but due to a technical error (such as a power outage, or prematurely abnormally exiting the screen in the browser, etc) the process did not complete. In the event that an interruption does occur while reviewing a claim, it can be possible that a claim is left in a state that has not yet had the Run Check completed. Acceptable - Claims with this status have been accepted as OK. They can be clean claims or also you may see an edit and deem it as OK anyway and accept the claim with the edit still attached. This is the default status for claims that are "OK" or clean for edits. Clean - Claims with this status do not have any edits. The claim is clean and good for submission. Analyzing - Claims with this status are in the process of the Run Check happening. Under normal conditions this status is very brief. Flag: This column contains check boxes that you can check and uncheck to mark a claim for additional attention if needed. This flag status has no bearing on claim edits or status. It is a tool that you can use for your own tracking purposes. The box is active in both the Claims List screen and in the Repair Toolkit screen. If you check the box in either screen, it will show up as checked in the other screen as well. Edit Conflicts: This column displays all the unique edits that pertain to line items of a claim. For example if a claim has 6 line items, and has a total of 10 edits on those lines, but 7 of the edits are unique (meaning three of them are duplicates on multiple lines (ex. modifier issues)) then this column will display only the 7 unique edit icons, not the complete

260 Repair Toolkit Claims Batch Editor & Repair Toolkit is an add-on module available for purchase. The Repair Toolkit screen showing the contents of a good claim (no repairs necessary). 248

261 Sample Repair Toolkit screen with a claim needing repairs: How to access this screen: Click the Claim ID number of a claim within the Claims List screen. The claim information for the claim will displayed in the Repair Toolkit screen. The Repair Toolkit screen, is very similar to the Compliance Editor screen but has a few differences.claims will be displayed in this screen based on the filter selected in the previous screen. There is a button bar across the top with buttons for Previous, Run Check, Accept, Next, Claims List, and Variance Report. The Batch name and file name of the batch is shown in the title of the button bar section. 249

262 Click the Previous button to go to the previous claim in the batch list. If this is the first claim in the list then the button will be greyed out. When you make changes to the claim, this button is greyed out until the run check process has been completed again. Click the Run Check button to run the compliance check rules on this claim. This is useful if you make a change to the claim and need to check it before moving on to another claim. This button is greyed out until you make a change to the claim. While the Run Check process is happening on a claim, a spinner indicates that the system is analyzing the claim data for edits. Click the Accept button to indicate the claim as Acceptable and go to the next claim in the filtered list. If this is the last claim in the list, then clicking this button will accept the claim and return back to the Claims List screen. When you make changes to the claim, this button is greyed out until the run check process has been completed again. Click the Next button to go to the next claim in the filtered list. If the claim has unrepaired, unaccepted edits then the claim is skipped with no changes. If the claim has been fixed, the changes are accepted. If this is the last claim in the list, then clicking this button will return you to the Claims List screen. When you make changes to the claim, this button is greyed out until the run check process has been completed again. Click a check mark in the Flag box marks the claim as flagged. This is simply marking the claim for additional attention. It is independent of the claims review status. You can flag any claim you need to; clean, needs review, and acceptable. This flagged state of the claim is also available as a filter in the Claims List screen. The check box in this screen will "carry over" into the Claims List screen. Additionally, if changed in the Claims List screen, it will carry over into this screen as well. Click the Claims List button to go back to the Claims List screen. The current state of the fixing process will be saved before exiting the screen. <Number> of <Number> This is an indicator showing you where you are within the list of claims that are being reviewed. For example, if there are 45 claims being reviewed and you are currently fixing claim #23 in the list then 23 of 45 will be displayed. Click the Variance Report button to finishes the current repair process and display the Variance Report in PDF format. 250

263 Sample Variance Report: Sample Variance Report with some repairs shown. This report shows the differences between the claims before any changes were made and after any changes were made. You can then use this report as an aid to fix your claims in your practice management system prior to submitting them to the billing entity. Click the mnemonic icon in the Claims Lines section to highlight the corresponding line in the edit conflicts section below and also highlight the corresponding claim line on the screen. To make repairs to the claim line, you can click and then change the information in the other fields of claim repair toolkit screen as needed. The most recent state of changes is tracked for each claim and the cumulative results will be shown on the variance report. If you attempt to delete ALL the line items of the claim, a warning message will be displayed --"You cannot delete all the charges in a claim. You must allow for at least one line item within a claim." Please note: You cannot add an entire new claim to the list of claims. 251

264 Batch Providers Managing the list of provider names and numbers is available through the Batch Providers screen. How to access this screen: Click the User Administration Button on the Toolbar and click the pencil icon in the Edit column for the user. Select the User Subscriptions tab. Then click the pencil icon in the Edit column for the user's subscriptions. Then click the Manage Providers link. Or, click the User Profile Button on the Toolbar and select the User Subscriptions tab. Then click the pencil icon in the Edit column for the user's subscriptions. Then click the Manage Providers link. Adding a new provider to the list: You do not normally need to add providers to this list since they are added automatically through the batch import process when you add a batch of claims to the claims batch list. However if you need to manually add a provider to the list that you have purchased a license for, that is not in a batch of claims, you can do so in this screen Enter the provider's name and the provider's ID number (NPI number) in the fields provided. Click the Add button. Or click the Cancel button to not add the provider information to the list of providers. Deleting a provider from the list: If a provider has left the practice or for some other reason needs to be removed from the list simply click the delete icon corresponding to the provider listed and confirm the deletion. Deleting a provider from the list does not remove the provider from the claims data or affect the practice management system in any way, it only removes the provider from this list, allowing for another to be added if necessary. 252

265 DrugReimbursement Drug Reimbursement.com is an add-on module available for purchase. DrugReimbursement.com is an online drug coding and reimbursement reference tool and database that provides the latest coding, billing and reimbursement information for FDA-approved drug codes. Search for drugs by CPT code, HCPCS Level II code, NDC, drug name (brand or generic) and by manufacturer. DrugReimbursement.com provides hospitals, physicians and payers the ability to: Title Bar Save research time. Provides complete, up-to-date crosswalk of approved national drug codes (NDCs) to CMS-billable drug codes. Simplify drug searches. Flexible search capabilities allow you to quickly search for drugs by CPT code, HCPCS Level II code, NDC, drug name (brand or generic) and by manufacturer. Improve billing and chargemaster accuracy. Detailed drug data identifies packaging and billable unit variations, and provides link to national and local coverage issues, billing guidelines and fraud alerts. Special icons alert you to new, revised, or deleted codes and quality issues. Improve drug cost management. Current Medicare ASP and APC drug pricing information helps you monitor drug charges, costs, and expected Medicare reimbursement. 1. Select the type of search option from the -DRC Search- section in the first box. The options are: 2. Drug/Description 3. HCPCS/CPT Code (DRC) 4. ICD-9-CM Vol. 1/Vol. 3 (DRC) 5. NDC (National Drug Code) 6. Manufacturer 7. Therapeutic Class 2. Enter the search text or code based on your type of search. Note: The search function can start searching based on a few letters. 3. Select the option for the search function: 4. Starts With (default search) 5. Contains 4. Click Search. Search Box The Search Box is on the Toolbar and is accessible from most of the screens in your product. It is used to enter search terms in order to quickly find the code you are looking for. You can also type in a valid code number to bypass the search and go directly to the Code Section. To search for terms: 1. Type up to four key words or a code number in the search box. 2. Click Search or press your Enter key to initiate a search. If you specify a code set from the drop-down list, the program searches the specific code set. If you specify All Code Sets, the program searches all code set databases for a specific match based on the key words. If you do not enter anything in the Search box and click the Search button or press the Enter key, a message will be displayed to remind you that something must be entered before a search can be initiated. 253

266 If you purchased the DrugReimbursement.com Add-on Module the DRC Search section is displayed. You can specify a code set for DRC, NDC or Manufacturer. The following options are available for DrugReimbursement.com searching: Starts With (default search) Contains Active Inactive NOTE: If you specify All Code Sets or the code sets above the DRG Search section, your search results will display the available codes from EncoderPro.com. Search Results After you initiate a term search, the Search Results screen displays the matches found in all applicable code sets. You can set your desired code sets in the Code Sets Drop-down list on the Toolbar. If there are too many results for the criteria entered a message will be displayed. You can limit the possible results by entering up to 4 terms in the search box. The Search Results screen also includes the subsection range that the code belongs to for all CPT and HCPCS results. Viewing Additional Digit ICD-9-CM and ICD-10-CM Codes The Search Results screen displays the code results. The parent grouping for ICD CM codes is the category code number without a decimal. ICD-CM codes with additional digits are consolidated into a common category. Codes that require additional digits have a plus sign to the left of their folder. Click the plus to expand the category and display subcodes. Click the minus sign to hide subcodes. Note: Only those subcodes that pertain to the search results are listed; not all additional digit codes are listed. Viewing CPT and HCPCS Codes CPT and HCPCS codes are consolidated into subsections identified by the range of codes in that subsection. For example, if CPT code Excision of torus mandibularis is part of your results, it is listed under this subsection range: Musculoskeletal System, Head, Excision. Each subsection range has a plus sign to the left. Click the plus to expand the subsection listing and display codes. Note: Only those codes that pertain to the search results are listed; not all codes in the subsection are listed. When you have narrowed your search results sufficiently, you can click any code in the Search Results list to select it. The full description for the code and all neighboring codes is displayed on the right side of your screen in the CPT Code Detail or the HCPCS Code Detail. 254

267 Note: When obtaining search results for CPT codes, please be aware that due to the AMA resequencing guidelines some codes may appear out of numerical order. To go to the code in the Code Detail, click any code from the Code Sections. After you initiate a search, the Search Results screen displays the matches found in the applicable code set. The Search Results screen also includes the subsection range that the code belongs to for all CPT and HCPCS results. Viewing Additional Digit ICD-9-CM and ICD-10-CM Codes The Search Results screen displays the code results. The parent grouping for ICD CM codes is the category code number without a decimal. ICD-CM codes with additional digits are consolidated into a common category. Codes that require additional digits have a plus sign to the left of their folder. Click the plus to expand the category and display subcodes. Click the minus sign to hide subcodes. Note: Only those subcodes that pertain to the search results are listed; not all additional digit codes are listed. Viewing CPT and HCPCS Codes CPT and HCPCS codes are consolidated into subsections identified by the range of codes in that subsection. For example, if CPT code Excision of torus mandibularis is part of your results, it is listed under this subsection range: Musculoskeletal System, Head, Excision. Each subsection range has a plus sign to the left. Click the plus to expand the subsection listing and display codes. Note: Only those codes that pertain to the search results are listed; not all codes in the subsection are listed. When you have narrowed your search results sufficiently, you click any code in the Results to select it. The full description for the code and all neighboring codes is displayed on the right side of your screen in the CPT Code Detail or the HCPCS Code Detail. Note: When obtaining search results for CPT codes, please be aware that due to the AMA resequencing guidelines some codes may appear out of numerical order. To go to the code in the Code Detail, click any code from the Code Sections. DRC Search Results Enter your search terms or code in the Search Box on the Title Bar. Click the Search button. After you initiate a term search, the Search Results screen displays the matches found in all applicable code sets. You can set your desired code sets in the Code Sets Drop-down list on the Toolbar. If there are too many results for the criteria entered a message will be displayed. You can limit the possible results by entering up to 4 terms in the search box. The name of grid is based on your drop-down list selection. Your results will be similar to the following image. The default sort is based on the Brand Name column. You can sort on each column by clicking on the title or the arrows. The arrow (up or down) changes to bold on the column that was used for the sort. Hover your mouse pointer over the arrows to see a tip that displays which sort, ascending or descending, is available when you click the arrows. Each time you click the arrows, the sort is reversed. 255

268 to display a pop- You can customize the grid with other column information. Click the custom grid button up box that will allow you to select which columns to be displayed. Customizing the Grid: When you click the customize grid icon the following pop-up window is displayed: All possible columns for display are listed on the left side, and currently selected columns are listed on the right side. Columns that are already selected for display are grayed out. Note: By default the Code column and the National Drug Code (NDC) column are not customizable and will always be displayed. To select a column to be displayed highlight it in the left column and click the right arrow to move it to the right column. To remove a column from being displayed, highlight it in the right column and lick the left arrow to move it to the left column. To change the order of the columns, highlight the desired column and click the UP or DOWN buttons to shift the column within the list. Columns listed at the top of the list will be display from left to right in the application grid. Click Save to save your changes and return to the grid. Any changes you make are for your individual login and do not affect other users. Additionally, all saved changes are remembered by the application for future sessions. Or click Cancel to go back without saving changes. In the DRC Search Results screen you can do the following: Click the Code link in the Code column to go to HCPCS Code Detail or CPT Code Detail for the code. Click the NDC link in the NDC column to go to Drug Detail. Click the Manufacturer link in the Mfg./Labeler column to display a list of all drugs for the selected manufacturer in the grid. ICD-9-CM Vol. 1/Vol. 3 Search Results Select ICD-9-CM Vol. 1/Vol. 3 from the drop-down list and enter your ICD-9-CM code. Click the Search button. 256

269 The Search Results grid is displayed. The name of grid is based on your drop-down list selection. Your results will be similar to the following image. Click the link (code or range) in the Code column to go to the list. You can also perform a secondary search within the preliminary displayed Search Results to further narrow down your listed results. Select the corresponding column header from the drop down box and type the search criteria in the text field. Then click the search button. The Search Results list will be filtered to show the new results based on the new search criteria. The title of screen will show a historical "bread crumb trail" of your search within a search. Code Information I9 Codes Click the link in the Code column from the ICD-9-CM Vol. 1/Vol. 3 Search Results. Click the Code link from I9 Codes to go to the ICD-9-CM Vol. 1 Code Detail or ICD-9-CM Vol. 3 Code Detail. 257

270 Drug Information Drug Detail The Drug Detail displays specific information about the drug. From the DRC Search (Search Results) screen, click the NDC code link to go to the Drug Detail. Other NDC Data This section contains specific information about the drug. NDC Data Data information about the NDC. Related NDCs Click the icon or the Related NDCs link to go to the Related NDCs List. AWP This section displays the Average Wholesale Price information. Drug Description This section displays the drug code, generic name, brand name, form, strength, route of administration and product category. Packaging Specific information about packaging is displayed in this section. Manufacturer/Labeler 258

271 The Manufacturer/Labeler is displayed in this section. CPT/HCPCS Codes Any applicable CPT codes or HCPCS codes and descriptions are displayed in this section. Click the code link to go to the Code Detail. ICD-9-CM Codes Any applicable ICD-9 codes and descriptions are display in this section. Click the code link to go to the Code Detail. 259

272 National Drug Code (NDC) Each drug product listed under Section 510 of the Federal Food, Drug, and Cosmetic Act is assigned a unique 11-digit, 3-segment number. This number, known as the National Drug Code (NDC), identifies the labeler/vendor, product, and trade package size. All NDCs displayed in the application are billing NDCs and are used for billing and payment. They are identified as the format, however, we have removed the hyphens in DrugReimbursement.com. Claim forms such as NCPDP universal claim form require the 11-digit NDC. The first five digits represent the labeler code that correlates with the manufacturer. The next 4 digits is the product component, and the last 2 digits is the package size. Strength For single entity products, this is the potency of the active ingredient. For combination products, it may be blank or a number or combination of numbers, e.g., Inderide 40/25. Unit Unit of measure corresponds to strength. This non-mandatory field contains the unit code for a single entity product, e.g., MG. Code Description %VV %WV %WW AMP BAG BOL BOT BOX PERCENT VOL./VOL. PERCENT WT./VOL. PERCENT WT./WT. AMPULE BAG BOLUS BOTTLE BOX C HOMEOPATHIC DILUTION (CENTESIMAL 1/100) CAN CAP CC CMM CNT CTG CTR DIS DRM CAN CAPSULE CUBIC CENTIMETER CUBIC MILLIMETER COUNT CARTRIDGE CONTAINER DISK DRUM 260

273 FLD FLO FTC FTS GAL GM GR IN INC JAR KG KIT L LB FLUID DRAM FLUID OUNCE FEET, CUBIC FEET, SQUARE GALLON GRAM GRAIN INCH INCH, CUBIC JAR KILOGRAM KIT LITER POUND LM HOMEOPATHIC DILUTION (FIFTY MILLESIMAL 1/50,000) LOZ MCG MCL MCM MCN MEQ MG MG/ML MIC MIL MIN MIS ML MM LOZENGE MICROGRAM MICROLITER MILLIMOLE MICRON MILLIEQUIVALENT MILLIGRAM MILLIGRAMS PER MILLILITER MICROCURIE MILLICURIE MINIM MISCELLANEOUS MILLILITER MILLIMETER 261

274 MMO MOL NL NMG NMO NS OZ PEL PKG PNU PPM PT QS QT SAT SPR SQC STP SUP SYR TAB TBL TES TON TPN TRC TRO TSP TUB MICROMOLE MOLAR NORMAL NANOGRAM, MILLIMICROGRAM NANOMOLE, MILLIMICROMOLE NOT STATED OUNCE PELLET PACKAGE PROTEIN UNIT PART PER MILLION PINT QUANTITY SUFFICIENT QUART SATURATED SPRAY SQUARE CENTIMETER STRIP SUPPOSITORY SYRINGE TABLET TABLESPOON TEST TON TAMPON TRACE TROCHE TEASPOON TUBE 262

275 UMG UNT VIL VPR WAF UNITS PER MILLIGRAM UNITS VIAL VARIES PER REGIMEN WAFER X HOMEOPATHIC DILUTION (DECIMAL 1/10) YDL YDS YARD, LINEAR YARD, SQUARE 263

276 Related NDCs List Click the icon from the Drug Detail, Code Section or the Code Detail to go to the Related NDCs List. Click the code link from the Code column to go to the Code Detail. Click the link from the NDC column to go to the Drug Detail. Click the link from the Mfg/Labeler column to go to the Manufacturer Drug List. The columns that have the sort icon can be sorted. When you stop your pointer over the arrows a tool tip displays the sorting option that is available for the column, ascending or descending. Package Type The Package Type standard provides for all types of packages that bulk drug substances and final drug dosage forms are contained in, including both the immediate (or primary) and secondary containers. The source of this information is the Drug registration and Listing System. All package types shall comply with any applicable 21 CFR regulations, CDER guidances, and compendial monographs. The container is that which holds the article and is or may be in direct contact with the article. The immediate container is that which is in direct contact with the article at all times. The closure is a part of the container. NAME DEFINITION CODE AMPULE A container capable of being hermetically sealed, intended to hold sterile materials. AMP APPLICATOR A pre-filled non-injectable pipette, syringe or tube. AP BAG A sac or pouch. BAG BLISTER PACK A package that consists of molded plastic or laminate that has indentations (viewed as "blisters" when flipped) into which a dosage form, is placed. A covering, usually of laminated material, is then sealed to the molded part. A strip pack is a specialized type of blister pack where there are no pre-formed or molded parts; in this case there are two flexible layers that are sealed with the dosage form in between. Suppositories that are strip packed between two layers of foil are also considered a blister pack. BLPK BOTTLE A vessel with a narrow neck designed to accept a specific closure. BOT BOTTLE, WITH APPLICATOR A bottle which includes a device for applying its contents. BOTAP BOTTLE, DISPENSING A bottle that is used by the pharmacist to dispense the prescribed medication. It includes preparations for which a dropper accompanies the bottle. BOTDIS BOTTLE, DROPPER A bottle that has a device specifically intended for the application of a liquid in a drop by drop manner, or a device intended for the delivery of an exact dose (e.g., calibrated dropper for oral medications). BOTDR 264

277 BOTTLE, GLASS A glass vessel with a narrow neck designed to accept a specific closure. BOTGL BOTTLE, PLASTIC A plastic vessel with a narrow neck designed to accept a specific closure. BOTPL BOTTLE, PUMP A bottle that is fitted with a pumping mechanism for the administration of drug product. BOTPU BOTTLE, SPRAY A bottle that is fitted with an atomizer or a device which produces finely divided liquid carried by air. BOTSPR BOTTLE, UNIT- DOSE A bottle that contains a single whole dose of a non-parenteral drug product. BOTUD BOX A square or rectangular vessel, usually made of cardboard or plastic. BOX BOX, UNIT-DOSE A box that contains a single dose of a non-parenteral drug product. [Note: Boxes that contain 100 unit dose blister packs should be classified under blister pack, since this is the immediate container into which the dosage form is placed.] BOXUD CAN A cylindrical vessel, usually made of metal. CAN CANISTER A type of can for holding a drug product. CSTR CARTON A cardboard box or container which is usually considered a secondary packaging component. CRTN CARTRIDGE A container consisting of a cylinder with a septum at one end, and a seal at the other end, which is inserted into a device to form a syringe which contains a single dose of a parenteral drug product. CASE A receptacle for holding something (e.g., that into which some oral contraceptive blister packs are placed). CASE CELLO PACK A plastic "clamshell" [thin plastic pre-formed structure for a device]. CELLO CONTAINER A receptacle designed to hold a specific dosage form. CTR CUP A bowl-shaped container. CUP CUP, UNIT-DOSE A cup intended to hold a single dose of a non-parenteral drug product. CUPUD CYLINDER A container designed specifically to hold gases. CYL DEWAR A container, usually made of glass or metal, that has at least two walls with the space between each wall evacuated so as to prevent the transfer of heat. The inside of the container often has a coating (as silvering) on the inside to reduce heat transfer, and is used especially for storing liquified gases or for experiments at low temperatures. The size can vary from that of a small thermos bottle up to that which may be mounted upon a large truck (also known as a "cryogenic truck"). DEW DIALPACK A dose pack container designed to assist with patient compliance. The patient turns a dial to the correct day and the correct dose is made available and the container indicates that the dose has been removed. DLPK DOSE PACK A container in which a preselected dose or dose regimen of the medication is placed. DSPK DRUM A straight-sided cylindrical shipping container with flat ends; one of which can be opened/closed. DRUM 265

278 INHALER A device by means of which a medicinal product can be administered by inspiration through the nose or the mouth. INHL INHALER, REFILL A container of medication intended to refill an inhaler. INHLRE JAR A rigid container having a wide mouth and often no neck which typically holds solid or semisolid drug products. JAR JUG A large, deep container that has a narrow mouth, is typically fitted with a handle, and is used to hold liquids. JUG KIT A package which includes a container of drug product(s) and the equipment and supplies used with it. KIT NOT STATED The package type is not stated or is unavailable. NS PACKAGE The drug product container with any accompanying materials or components. This may include the protective packaging, labeling, administration devices, etc. PKG PACKAGE, COMBINATION A package in which two or more drug products that are normally available separately are now available together. PKGCOM PACKET An envelope into which only one dose of a drug product, usually in the form of granules or powder, has been directly placed. An example includes glassine powder paper containing aspirin. Other examples include aluminum foil packets into which alcohol swabs and pledgets are placed. PKT POUCH A flexible container used to protect or hold one or more doses of a drug product (e.g. a pouch into which oral contraceptive blister packs are inserted, and an overwrap pouch for large volume parenterals). POU SUPERSACK A multilayer paper bag for shipping some solid bulk excipients, usually in the form of powder or granules. SUPSACK SYRINGE A device for the administration of parenteral drug products that consists of a rigid barrel fitted with septum with a plunger at one end and a seal or needle at the other end. The needle assembly may be part of the device or separate. SYR SYRINGE, GLASS A device for the administration of parenteral drug products that consists of a rigid glass barrel fitted with septum with a plunger at one end and a seal or needle at the other end. The needle assembly may be part of the device or separate. SYRGL SYRINGE, PLASTIC A device for the administration of parenteral drug products that consists of a rigid plastic barrel fitted with septum with a plunger at one end and a seal or needle at the other end. The needle assembly may be part of the device or separate. SYRPL TABMINDER A specialized package; it registers each time it is opened and is used for checking patient compliance to prescribed medication regimens. TABMIND TANK A large receptacle used for holding, transporting, or storing liquids or gases, and often referred to as a reservoir. TANK TUBE A flexible container for semisolid drug products which is flattened and crimped or sealed at one end and has a reclosable opening at the other. TUBE TUBE, WITH APPLICATOR A tube which is provided with a device (the applicator) for administering the dosage form. The applicator may be part of the tube closure or be separate. TUBEAP 266

279 VIAL A container designed for use with parenteral drug products. VIAL VIAL, DISPENSING A vial that is used by the pharmacist to dispense the prescribed medication. VIALDIS VIAL, GLASS A glass container designed for use with parenteral drug products. VIALGL VIAL, MULTI- DOSE A vial intended to contain more than one dose of the drug product. VIALMD VIAL, PATENT DELIVERY SYSTEM A vial that has a patented delivery system. VIALPAT VIAL, PHARMACY BULK PACKAGE A container of a sterile preparation whose contents are intended for use in a pharmacy admixture program and are restricted to the preparation of admixtures for infusion or, through a sterile transfer device, for the filling of empty sterile syringes. VIALPHR VIAL, PIGGYBACK A vial that contains a parenteral preparation that can be attached directly to the tubing of a parenterally administered fluid. VIALPIG VIAL, PLASTIC A plastic container designed for use with parenteral drug products. VIALPL VIAL, SINGLE- DOSE A vial containing a single unit of a parenteral drug product. VIALSD VIAL, SINGLE- USE A vial where a single dose of a parenteral drug product can be removed, and then the vial and its remaining contents can be disposed. VIALSU 267

280 Manufacturer Drug List The Manufacturer Drug List displays information and provides links to other information about the drugs by the Manufacturer/Labeler. The columns that have the sort icon can be sorted. When you hover your mouse pointer over the arrows, a tool tip displays the sorting option that is available for the column, ascending or descending. NOC Price Click the icon from the Code Section or the Code Detail to go to the NOC NDC List. 268

281 Optum Data Color Codes Legend Click this icon on the Toolbar that appears when you are in the Code Section or Code Detail. Crosscodes The Crosscodes are displayed in the CPT Code Detail and the HCPCS Code Detail. IR Crosscodes Revenue Codes OPPS Crosscodes NDC Crosscodes The Interventional Radiology Crosscodes (IR) icon is displayed when the surgical intervention must be reported on the bill to accurately reflect all aspects of the procedure performed. Revenue codes icon provides access to a list of Revenue Codes that are appropriate when billed with the code. OPPS Crosscodes icon provides access to a list of OPPS Crosscodes that should be billed. NDC Crosscodes icon provides access to the NDC Crosswalk list. NDC Crosscodes Click the NCD Crosscodes icon from the Code Detail or Code Section to go to the NDC Crosswalk list. Click the code link in the NDC column to go to the Drug Detail. Click a link in the MFG/Labeler column to go to the Manufacturer Drug List. 269

282 FeeAnalyzer Welcome to Fee Analyzer, Optum's powerful browser-based national fee analyzer. Fee Analyzer is designed to assist and prepare clinicians and their staff to manage successfully today's dramatic changes in health care. Its purpose is to help physicians develop reasonable and equitable fee schedules for their practices and to provide accepted industry and Medicare coding standards as they apply to Physicians' Current Procedural Terminology (CPT Codes) the most commonly used procedure coding system in the country. Features Display of the area-specific fee information of various selected percentile charges for CPT codes, CPT specialty code subset, HCPCS codes and HCPCS specialty code subsets Area-specific estimated indemnity allowable amounts (CPT codes and CPT specialty code subset) Calculated Medicare fee for CPT codes in the Medicare Physician Fee Schedule (CPT codes and CPT specialty code subset) PC/TC split Follow-up days, anesthesia units, and surgical assists Add user notes to any code Print data for selected CPT code sections or specific codes and/or code ranges Export data into a tab-delimited text file, CSV text format, CSV Excel spreadsheets Online help for using the application and information on how to use the FeeAnalyzer data Quarterly Data updates In-depth information to help evaluate your fee schedule A comparison of your current charges to those of other physicians in your area at various customizeable percentiles. A comparison of your charges to a range of estimated national allowable amounts by indemnity carriers A tool to identify allowable charge errors on explanations of benefits (EOBs) from third-party payers A method of developing fees for new or seldom-performed procedures A tool to modify current fees, that are either too high or too low, with relative values A tool to analyze your market's fee information A tool to analyze your workers' compensation fee information Notice Fee Analyzer contains confidential information that is made available to you on the condition that you do not copy or disclose its contents. This information is for general informational purposes only. Such information represents the assessments and opinions of Optum, as of the date of this publication, based upon the experience, research, evaluation, and assumptions of Optum. Optum is not responsible for any decisions made or actions taken in reliance on this information. Optum does not warrant that this information is error free or accepted or approved by others. Fee data included within this application is provided in conjunction with FAIRHealth. 270

283 Fee Analyzer Menu Fee Analyzer is an add-on module available for purchase. Select Fee Analyzer on the Toolbar where you can select Percentile to go to the Fee Analyzer grid and view fee schedules, Fee Loader to import files, or Release Information to view the release information for the Fee Analyzer data. Main Screen Functions Select Fee Analyzer on the Toolbar and Percentile from the menu to go to the Fee Analyzer. Fee Analyzer displays a grid that contains the charge data for evaluating fees nationwide. You can change the selections in the available fields to view all CPT and HCPCS codes or the CPT and HCPCS codes by specialty, Facility or Non-Facility, by a specific Medicare Carrier/Locality (in your U.S. Zip code) and for your purchased U.S. Zip codes. You can customize the grid to include or exclude certain columns. See the following information about the grid: Find Code Type a CPT code in the Find Code field to narrow your search and quickly go to the fee data associated with the code or code ranges. Specialty This field used in conjunction with the Percentile Pricing Information field allows you to view MDR percentile data and Medicare fee data by specialty or all codes. Medicare Pricing Click either the Non-Facility button or the Facility button to specify whether the Medicare Fee information in the Medicare Fee column should be based on Non-Facility or Facility RVUs. Select Medicare Carrier Locality The Select Medicare Carrier/Locality lists all Medicare carriers and localities in your U.S. zip code. The selection determines the area-adjusted Medicare Fee. The default selection in the selection box is the first carrier from the list. U.S. Zip If you purchased more than one geo zip, you can change from one to another in the U.S. Zip field. This box shows the geo zip area, state and city information for and purchased geo zips. The pricing is based on the U.S. Zip. Click the Update Display button to refresh the grid after you make changes. Click the Customize View button to customize the grid display. Export the contents of the grid to one of three external formats. 271

284 Using the FeeAnalyzer Format Fee Analyzer cross-references CPT codes to the relative value study (RVS), to the percentiles and variances (50th, 60th, 75th, 80th, 95th) of the specified area's prevailing fees, Medicare fee, Facility total and Non-Facility total, and to average national allowable amounts paid by indemnity carriers. Reading across the top from left to right, the specific information provided in this product is as follows: User Notes: Click the icon in this column to access user notes for the corresponding code. Code: This column lists procedure codes from the American Medical Association's CPT Codes. Mod (Modifier): FeeAnalyzer.com lists global fees for services by specialty or for all CPT Codes, including codes that can be split into technical (TC) and professional (26) components. The global fee and component splits are listed on separate lines with a G, TC, or 26 in the field. If the service is 100 percent technical, the global service line shows the total amount, the technical component line shows the same total amount, and the professional component line shows zeroes. If the service is 100 percent professional, the global service and professional component lines show the same total amount, and the technical component line shows zeroes. G = Global TC = Technical component 26 = Professional component Sub: The Sub column indicates the status of the code with: C = Change in procedure description from the previous edition of CPT N = New code in CPT D = Deleted code in CPT U = Unlisted UN = Unlisted, New Description: The descriptions are 48-character abbreviations of the current CPT code descriptions. RVS (Relative Value Study): This column contains the Relative Value Study. This copyright scale is a resource-based methodology and has been in wide use throughout the industry since The study is frequently updated by coding, clinical, and statistical experts. The relative value units (RVUs) for listed professional and technical component splits are the same as the global service RVU. The fee information for the component splits is created by changing the conversion factor, not by splitting the RVU by a percentage. This information allows you to determine how technical and professional amounts for your geographic area would be determined if the calculation was based on the PC/TC split percentage multiplied by the global fee. 50th Percentile: A fee at the 50th percentile is not necessarily 50 percent of the highest charge. If your fee for a given service is at the 50th percentile, 50 percent of the submitted charges for that service are higher than your fee. If your fee is at the 75th percentile, 25 percent of the charges are higher than yours. 60th Percentile: This column is the 60th percentile of our database for your geographic area. 75th Percentile: This column is the 75th percentile of our database for your geographic area. 80th Percentile: This column is the 80th percentile of our database for your geographic area. 85th Percentile: This column is the 85th percentile of our database for your geographic area. 90th Percentile: This column is the 90th percentile of our database for your geographic area. 95th Percentile: This column is the 95th percentile of our database for your geographic area. This figure is included so that health care professionals can see a picture that is as complete as possible, but it is often inadvisable to bill at this level. In the current political atmosphere of cost containment, consistent high-level billing can be harmful to the financial well-being of your practice. As managed care networks become more prevalent, high-priced physicians may find themselves without an invitation to be involved with health care organizations. Or, equally painful, physicians may find themselves losing patients who are increasingly unable or unwilling to tolerate high out-of-pocket expenses. 272

285 Comparing your charges to FeeAnalyzer.com data provides a "snapshot" of how your fee schedule stands in relation to other health care professionals in your area, and helps you see where you need to position your fees for successful negotiation of managed care contracts. Please note that while hundreds of payers contribute billed charges to the data used in this product, no individual physician, clinic, or payer schedules appear in the data. Status The Status field indicates the fee methodology of the code from a Medicare perspective: A = Active code B = Service is always bundled in a payment for another service C = Medicare allows the carrier to determine the payment level for these codes D = Codes have been deleted E = Excluded by regulation from the Medicare Physician Fee Schedule F = Deleted/Discontinued Code (Code not subject to 90 day grace period) G or I = Code is not valued for Medicare purposes M = Measurement codes, used for reporting purposes only N = Non-covered service P = Codes are considered to be bundled or excluded by Medicare R = Codes have restricted coverage T = Injection codes X = Codes are excluded by law Note about variance -- Variance is the percentage higher than 100% of the Medicare fee. For example: for a 50th Variance, assume a procedure code with a Medicare charge amount of $ Then assume the industry typically charges $ for the procedure code.the difference between the two charge amounts is $ $ is % of the medicare fee. This is the variance. Another example: Lets suppose the variance or the 50th percentile was 100% of the Medicare fee and the Medicare fee was $1, The 50th percentile fee would be the $ ($ $ = $ ) This helps you understand the billed physician fees within your geographic region's relationship with the Medicare fee to baseline YOUR fees. This information can be used as part of negotiation with the payers during contract negotiation. Conversion Factor The Conversion Factor represents the dollar value of each relative value unit and is used to calculate the reimbursement rate for the specific service. The Conversion Factor default is the Medicare default for each year. FeeAnalyzer.com does not perform anesthesia fee calculations. The Conversion Factor is displayed in the Medicare Reference section of the CPT Code Detail. You can change the entry in the Conversion Factor field which will also change the % of Medicare field. If you change the entry in the % of Medicare field, the entry in the Conversion Factor field changes appropriately. 273

286 Customize Grid View Columns Click the button from the Fee Analyzer page to customize the grid display. If the field has a check in the box, the field is displayed in the grid. Click the check to remove it and the field will not be displayed in the grid. Click Save or Cancel to go back to the grid. The User Notes displays the active User Notes icon in the User Notes column for each applicable code. The Fee Data displays or hides the following fee columns: The Percentile displays the corresponding percentile data column. The Variance displays the corresponding variance data column. The RBRVS Data displays or hides the following columns: The Non Facility Total column displays the Non-Facility Total RVUs. The Facility Total column displays the Facility Total RVUs. The Status column displays the Status code. Note about variance -- Variance is the percentage higher than 100% of the Medicare fee. For example: for a 50th Variance, assume a procedure code with a Medicare charge amount of $ Then assume the industry typically charges $ for the procedure code.the difference between the two charge amounts is $ $ is % of the medicare fee. This is the variance. Another example: Lets suppose the variance or the 50th percentile was 100% of the Medicare fee and the Medicare fee was $1, The 50th percentile fee would be the $ ($ $ = $ ) This helps you understand the billed physician fees within your geographic region's relationship with the Medicare fee to baseline YOUR fees. This information can be used as part of negotiation with the payers during contract negotiation. 274

287 Fee Loader Select Fee Analyzer on the Toolbar and Fee Loader from the menu to go to the User Fee Schedules. User Fee Schedules Select Fee Analyzer on the Toolbar and Fee Loader from the menu to go to the User Fee Schedules. Click the Add button to go to Add User Fee Schedule. Click a user fee schedule link from the Fee Schedule section to go to the User Fee Schedule View. Add User Fee Schedule To upload a new User Fee Schedule, click the Add button from the User Fee Schedules. Click the Browse button, locate your file, give it a name and click Save. A User Fee Schedule file must be formatted as Tab Delimited text file or a Comma Separated Value (CSV) text file. Note: If your file is in Excel format, convert it to a Tab Delimited Text file or Comma Separated Value (CSV) and then do the import. User Fee Schedule View This view is available after you import your fee schedule. The User Fee Schedule View is similar to the Fee Analyzer page and displays the name you gave to your User Fee Schedule. Click a Fee Schedule link from the User Fee Schedules. It displays a grid that contains the charge data for evaluating fees nationwide. You can change the selections in the available fields to view all CPT codes or the CPT codes by specialty, Facility or Non-Facility, by a specific Medicare Carrier/Locality (in your U.S. Zip code) and for your purchased U.S. Zip codes. You can customize the grid to include or exclude certain columns. 275

288 Click to go to the Update Fee Schedule to change the selected percentile in the Imported Fee column in the grid to display. This function does not change the Imported Fee for codes set manually through the Edit process. If you want to edit a fee schedule manually, click the pencil icon Edit User Fee Schedule Record. from the Edit column for the code to go to Update Fee Schedule Click in the grid. from the User Fee Schedule View to update your fee schedule in the Imported Fee column Add Payer Fee Schedule A Payer Fee Schedule File must be formatted as Tab Delimited text file or a Comma Separated Value (CSV) text file. (example format: Code,Modifier,Fee) NOTE: If you make a selection to import a new Payer Fee Schedule File and it already exists, the existing records will be overwritten. You can import three payer fee schedule files, one file during each import. Click Fee Schedule View to go to Add Payer Fee Schedule. from the User Click Browse, select your Payer Schedule, locate your file and click Save. The imported fee schedule is displayed in the column on the User Fee Schedule View and matches your Payer Schedule selection, Payer Fee 1, Payer Fee 2 or Payer Fee 3. Note: If you select a Payer Schedule that already exists, the existing file will be overwritten. 276

289 Edit User Fee Schedule Record Click the pencil icon in the Edit column from the User Fee Schedule View to change the code record. Release Information This dialog box displays the release information of the data used in Fee Analyzer. Select Fee Analyzer on the Toolbar and Release Information. The HCPCS database is updated and released four times per year. The Medical database is updated and released four times per year. The Medicare database is updated once a year by the Centers for Medicare and Medicaid Services (CMS). Click the Release Notes link to go to Release Notes Downloads. Release Notes Downloads Click the Release Notes link on the Release Information screen to download files that contain important information. Printing and Exporting Three types of export formats are available: tab delimited CSV text CSV Excel The Export feature is available from the Fee Analyzer page to export your grid information. Hover the mouse pointer over each image to see a tool tip and verify your export selection. Print 277

290 Click the print button on the Toolbar to open the print dialog box and print the page you are viewing. 278

291 I10 Map Manager I10 Map Manager is an add-on module available for purchase. The U.S. Department of Health and Human Services (HHS) has announced that starting in October of 2014; ICD-10 codes will replace ICD-9 codes as the HIPAA adopted code set for use in coding diagnoses in physicians offices and other outpatient settings for diagnoses. EncoderPro has implemented a tool that will allow you to see which ICD-10 codes map to the current ICD-9 codes, so that you can be ready when ICD-10 codes are required. The I-10 Map Manager add-on allows you to load multiple mappings or batches. You can map these batches manually to the specific target code, to all available targets, or apply the Optum suggested code. The ability to map simple one to one codes as well as more complex advanced mappings, including one to many, is part of the functionality and is included as part of the Map Manager add-on. For example, if you currently use the ICD-9 code of for the diagnosis for a skull fracture, you can click a button or link to see multiple new ICD-10 diagnosis code(s) all related to a skull fracture which indicate different degrees of specificity. You can also export a file of completed mappings to a text file or a comma separated value list. The main Map Management page allows you to add a new map, to copy, edit, view or even delete an existing map. There are safety features (file locks) in place that prevent multiple people from working on the same file at the same time. The map file will remain locked until you have either saved and/or exited the mapping page or until you have manually checked-in the map. You can see information as to when the file was created as well as who the last user was that last worked on the map file and the last modification date checked out date and export date. Through links on this screen you can also purchase additional data files through optumcoding.com. More basic mapping functionality is also available with the main EncoderPro application in the ICD-9 to ICD-10 mapping screen. Note: ICD-10 is still in draft mode. The industry is set to begin using ICD-10 in the latter part of

292 I10 Map Management Page Example Encoder Pro 280

293 II0 Map Manager - User Preferences After purchasing the I10 Map Manager Add-on, those with administrative privileges will have access to the Map Manager software. All other users will need to have the add on added through User Subscriptions. The process is consistent with all other EncoderPro Add-ons. Administrator will need to select I10 Map Manager. Each company will have the same number of subscriptions as EncoderPro users. A grayed out box indicates the I10 Map Manager has not been purchased. Edit User Subscription User Subscription Default when adding a new user for I10 Map Manager is Read/Write/Delete. Ability to check read only is available for users that will need view only access. 281

294 Access the I10 Map Management module by selecting I10 Map Manager in the Add-ons menu on the toolbar. 282

295 I10 Map Manager The I10 Map Manager is the main screen for you to access any mappings you may have completely mapped or partially mapped. It allows you to add a new map, copy, edit, view or delete an existing map. There are safeguards built in so that multiple people cannot over write each other's changes. A mapping file remains locked while being accessed or worked on by someone else until it has been either saved and exited or until it has been manually checked-in. You can see information as to when the file was created as well as the last user who that last worked on the map file. You can also see the last modification date, the checked out date, and the export date. The user assigned to read only through user preferences will have access to both the I10 Map Management and Mapping pages. All action items are disabled. How to access the I10 Map Management screen: Select the Add-ons menu on the toolbar and then select I10 Map Manager. Note: To see the most recent information about changes made by other users in this screen, use your browser's refresh function periodically to see any recent activity by fellow users. 283

296 User Maps: The User Maps table shows all of the maps that you have within the Map Manger Add-on: Click the Add button to add a new mapping file to the list of User Maps. See Add Map for more information. New Data File Uploaded Date indicates the last time OptumInsight updated any mapping codes. This includes Target as well as Source Code. Status: Check Out/Check In- This column indicates whether a the map record is locked or unlocked for editing. Click the column header or double arrow to sort the column in ascending or descending order. When map is first loaded, it is checked in and is unlocked. It is available for mapping the target code to the source code. When the Edit action item is selected, this map is checked out and becomes locked. When a mapping file record is locked, the only available action is View; the other actions are not available until the record is unlocked. Only the user who locks a record can unlock the record. if you are the user who locked the record, you can click the icon to unlock the record. The user that has checked out the map has the ability to edit, delete, and export. This is available regardless of status. With read only privileges, these icons will remain the same but they will be disabled. Map Type: This column indicates the type of map associated with this record. It displays wether the map is for I9V1 to I10CM mapping or for 110CM to I9V1 mapping, etc. The map type is assigned during the add process. Click the column header or double arrow to sort the column in ascending or descending order. Map Name: 284

297 This column shows the name of the map. You assign the name to the map during the add map process. Click the column header or double arrow to sort the list in ascending or descending alphabetical order. Creation Date: This column shows the date that the map was created. Click the column header or double arrows to sort the column in ascending or descending order. Created By: This column shows the user name of the person who initially created the mapping record. Click the column header or double arrows to sort the list in ascending or descending alphabetical order. Modification Date: This column shows the last date that the mapping record was modified. Click the column header or double arrows to sort the column in ascending or descending order. Modified By: This column shows the user name of the person who last modified the mapping record. Click the column header or double arrows to sort the list in ascending or descending alphabetical order. Checked Out Date: This column shows the date that the mapping record was checked out and became locked. Click the column header or double arrows to sort the column in ascending or descending order. This column is blank when the record is unlocked. Checked Out By: This column shows the user name of the person who checked out the mapping record. Click the column header or double arrows to sort the list in ascending or descending alphabetical order. This column is blank when the record is unlocked. Export Date: This column shows the date when the mapping file was last exported. You can export the mapping files for use in other third party applications. Exported By: This column shows the user name of the person who last exported the mapping file. See Actions below for more information about exporting. Actions: This column has icons that indicate various actions you can take with the mapping file. The Actions available are: View, Edit, Copy, Export, and Delete. When a mapping file is locked, the only available action is View, the other actions; edit, copy, export and delete, are not available while the mapping file is locked. View - Select the magnifying glass icon to view a mapping file. The mapping file will be displayed in a new window in read only mode. You cannot make any changes in read only mode. See the Mapping Page for more information. Edit - Select the pencil icon to edit or change a mapping file record. The mapping file will be displayed in a new window in dedit mode where you can make necessary changes to code mappings. See the Mapping Page for more information. If the mapping is checked-out by a different user, the icon will be grayed out. When you choose to edit a mapping record, the status will change to locked until either you exit the mapping page or chooses the option to unlock it. Copy - Select the copy icon to copy a map from one name to a duplicate map with a different name. This process copies everything from the corresponding selected mapping file into a new mapping file. If the icon is grayed out, the mapping file cannot be copied because it is currently checked-out by another user. 285

298 Fields: Map Name: This is the original name of the mapping file. This field is read only. Map Type: This field displays the type of map for this mapping record. This field is read only. Create Map Name: Type a name for the new copy of the mapping file. This name must be unique and cannot be a duplicate of the original file name above. This field is required. Click the Save button to save the changes to the new copied file. Or click the Cancel button to go back to the list of mapping records without making a copy. The new map will appear at the top of the list of mapping file records. Export - Select the disk icon to export a completed or partially completed mapping file. A pop-up window will be displayed that allows you to indicate which details to be exported. The exported file format is selected as part of the export. This file can then be imported into any other third party application for further editing as needed. The layout of the text file corresponds to the boxes selected in the export map options; the first column is Source, the second column is Source Descriptions, etc... The record details that can be exported are: Source Code, Source Description, Target Code, Target Description, User Rationale, MapSelect Rationale (not yet available - coming soon), and Bill Together. Click the Save button to save changes and run the export process. A Windows dialog box will be displayed allowing you to Save the file, Open the file, or cancel the process. Click Save to save the file for use later. Click open to open the export file within the third party spreadsheet program; in most cases this is Microsoft Excel. Remember to save the file using the third party application's save functions. Or click Cancel to go back without doing the export. After the export action has been run, the date, time and user name will be displayed within the appropriate columns on the Map Management page. Delete- Select the delete icon to remove a mapping file from the list. A warning message will be displayed. Click OK, to permanently delete the mapping file. Or click Cancel to go back without deleting the file. 286

299 OptumInsight Data Files: The mapping page also provides clickable links that you can use to purchase additional data files available through optumcoding.com The available files are: ICD-10 Base Draft Files Subscription ICD-10 CM & PCS Base Draft File ICD-10-CM and ICD-10-PCS Base Draft File ICD-10-CM and ICD-10-PCS Mapping Files for Facilities ICD-10-CM and ICD-10-PCS Mapping Files for Payers ICD-10-CM and ICD-10-PCS Mapping Files for Providers I10 Add Map You can map either a single code, small numbers of codes, or load an entire batch of codes with the add function. 1. To add a map, select the add button on the I10 Map Manager screen. The Add Map Screen will be displayed. Use the Add Map screen to load file for mapping or create a map with no codes. Map Manager Add 2. Complete the requested information. This screen requires that the Map Name and Map Type fields be completed before saving. Import Map Screen: Fields: 287

300 Map Name -. Type a unique name for the map file. If a duplicate name is entered an error message will be displayed The map name, already exists, please select a different name and try again. This field is required. Map Type - Select a map type from the drop down list. The default map type is I9V1 to I10CM. The map type determines the code type for the Source Code. Make sure to select the correct map type for the ICD codes being imported. Select ICD9V1 for the source codes of ICD-9-CM type codes, select I10CM for the source codes of ICD-10-CM and select I9V3 for ICD-10-PCS. If the actual imported codes do not match the selected map type, and error message will be displayed Invalid map type. This field is required. File Type Drop Down Choose File - Type a path and file name or you can select the Browse button to browse through your file system and select a source file to be imported into I10 Map Manager for mapping. This field is not required. By leaving this field blank an empty map will be created. When importing an existing file, the following rules apply: 1. The correct valid file format is either a comma separated text (TXT) file or comma separated value (CSV) file. For examples, see "Mapping File Examples" below. 2. The file must contain a header row for the data columns being loaded. The data columns can be in any order. The header names must correspond correctly with the data in the columns. If there are no data column headers within the source file, the following error will be displayed: 'The source file does not have column descriptions. Please correct and try again' Use the following data column header descriptions: * Source * Source Description * Target * Target Description * User Rationale 3. Data limitations include 10 alpha numeric characters and decimals as needed; other symbol characters are invalid. You can create an empty mapping file by simply naming and selecting the map type. Leave the 'Choose File' field blank. This is useful for a small list of codes or if you do not have a source file to import. When importing the file, if there are duplicate items within the list, they will not be imported. However, if duplicate source codes are mapped to different target codes, they will be imported. Please note: Depending on the size of the file being loaded, this process could take some time 3. Select an action- 1. Save - Click the 'Save' button to import and load the file. The Import Map window will close and you will be returned to the Map Manager screen. The Map Manager screen will automatically be updated with newest map at the top of the list. 2. Cancel - Click the 'Cancel' button to close the Import Map window and return to the Map Manager screen without making any changes. 288

301 Mapping File Examples Source Code Only Source Code, Description Source Code, Description,Target Description 289

302 Source Code, Description, Target Code, Description Source Code, Description, Target Code, Description, User Rationale Source Code, Description, Target Code, Description, User Rationale, Bill Together 290

303 ICD-10-CM Mapping Page This Code Mappings screen displays a list of source codes along with their target codes Depending on the file being displayed, this screen can display mappings for ICD-9-CM Vol. 1 source codes to ICD-10-CM target codes, or for ICD-10-CM source codes to ICD-9-CM Vol.1 target codes. When a mapping file is imported into this screen, the original import file should only contain codes with no descriptions. The IMM Map Management process will automatically add code description information according to the data stored internally within the data base. Access this screen through the Map Manager screen's view or edit icons. Also note the following when closing the screen: When closing this screen, click the button labeled "Exit" to save changes and correctly set the file status. Do not close this window with the Windows "X" in the upper right corner of the screen, doing so will leave the file locked so that other users cannot edit the file, if necessary. This screen can be displayed in two different modes: view only mode or edit mode. View Only Mode: Select the magnifying glass in the Map Manager screen to display the corresponding mapping information in view only within this screen. You cannot make any changes in read only mode. Read only users setup through user preferences will have similar functionality. Edit Mode: Select the pencil icon in the Map Manager screen to display the corresponding mapping information in edit mode in this screen. You can add source codes, map source codes to other target codes, and select combination mappings. You can also delete any unnecessary mappings within the mapping page. Target code filter allows you to view only the target code type associated with the selected source code. Using Select to Map, will map the filtered source codes to the appropriate target type. You can not select multiple target types. The default filter is All. If mapping ICD10CM to I9V3 there will not be a tree structure only the select mapped code will show. All- All target codes available to the specific source codes within the mapping list. When using the Select to Map option while All is selected, will map all target codes to matching source codes. GEM- Only targets with the code type GEM will be shown in the target list. The source code list will show only the source codes with GEM code type. When using the Select to Map option while GEM is selected, will unselect all previously mapped target codes and map to GEM only. Optum MapSelect- Only targets with the code type Optum MapSelect will be shown in the target list. The source code list will show only the source codes with Optum Map Select code type. When using the Select to Map option while Optum MapSelect is selected, will unselect all previously mapped target codes and map to Optum MapSelect only. Premier Pick- Only targets with the type Premier Pick will be shown in the target list. The source code list will show only the source codes with Premier Pick code type. When using the Select to Map option while Premier is selected, will unselect all previously mapped target codes and map to Premier Picks only. 291

304 Mapping Screen in EncoderPro: Source Code Filter: Select an option to filter the list of source codes. 292 Filters: All Codes- Displays all source codes within the mapping file. Sort is alphanumeric in order. All codes defined by a user (source)- When filtering on this list of codes, only those codes that have been identified as User Defined will be displayed. While in edit mode, you can map, edit, or delete the code. All codes mapped to a premier pick- This filter displays only those codes that have been mapped to the Optum suggested code. You can then review the selected targets and determine if they agree. While in edit mode, you can change the mapping by selecting the source code. All codes mapped to a single code alternative- This filter displays the source codes that are mapped to only 1 single target code. These codes can include user defined or code alternative combinations. All codes mapped to multiple code alternatives- This filter displays all source codes that have more than one mapped target code. All codes mapped to one or more alternatives- Use this filter to display all mapped codes. This includes everything mapped including UD, Premier Pick, etc.

305 All codes not mapped to a premier pick- Use this filter to review and reevaluate mappings that you may have selected and mapped to other than premier pick codes. If you select to map all premier picks, you can use this option to determine how to map the other codes without a premier pick mapping. All codes not mapped to any alternative- This filter displays any codes from the source code list that do not yet have a target code mapped. If the filter does not find any codes fitting the criteria chosen, a message will be displayed There are no codes that match your filtered criteria To see which target codes have been selected for each source code, first select the source code from the Source Code List box. The corresponding mapped information will appear in the Target Code List. In the case of multiple mappings or combination mappings, a pop-up window is available to display the Code Alternative Combinations. To open the Code Alternative Combinations, select the icon. The selected target code will be the displayed at the top of the list, with the remaining codes listed below in alphanumeric order. Use the Edit mode to change the mapping of the target code. Source Code List The Source Code List displays on the left side of the screen and is the list of codes from the imported mapping file. It is the source of the mapping or the original code you are starting with when doing a map. In ICD-9 to ICD-10 forward mapping, it is the ICD-9 codes. In the ICD-10 to ICD-9 backward mapping, it is the ICD-10 codes. Select a code within this list to see the corresponding mapped target codes in the Target Code List on the left side of the screen. If there are no target codes available for mapping a message will be displayed No Alternative codes were found for the selected Code. Add: Click the Add button to add another source code to the list. A pop-up window is displayed. Type the desired code to be added in the Code(s) field. Click Add to add the code, or click Cancel to go back without adding the code to the list. You can enter more than one code by typing the codes in a comma separated list. Search: Type a code in the text field and click the Search button to search for a code within the list of codes in the Source Code list. Reset View: Click the Reset View button to re-display all of the available codes in the Source Code List. Code Column: This column contains the source code being mapped. Description: This column contains a short description of the source code being mapped. The description comes from an internal database after the mapping file has been previously imported into the Map Manager module. If there is not a description entry in the data base that matches the code, the description field will be populated with the message Invalid code/user defined code. You will be able to either delete or edit the code. It is recommended that if the source code is indeed an error to delete it and add the correct code. Actions Column: Delete - Click this icon to remove the source code from the list. Edit - Click this icon to edit the description of the source code in the list. This option is only available for UD (user defined) codes. User Defined (UD) - This icon indicates that an invalid code or code type has been added either manually or by importing. You can either leave it as is, delete it, or edit the code. The use of User Defined codes should be limited to in-house specialty codes. Code Specific Information - Click this icon to display more complete information about the corresponding code. The code section range page will be displayed or the code detail page will be displayed, depending on the settings in your user preferences. Target Code List The Target Code List displays on the right side of the screen after a code has been selected in the Source Code list. It is the list of targeted codes that are mapped from the source codes. In ICD-9 to ICD-10 forward mapping, it is the ICD-10 codes. In the ICD-10 to ICD-9 backward mapping, it is the ICD-9 codes. 293

306 Add: Click the Add button to add another source code to the list. A pop-up window is displayed. Type the desired code to be added in the Code(s) field. Click Add to add the code, or click Cancel to go back without adding the code to the list. You can enter more than one code by typing the codes in a comma separated list. Checkbox Column: Click the checkbox to select or deselect the code to map it to the corresponding source code. You can check all the boxes at the same time by clicking the Select ALL Target Code Alternatives button at the top of the screen, or you can select just the Optum suggested codes by clicking the Apply/Save Premier Pick button at the top of the screen. Code Column: This column contains the target code being mapped. Description: This column contains a short description of the target code being mapped. The description comes from an internal database after the mapping file has been previously imported into the Map Manager module If there is not a description entry in the data base that matches the code, the description field will be populated with the message Invalid code/user defined code. You will be able to either delete or edit the code. It is recommended that if the target code is indeed an error to delete it and add the correct code. Coding Tips Column: Combination Mapping or Code Alternative - When there is complex/combo mapping, click the icon to display the code alternative combination mapping scenarios that are possible for the corresponding code. GEM Map (General Equivalence Mappings) - This icon indicates General Equivalence Mapping between ICD-9 and ICD-10 codes. The GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM based-data. GEMs are complete in their description of all the mapping possibilities Optum MapSelect - This icon indicates Optum's pick for the target code. It is identified as a pick that our clinical experts have determined to be a better fit to the source code than defined by the GEM. When an Optum Pick is selected, you will also see the premier pick. Note: This is merely a suggestion; it is not a rule that this code is the correct choice. The actual services provided, or your billing practice may dictate that a different code should be used. Optum Premier Pick - This icon indicates that this code is identified as the Premier Pick and identifies the closes ICD-10 alternative mapping based on code descriptions, coding guidelines, and clinical expertise. You will be able to map an entire list to all premier pick codes by selecting the Apply/Save Premier Pick button at the top of the screen. Note: This is merely a suggestion; it is not a rule that this code is the correct choice. The actual services provided, or your billing practice may dictate that a different code be used. User Choice - The icon indicates that you have selected this code as the desired target code. and is at the top of the list. You can select multiple target codes which will all be displayed at the top of the list in alphanumeric order. User Defined (UD) - This icon indicates that an invalid code or code type has been added either manually or by importing. You can either leave it as is, delete it, or edit the code. The use of User Defined codes should be limited to in-house specialty codes. User Rationale - Click this icon to comment on a particular target code mapping. You can use the rationale as a knowledge item explaining why this particular code was chosen for the target mapping. A black icon means that there is no user rationale attached to this code. A red icon means that there is user rationale attached to the code. Hovering the mouse pointer over the icon, displays the attached information. Click the icon to open a pop-up window with the user rationale. User rationale is a note that can be exported to a third party application through the export process. See Map Manager for details. Code Specific Information - Click this icon to display more complete information about the corresponding code. The code section range page will be displayed or the code detail page will be 294

307 displayed, depending on the settings in your user preferences. At this time there is not a direction for ICD-10-PCS codes. Until this available, the disable icon will be displayed. Versioning: Only current target codes will show in the target window unless a version date is completed. Data changes and updates allows you to change your mappings accordingly. These changes are generally done once a month but in rare situations more frequently. At this time, only 6 months of data is stored. You are able to select the data according to the update date by using the drop down menu. Once a date is selected, the options to change your mappings by Select Added Codes, Change Premier Picks and Uncheck Deleted Codes. It is recommended that a mapping be copied if making changes based on the data updates. Target code filters, Source code filters, Source Code lists are not available once a date is selected in the versioning filter. Example of Filter Map and Display Mapping Effective drop down. Example of Filter Map and Display Mapping Effective with selection. Coding Tips Column: Add - added. indicates that this target code is newly added or association with source code has been Deleted - defines a target code that has been deleted from the associated source code. May not necessarily be deleted as a code. Premier Pick - identifies a target code that has had the Premier Pick changed User Defined - lets you know that this was a user selected target code that is no longer available. You may have this along with the deleted coding tip. 295

308 The user is able to select by update date or all updates. The source code list will adapt according to the selected dates and changes within time frame. An error message will appear if there are no changes to the mapped codes. Example of error message Bulk Mapping Options: (These will only change codes within the selected time frame unless choosing All Updates) Select Added Codes will select all target codes associated with the source codes in mapping. Any codes currently mapped will remain mapped. Change Premier Pick will unselect previously select premier picks and update to newly changed recommendations Uncheck Deleted Codes will deselect any code within the source code list of the time selected that has been deleted 296

309 I10 ICD-10-PCS Mapping Page This Code Mappings screen displays a list of source codes along with their target codes Depending on the file being displayed, this screen can display mappings for ICD-9-CM Vol. 3 source codes to ICD-10-PCS target codes, or for ICD-10-PCS source codes to ICD-9-CM Vol.3 target codes. When a mapping file is imported into this screen, the original import file should only contain codes with no descriptions. The IMM Map Management process will automatically add code description information according to the data stored internally within the data base. Access this screen through the Map Manager screen's view or edit icons. Also note the following when closing the screen: When closing this screen, click the button labeled "Exit" to save changes and correctly set the file status. Do not close this window with the Windows "X" in the upper right corner of the screen, doing so will leave the file locked so that other users cannot edit the file, if necessary. This screen can be displayed in two different modes: view only mode or edit mode. View Only Mode: Select the magnifying glass in the Map Manager screen to display the corresponding mapping information in view only within this screen. You cannot make any changes in read only mode. The user assigned to read only through user preferences will have access to both the I10 Map Management and Mapping pages. All action items are disabled. Read only users setup through user preferences will have similar functionality. Edit Mode: Select the pencil icon in the Map Manager screen to display the corresponding mapping information in edit mode in this screen. You can add source codes, map source codes to other target codes, and select combination mappings. You can also delete any unnecessary mappings within the mapping page. Click the Apply/Save Premier Pick button to automatically select ALL the Optum suggested target codes and map them to the corresponding codes for all source codes within the Source Code List. This button is only displayed while in edit mode. Click the Select ALL Target Code Alternative button to automatically select all target codes and map them to the corresponding codes for all source codes within the Source Code List. This button is only displayed while in edit mode. 297

310 Mapping Screen in EncoderPro: Source Code Filter: Select an option to filter the list of source codes. 298 Filters: All Codes- Displays all source codes within the mapping file. Sort is alphanumeric in order. All codes defined by a user (source)- When filtering on this list of codes, only those codes that have been identified as User Defined will be displayed. While in edit mode, you can map, edit, or delete the code. All codes mapped to a premier pick- This filter displays only those codes that have been mapped to the Optum suggested code. You can then review the selected targets and determine if they agree. While in edit mode, you can change the mapping by selecting the source code. All codes mapped to a single code alternative- This filter displays the source codes that are mapped to only 1 single target code. These codes can include user defined or code alternative combinations. All codes mapped to multiple code alternatives- This filter displays all source codes that have more than one mapped target code. All codes mapped to one or more alternatives- Use this filter to display all mapped codes. This includes everything mapped including UD, Premier Pick, etc.

311 All codes not mapped to a premier pick- Use this filter to review and reevaluate mappings that you may have selected and mapped to other than premier pick codes. If you select to map all premier picks, you can use this option to determine how to map the other codes without a premier pick mapping. All codes not mapped to any alternative- This filter displays any codes from the source code list that do not yet have a target code mapped. If the filter does not find any codes fitting the criteria chosen, a message will be displayed There are no codes that match your filtered criteria To see which target codes have been selected for each source code, first select the source code from the Source Code List box. The corresponding mapped information will appear in the Target Code List. In the case of multiple mappings or combination mappings, a pop-up window is available to display the Code Alternative Combinations. To open the Code Alternative Combinations, select the icon. The selected target code will be the displayed at the top of the list, with the remaining codes listed below in alphanumeric order. Use the Edit mode to change the mapping of the target code. Source Code List The Source Code List displays on the left side of the screen and is the list of codes from the imported mapping file. It is the source of the mapping or the original code you are starting with when doing a map. In ICD-9-CM Vol. 3 to ICD-10-PCS forward mapping, it is the ICD-9-CM Vol. 3 codes. In the ICD-10-PCS to ICD-9-CM Vol. 3 backward mapping, it is the ICD-10-PCS codes. Select a code within this list to see the corresponding mapped target codes in the Target Code List on the left side of the screen. If there are no target codes available for mapping a message will be displayed No Alternative codes were found for the selected Code. Add: Click the Add button to add another source code to the list. A pop-up window is displayed. Type the desired code to be added in the Code(s) field. Click Add to add the code, or click Cancel to go back without adding the code to the list. You can enter more than one code by typing the codes in a comma separated list. Search: Type a code in the text field and click the Search button to search for a code within the list of codes in the Source Code list. Reset View: Click the Reset View button to re-display all of the available codes in the Source Code List. Code Column: This column contains the source code being mapped. Description: This column contains a short description of the source code being mapped. The description comes from an internal database after the mapping file has been previously imported into the Map Manager module. If there is not a description entry in the data base that matches the code, the description field will be populated with the message Invalid code/user defined code. You will be able to either delete or edit the code. It is recommended that if the source code is indeed an error to delete it and add the correct code. Actions Column: Delete - Click this icon to remove the source code from the list. Edit - Click this icon to edit the description of the source code in the list. This option is only available for UD (user defined) codes. User Defined (UD) - This icon indicates that an invalid code or code type has been added either manually or by importing. You can either leave it as is, delete it, or edit the code. The use of User Defined codes should be limited to in-house specialty codes. Code Specific Information - Click this icon to display more complete information about the corresponding code. The code section range page will be displayed or the code detail page will be displayed, depending on the settings in your user preferences. This option is not available for ICD-10- PCS target codes at this time. Target Code List The Target Code List displays on the right side of the screen after a code has been selected in the Source Code list. It is the list of targeted codes that are mapped from the source codes. In ICD-9-CM Vol. 3 to ICD

312 PCS forward mapping, it is the ICD-10-PCS codes. In the ICD-10-PCS to ICD-9-CM Vol. 3 backward mapping, it is the ICD-9-CM Vol. 3 codes. Add: Click the Add button to add another source code to the list. A pop-up window is displayed. Type the desired code to be added in the Code(s) field. Click Add to add the code, or click Cancel to go back without adding the code to the list. You can enter more than one code by typing the codes in a comma separated list. Checkbox Column: Click the checkbox to select or deselect the code to map it to the corresponding source code. You can check all the boxes at the same time by clicking the Select ALL Target Code Alternatives button at the top of the screen, or you can select just the Optum suggested codes by clicking the Apply/Save Premier Pick button at the top of the screen. Code Column: This column contains the target code being mapped. Description: This column contains a short description of the target code being mapped. The description comes from an internal database after the mapping file has been previously imported into the Map Manager module If there is not a description entry in the data base that matches the code, the description field will be populated with the message Invalid code/user defined code. You will be able to either delete or edit the code. It is recommended that if the target code is indeed an error to delete it and add the correct code. Coding Tips Column: Combination Mapping or Code Alternative - When there is complex/combo mapping, click the icon to display the code alternative combination mapping scenarios that are possible for the corresponding code. GEM Map (General Equivalence Mappings) - This icon indicates General Equivalence Mapping between ICD-9-CM Vol. 3 and ICD-10-PCS codes. The GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM Vol. 3-CM based-data. GEMs are complete in their description of all the mapping possibilities Optum Pick - This icon indicates Optum's pick for the target code. It is identified as a pick that our clinical experts have determined to be a better fit to the source code than defined by the GEM. When an Optum Pick is selected, you will also see the premier pick. Note: This is merely a suggestion; it is not a rule that this code is the correct choice. The actual services provided, or your billing practice may dictate that a different code should be used. Premier Pick - This icon indicates that this code is the preferred code for billing purposes. You will be able to map an entire list to all premier pick codes by selecting the Apply/Save Premier Pick button at the top of the screen. Note: This is merely a suggestion; it is not a rule that this code is the correct choice. The actual services provided, or your billing practice may dictate that a different code should be used. User Defined (UD) - This icon indicates that an invalid code or code type has been added either manually or by importing. You can either leave it as is, delete it, or edit the code. The use of User Defined codes should be limited to in-house specialty codes. 300

313 When mapping a code to ICD-10_PCS the target code list will be vastly different. This section will only contain the code description and Coding Tips. The ability to expand and collapse codes has been added to the base description and code because of the possibility of a large number of codes for mapping. The user is only able to select a code for mapping once it has been drilled down to 7 digits. next to the 3rd and 4th digits codes notifies the user that this code can be broke into sub- Expanders levels. identifies the code as an expanded code. To collapse the selected item, click the icon a second time only appears when the codes have been completely expanded to a valid 7 digit code. Description includes the root description or operation followed by the body description. This will change with each expansion. Coding Tips are available with the expansion Action Items are not available in the Target List when mapping an ICD-10-PCS Quantity represent the number of codes available for mapping associated with the root code/description 301

314 Show User Choices the screen. will open an additional window that is dynamic. It can be expanded and moved on User choices window will show every target code mapped to the selected source code. This column contains a short description of the target code being mapped. The description comes from an internal database after the mapping file has been previously imported into the Map Manager module If there is not a description entry in the data base that matches the code, the description field will be populated with the message Invalid code/user defined code. You will be able to either delete or edit the code. It is recommended that if the target code is indeed an error to delete it and add the correct code. Actions Column: User Rationale - Click this icon to comment on a particular target code mapping. You can use the rationale as a knowledge item explaining why this particular code was chosen for the target mapping. A black icon means that there is no user rationale attached to this code. A red icon means that there is user rationale attached to the code. Hovering the mouse pointer over the icon, displays the attached information. Click the icon to open a pop-up window with the user rationale. User rationale is a note that can be exported to a third party application through the export process. See Map Manager for details. Code Specific Information - At this time there is not a direction for ICD-10-PCS codes. Until this available, the disable icon will be displayed. Coding Tips Column: Combination Mapping or Code Alternative - When there is complex/combo mapping. In order to see the target codes associated with this mapping, do so by selecting the icon in the target list. GEM Map (General Equivalence Mappings) - This icon indicates General Equivalence Mapping between ICD-9 and ICD-10 codes. The GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate any ICD-9-CM based-data. GEMs are complete in their description of all the mapping possibilities Optum Pick - This icon indicates Optum's pick for the target code. It is identified as a pick that our clinical experts have determined to be a better fit to the source code than defined by the GEM. When an Optum Pick is selected, you will also see the premier pick. Note: This is merely a suggestion; it is not a rule that this code is the correct choice. The actual services provided, or your billing practice may dictate that a different code should be used. 302

315 Premier Pick - This icon indicates that this code is the preferred code for billing purposes. You will be able to map an entire list to all premier pick codes by selecting the Apply/Save Premier Pick button at the top of the screen. Note: This is merely a suggestion; it is not a rule that this code is the correct choice. The actual services provided, or your billing practice may dictate that a different code should be used. User Choice - The icon indicates that you have selected this code as the desired target code. and is at the top of the list. You can select multiple target codes which will all be displayed at the top of the list in alphanumeric order. User Defined (UD) - This icon indicates that an invalid code or code type has been added either manually or by importing. You can either leave it as is, delete it, or edit the code. The use of User Defined codes should be limited to in-house specialty codes. 303

316 Patient Encounter Form (Patient Encounter Plus Add-on subscription) The Administrator can activate this option if you have an available Patient Encounter Plus Add-on subscription. Select the Add-ons menu on the Toolbar, then select Patient Encounter Plus Add a Patient Encounter Form (Administrator only) Click Add-ons from the Toolbar > Patient Encounter Plus Click Add from the Patient Encounter Form List. Type: Form Name Company Name Click Save Print a Patient Encounter Form (Administrator only) Administrator only - If you want to print a Patient Encounter Form, click the icon in the Print column for the Patient Encounter Form. Edit a Patient Encounter Form and Create Code Groups (Administrator only) 304

317 Click Add-ons from the Toolbar > Patient Encounter Plus > Edit Pencil in the Edit column for the Patient Encounter Form (PEP) Change the Patient Encounter Form name or Company Name, if necessary, and click Save. To Create Code Groups, click the Add button. To Edit an existing Code Group, click the pencil icon in the Edit column for the Group. The Create Code Groups section displays the groups that will be displayed on the Patient Encounter Form. If you want to add a Group to your Patient Encounter Form, click Add. The Modifier Group is always available and cannot be deleted. Click The pencil icon in the Edit column to add codes to the Modifier Group. Add Codes to Group (Administrator only) Click Add-ons from the Toolbar > Patient Encounter Plus > Edit Pencil in the Edit column for the PEP (Patient Encounter Plus) > Add button Type: Group Name Codes separated by commas Click Update Display Edit Codes to Group (Administrator only) 305

318 Click Add-ons from the Toolbar > Patient Encounter Plus > Edit Pencil in the Edit column for the PEP (Patient Encounter Plus) > Edit Pencil in the Edit column for the Group You can change the group name in the Group Name field. Click Update Display. Type the codes in the Codes field separated by commas and click Update Display to display them in the Codes List. You can select any or all codes from the list. Check the box next to the codes from the Include Code column to display the codes in the Patient Encounter Form and click Save. 306

319 Run Edits for Patient Encounter Form From the Patient Encounter Form List, click the Patient Encounter Form link to display the codes. Click Print Preview to view the Patient Encounter Form. Export to Compliance Edit. Codes can be exported from the Patient Encounter Form and added to the Compliance Edit. Place a check in the box next to the codes and click Export to C.E to go to Codes to Compliance Edit. Compliance Edit Click Add-ons from the Toolbar > Patient Encounter Plus and click the link for the Patient Encounter Form from the list. Click: Export to C.E. Export to Compliance Editor (Codes to Compliance Edit) Your codes from the Patient Encounter Form are displayed in the Compliance Edit. ABN Form Click the Print ABN from Compliance Edit. 307

320 Remit Advice Professional Remit Advice Professional is an add-on module available for purchase. Remit Advice Professional is a tool that allows you to export your electronic remittance advice files (ANSI 835 files) from your local system and import them into the RemitData portal. You can then analyze them for all kinds of remittance related data. You can see charts and graphs as well as reports about frequency of charges, rate of a failure or denial of claims charges, success of payments, reason codes, adjustment codes, etc. How to access this feature: Select Remit Advice Professional from the Add-ons menu. Using Remit Advice Professional: After selecting the menu option, the system will automatically open a new browser window, and sign on to Remit Advice Professional where you can view your electronic remittance advice information within various charts, graphs and reports. If there is a communications problem or if the server at RemitData is unavailable, the following message will be displayed: "The Remit Advice Professional data server is currently unavailable. Please check again later. We are sorry for the inconvenience." When signed on successfully you will be able to access the electronic remittance information. 308

321 Sample Screen: You can set up Insights rules, make comparisons, see payer information, procedure information, reimbursement and denial information, physician information and details and trends about patient visits. To use this tool you need to set up the service program on your system so that it can monitor your remittance files and upload them for analysis. See Remit Advice Professional setup for details. Remit Advice Professional is copyright by Optum, OptumInsight, and UnitedHealthGroup 309

322 Remit Advice Professional Setup Remit Advice Professional is an add-on module available for purchase. Before using Remit Advice Professional, you need to setup the service on your system. If you try to access Remit Advice Professional before setup has been completed, the following message will be displayed: "Remit Advice Professional has not yet been set up. Please contact Sales Support for more information about setting up this add-on for use with EncoderPro." Contact the Sales Support representative for your local time zone for further help with setting up Remit Advice Professional. 310 Pacific/Mountain Time -- Heather Hoggan; Central Time -- Steve Charloff; Eastern Time -- Gary Carroll; Setting up Remit Advice Professional: There are two methods of set up: Desktop Service Web based Service (preferred method) Setting up the desktop service: This method is not commonly used. The preferred method is the web based service as outlined below. Please follow these directions to set up the desktop service: (click here) 1. Type the address in your browser: 2. Select Open 3. Double Click the RSErn.exe and select Run. 4. Select Next, Install, and Finish to complete the installation of RemitSUBMIT. (If the program opens, please Minimize.) 5. Go to the desktop of your computer. 6. Double click My Computer 7. Go to C:\remitsubmit\xxx001 (xxx001=username/account number, cpt001 or cpt002 depending on billing software) 8. Rename the xxx001 folder to your login/account number. 9. Go to C:\ProgramFiles\RemitDATA 10. Open up the ErnWatcher.exe 11. (If you receive an error message when opening the ErnWatcher, please install the Microsoft.Net Framework 1.1), Click on the link to install the program: Once the ErnWatcher has been opened, you will see a calendar with a magnifying glass next to your clock. 13. On the ErnWatcher, make sure the program notes Start. 14. Double click the first line of the program that notes C:\. An edit watch box opens. 15. Source Directory: Browse to the location of your ERN files. 16. Destination Directory: This line should note C:\remitsubmit\xxx001 (xxx001=your username/account number) 17. File Filter: Name of your ERN files (ex: *835, if you are unsure of the name of your ERNs, we can help you with this setting) 18. Select Save 19. Right Click the Title Bar and select Add to Start Menu 20. Right Click the Title Bar and select Copy Config to Clipboard 21. Right Click the Title Bar and select Copy Files Now. 22. After the log displays Manual Copy Finished, select Start and then Minimize the program. (Do NOT close the program) 23. Create an . In the body of the select Control + V to paste your settings. 24. Send the to customerservice@remitdata.com. Please include your telephone number.

323 25. Double Click the yellow box next to your clock. The RemitSUBMIT Program Opens. 26. Please make changes to your program to reflect the screen shot below. 27. The first line, Directory to Watch, should note C\remitsubmit. (You may use the gray box on the right to browse.) 28. The second line should be blank. 29. Select the Day To Run and Start Time. These settings are based on when you would like to receive RemitDATA Reports. Setting up the web based service Setup: The web based service uses less system resources and is the preferred method for uploading your electronic remittance files. 1. Download the RemitSubmit installation program from 2. Save the file to your local desktop and double click it to run. 3. Click setup to begin the installation. 311

324 4. If you do not have.net Framework installed on the machine. 5. Click Accept. Depending on the computer and the speed of your internet connection, this could take up to 30 minutes. 6. Once this is complete or if you already have.net 4.0 installed. 7. Click Next on this page and the next to complete installation 312

325 Configuration: Once installation is complete, start RemitSubmit by double clicking on the icon on your desktop. The first time to run the program, you'll see a page like this. This is the initial set up screen. It allows you to set up the basic information needed for the application to run. Most users will not need any additional configuration after entering this information, but the application does allow for additional configuration, including multiple accounts, multiple file locations and more complex scheduling. 1. Enter your RemitDATA username and password in the given fields. 2. Select the location for your ERN files. 3. If desired, select an archive location. If an archive location is entered, after the process runs all files processed will be moved to the archive directory 4. Set the desired schedule for the process to run. 5. Click Save to continue. 313

326 Application: 1. The page to set up your account, file location and schedule. 2. The page to set up any pre and post run actions. These will run before and after every time the process runs. 3. The page to view history of when the process last ran, how many files it uploaded and any errors. 314

327 4. The page to view version information, contact customer support, import or export config files, check for updates and set up user impersonation. 315