The Coding Book For Military Occupational And - Navy Medicine



Version 3

Published By Navy and Marine Corps Public Health Center 620 John Paul Jones Circle, Suite 1100 Portsmouth, Virginia 23708-2103

April 2008

Contents CHAPTER ONE: Basic Concepts of Coding 1-1 From Recording Workload to Identifying Services 1-2 Coding Systems 1-3 Reimbursement and Workload Credit CHAPTER TWO: ICD-9-CM Diagnostic Coding 2-1 Injury and Illness Codes 2-2 E Codes 2-3 V Codes CHAPTER THREE: Coding for Privileged Provider Services 3-1 E&M Categories in OEM 3-2 Problem-Oriented Services 3-3 Preventive Medicine Services 3-4 Preventive Medicine Counseling Services 3-5 Case Management Services 3-6 Prolonged Services 3-7 Special Services 3-8 CPT Procedure Coding 3-9 Other Services CHAPTER FOUR: Codes for Support Staff and Supplies 4-1 Occupational Health Nurses 4-2 Occupational Health Technicians 4-3 Durable Medical Equipment and Supplies CHAPTER FIVE: AHLTA and Coding 5-1 AHLTA Coding Features 5-2 Templates 5-3 Screenshots CHAPTER SIX: Scenarios APPENDICES A – Outpatient Physician Services: History Component B – Outpatient Physician Services: Exam Component C – Outpatient Physician Services: Medical Decision-Making Table of Risk D – Outpatient Physician Services: Final E&M Selection E – Quick Guide to Occupational Health Clinic Coding

CHAPTER 1: BASIC CONCEPTS OF CODING 1-1. FROM RECORDING WORKLOAD TO IDENTIFYING SERVICES a. In the past, workload measured by number of patient visits was the basis for reimbursement of the military treatment facilities (MTFs). Reimbursement now depends on identifying the services provided to the patient rather than a simple count of visits. b. The military has adopted coding systems from the civilian sector for identifying services provided by its clinics. Policy requires that military clinics use these codes in the same manner as their civilian counterparts. The Military Health System Coding Guidance supplements these coding systems with military-specific direction and takes precedence over them in the event of conflicting guidance. c. Inaccurate coding in both military and civilian clinics can lead to penalties. “Overcoding” (i.e., coding for services beyond those provided) constitutes fraud. “Undercoding” leads to lower reimbursement. Documentation in the patient record must substantiate the codes selected.

1-2. CODING SYSTEMS a. The International Classification of Disease, 9th Revision - Clinical Modification (ICD-9-CM) is the diagnostic coding system describing why the practice provided services to the patient, thereby establishing the medical necessity of the care provided. The ICD-9-CM is updated annually on 1 October. A three-digit code represents the general diagnosis, with up to two additional digits after the decimal point adding additional detail. The first step in identifying the services provided to a patient is to establish the medical necessity of the visit through ICD-9-CM diagnostic coding. b. The Healthcare Common Procedure Coding System (HCPCS) Level I, commonly known as Current Procedural Terminology (CPT), is the coding system describing the services and procedures provided to the patient. Updates to CPT occur annually on 1 January. CPT codes are five digits and can further describe or explain services rendered by adding modifiers to the basic five-digit code when appropriate. After ICD-9-CM diagnostic codes establish the medical necessity of the visit, CPT codes determine the amount of reimbursement for services. A subset of CPT codes, Evaluation and Management (E&M) codes, describe complexity of care provided, place of service, and type of service. Higher intensity of care results in higher reimbursement. c. The Healthcare Common Procedure Coding System (HCPCS) Level II is a “catch-all” for reporting supplies and services for which no CPT codes exist. It often identifies durable medical equipment and supplies. Ensuring that applicable HCPCS Level II codes are used is the final step in coding a visit. Proper coding of HCPCS Level II codes captures all practice expense so that clinics can be budgeted adequately each year to meet their patient demands.

1-3. REIMBURSEMENT AND WORKLOAD CREDIT a. Relative Value Units (RVUs) assigned to most CPT codes determine the workload credit for the patient encounter. Higher complexity services receive higher RVUs. Under the prospective payment system, an average RVU is worth about $72 reimbursement to the MTF, depending on specialty. b. The mechanism by which a military clinic submits its “claim” for reimbursement for outpatient care is entry of ICD-9-CM, CPT, and HCPCS Level II codes describing the patient encounter in the Armed Forces Health Longitudinal Technology Application (AHLTA) by the provider. The billing system (TPOCS) then transfers this information from AHLTA onto a CMS-1500 Medical Claim Form for payment by the appropriate insurance company.

c. Coding is important to military providers for several reasons. First, the MTF relies on coding by the providers to collect reimbursement from individuals who have other health insurance (including those employed by other Federal agencies). Second, under the prospective payment system, MTFs receive funding based solely on what services they have provided (as documented by coding) in the previous fiscal year. Third, workload credit in the form of RVUs can provide input for performance evaluations (e.g., FITREPs). Finally, accurate ICD-9-CM codes have applications reaching beyond financial reimbursement to epidemiologic analysis and prevention. d. The provider is ultimately responsible for coding and documentation. For questions on coding issues, please contact the Service Representative, as follows: Army Air Force or 1-800-298-0230 Navy

CHAPTER TWO: ICD-9-CM DIAGNOSTIC CODING 2-1. INJURY AND ILLNESS CODING a. ICD-9-CM coding for evaluation and treatment of acute injuries and illnesses in an OEM practice is essentially the same as in an emergency department or primary care clinic. The worker’s symptom, sign, or diagnosis translates into an ICD-9-CM code, which establishes the medical necessity of the visit. Table 2-1 lists some ICD-9-CM codes commonly used in occupational health clinics. b. Use only the ICD-9-CM code for the condition that prompted the workers’ visit, regardless of other chronic conditions that may be present. As an example, consider an employee under treatment for essential hypertension who sustains a laceration to the finger. The reason for the visit to the OEM clinic is the laceration (coded as 883.0 under category Open Wound). The OEM provider should code only 883.0 in AHLTA. The laceration, not essential hypertension, resulted in provision of services to this employee. In contrast, a primary care clinic may also code for essential hypertension if blood pressure is measured, adequacy of treatment reassessed, and this reassessment is documented during the visit. c. Care for an illness or injury may arise during the course of a preventive visit such as a medical surveillance exam. In this instance, expanded documentation should include complete record of the injury or illness as well as all elements of the preventive visit. The injury or illness receives an ICD-9-CM diagnostic code to describe the medical necessity of the problem-oriented service. The CPT coding chapter provides more detail on coding these visits. d. Although AHLTA provides a rudimentary look-up of ICD-9-CM codes, it does not include all of the coding rules and information contained in the ICD-9-CM manual. To use the coding manual, start with the alphabetic index (Volume 2) using the diagnostic term for the injury or illness. Associated with this term will be a three-digit number or number range. Enter the tabular index (Volume 1) using this number. Select the highest order number, up to five digits, that matches the employee’s specific injury or illness. Do not select the code given from the alphabetic index without checking the tabular index for more specific diagnosis codes numbered beyond the decimal place of the three-digit code and any pertinent coding guidelines (i.e., multiple coding required, etc.) e. If an employee has signs and symptoms but no diagnosis yet, refer to Section 16 of the ICD-9CM book titled, “Signs, Symptoms, and Ill-Defined Conditions.” Use of these codes is as acceptable as specific diagnosis codes from the billing perspective since the important issue is why the employee sought care in the OEM clinic, not the diagnostic acumen of the provider.

Table 2- 1: ICD-9-CM Codes Commonly Used in OEM 486 Pneumonia, unspecified Signs and Symptoms 789.00 781.2 477.9 786.2 780.6 784.0 724.2 782.0 278.00 305.1 V15.82 465.9 305.01 780.97 285.9 719.47 300.00 401.1 786.50 276.51 V58.67 250.01 250.00 780.4 715.09 305.91 787.91 787.2 782.3 719.42 796.2 492.8 719.44 780.96 530.81 346.90 307.81 719.45 V65.43 719.49 719.46 780.79 401.0 787.02 V65.3 786.02 715.90 729.5 300.01 462

Abdominal Pain Unspecified Abnormal Gait Allergic Rhinitis Cough Fever Headache Low Back Pain Numbness Obesity, unspecified Tobacco Use Disorder Tobacco Use History Acute URI NOS Alcohol Abuse, Continuous Use Altered Mental Status Anemia, Unspecified Ankle (Foot Joint) Pain Anxiety State, unspecified Benign Essential HTN Chest Pain, unspecified Dehydration Diabetes - Long Term Insulin Use Diabetes Type I, Controlled Diabetes Type II, Controlled Dizziness/vertigo, nos DJD - Multiple Sites Drug Abuse, Continuous, Unsp Diarrhea NOS Dysphagia Edema Elbow (Upper Arm Joint) Pain Elevated BP w/o dx HTN Emphysema NOS Finger (Hand Joint) Pain Generalized Pain GERD Headache, Migraine, unspecified Headache, Tension Hip (Pelvic Region Joint) Pain Injury Prevention Counseling Joint Pain, Multiple Sites Knee (Lower Leg Joint) Pain Malaise / Fatigue / Weakness Malignant Essential HTN Nausea Alone Nutritional Counseling Orthopnea Osteoarthrosis Unspecified Pain in limb, axillary Panic disorder Pharyngitis, acute

* Remember to use E codes (See Table 2-2) ** Use secondary diagnosis code 323.71

518.89 780.39 786.05 719.41 729.81 780.02 401.9 599.0 787.01 719.43

Pulmonary Nodule NEC Lung Disease Seizure Disorder NOS Shortness of Breath Shoulder Joint Pain Swelling in Limbs Transient Alteration of Awareness Unspecified HTN Urinary Tract Infection, unspecified Vomiting w/ Nausea Wrist (Forearm Joint) Pain



915.0 924.21 871.3 924.20 923.20 921.0 930.0 931 923.11 959.3 921.9 959.09 920 923.3 923.10 873.42 959.01 924.01 924.11 959.7 924.10 932 873.1 873.0 923.00 959.2 733.94 733.95 733.93 924.00 924.3 983.1 985.1 986 983.0 984.0 **985.0

Injuries and Accidents* Abrasion/Friction Burn, Finger Ankle, Contusion Avulsion of eye Black Heel Black Palm Blackeye, NOS Corneal Foreign Body Ear Foreign Body Elbow, Contusion Elbow/Forearm/Wrist Injury Eye, Contusion/Injury, Unspecified Face/Neck Injury Unspecified Face/Scalp (except eyes) Contusion Finger, Contusion Forearm, Contusion Forehead/Eyebrow Laceration Head Injury Unspecified Hip, Contusion Knee, Contusion Knee/Leg/Ankle/Foot Injury Lower Leg, Contusion Nose Foreign Body Scalp, laceration complicated Scalp, laceration uncomplicated Shoulder, Contusion Shoulder/Upper Arm Injury Stress Fracture Metatarsals Stress fracture other bone Stress fracture tibia/fibula Thigh, contusion Toe, contusion (Talon Noir) Toxic effects of acid Toxic effects of arsenic Toxic effects of carbon monoxide Toxic effects of corrosive aromatics Toxic effects of inorganic lead Toxic effects of mercury

984.1 984.8 **985.8 983.9 **984.9 985.9 989.5 923.21 739.9 739.1 724.6 739.0 739.6 739.3 733.90 733.00 739.5 739.8 739.4 724.3 737.30 724.8 724.1 739.2 724.4 724.9 724.5 739.7

Toxic effects of Organic lead Toxic effects of Other lead Toxic effects of Thallium Toxic effects of Unspecified caustic Toxic effects of Unspecified lead Toxic effects of Unspecified metals Toxic effects of Venom Wrist, Contusion Spine and Back Abdomen & Other Sites Somatic Dys Cervical Somatic Dysfunction Disorder of the Sacrum Head Somatic Dysfunction Lower Ext Somatic Dysfunction Lumbar Somatic Dysfunction Osteopenia Osteoporosis, unspecified Pelvic Somatic Dysfunction Rib Cage Somatic Dysfunction Sacral Somatic Dysfunction Sciatica Scoliosis, Idiopathic Symptoms of the Back Thoracic Pain Thoracic Somatic Dysfunction Thoracic/Lumbosacral Radiculitis, unsp Unspecified Back Disorder Unspecified Back Pain Upper Ext Somatic Dysfunction

845.00 847.9 845.01 841.8 841.9 845.10 842.10 843.9 844.2 844.8 844.9 844.0 847.2 844.1 845.12 847.0 846.9 847.3 840.9 848.1 847.1 842.00

Sprains and Strains Ankle, unspecified Back, unspecified Deltoid Ligament, Ankle Elbow/Forearm, specified Elbow/Forearm, unspecified Foot, unspecified Hand, unspecified Hip/Thigh, unspecified Knee, Cruciate Ligament Knee/Leg, Other specified Knee/Leg, unspecified Lateral Collateral Knee Ligament Lumbar Spine Medial Collateral Knee Ligament Metatarsophalangeal (joint) Neck (whiplash injury) Sacroiliac Region, unspecified Sacrum (Sacrococcygeal ligament) Shoulder/Upper Arm, unspecified Temporomandibular (joint/ligament) Thoracic Spine Wrist, unspecified

2-2. E CODES a. For external causes of injury, poisoning and adverse reactions, the ICD-9-CM classification contains E codes which provide additional information about where, why, and how an injury occurred. This information is helpful in epidemiologic analysis and population-level prevention efforts. E codes may never serve as primary diagnosis codes; they merely supplement the information provided by the primary diagnosis code. For example, the coded diagnoses 883.0, E920.5 means a puncture wound to the finger (883.0) due to a hypodermic needle (E920.5). b. Use E-codes only during the first patient visit for an injury, not for follow-up visits UNLESS the injury is war-related. For war-related injuries, the E-code is used at all follow-up visits. c. AHLTA requires entry of E codes for ICD-9-CM codes recognized as injury diagnoses. Chapter Five contains more information on entry of E codes in AHLTA. d. The ICD-9-CM codebook contains a section on E codes at the end of the alphabetic index, Volume 2. Like the numeric codes, E codes have a hierarchical organization. Table 2-2 contains frequently used E-codes in OEM. e. Initial encounters for hearing loss acquired from performance of duties, but not associated with physical trauma to the head, should be identified with the appropriate E code as a secondary diagnosis. Table 2- 2: E Codes Used Frequently in OEM External Cause Accident by Caustic/Corrosive substance Accident by Hot Liquid/Vapors or Steam Accident by Hot Substance/Object Accidental Poisoning by Arsenic Accidental Poisoning by Lead Accidental Poisoning by Mercury Accidental Poisoning by Metals Cause-Electric Current Cause-Other Hand Tools/Implement Cause-Other Powered Hand Tools Conflagration, burning bldg/structure Conflagration, explosion bldg/structure Conflagration, fumes (PVC) bldg/structure Conflagration, other accident bldg/structure Conflagration, smoke and fumes bldg/structure Excessive heat-weather/man made Explosion/Fire/Burning watercraft (un-powered) Exposure to noise pollution

E Code E924.1 E924.0 E924.8 E866.3 E866.0 E866.1 E866.4 E925.1 E920.4 E920.1 E891.3 E891.0 E891.1 E891.8 E891.2 E900.1 E837.0 E928.1

External Cause Fall from chair Fall into hole or other opening Fall-slipping, tripping & stumbling Foreign body in eye & adnexa Hornet, wasp & bee stings Human Bite Hypodermic needlestick accident Lifting machine & appliance Metalworking machine Woodworking & forming machine Motor vehicle collision NOS Other spec air transport accidents Other specified machinery Overexert/strenuous mvmt from pull, lift & pushing Poisoning by corrosives & caustics Poisoning by motor exhaust Struck accidentally by falling object Vibration

E Code E884.2 E883.9 E885.9 E914 E905.3 E928.3 E920.5 E919.2 E919.3 E919.4 E812.0 E844.0 E919.8 E927 E864.0 E868.2 E916 E928.2

E991.0 E991.2 E991.9 E992 E994

Injury due to war ops from pellet (rifle) Injury due to war ops from antipersonnel bomb Injury due to war ops from unspecified source Injury due to war ops by explosion Injury due to war ops by unspecified forms Injury due to war ops but occurring after cessation of hostilities Injury due to war ops by laser Injury due to war ops by gas/fumes/chemical Injury due to unspecified form of unconventional warfare

E991.1 E991.3 E990.9 E993 E995

WAR Related E Codes Injury due to war ops from rubber bullet (rifle) Injury due to war ops from bullet Injury due to war ops from unspecified fragments Injury due to war ops by explosion of marine weapons Injury due to war ops by destruction of aircraft Injury due to war ops by nuclear weapons Injury due to war ops from gasoline bomb Injury due to war ops by biological warfare Injury due to specified form of unconventional warfare

E996 E990.0 E997.1 E997.8

E998 E997.0 E997.2 E997.9

2-3. V CODES a. OEM services frequently provide care to workers without specific symptoms or diagnoses, such as medical surveillance or job certification exams. Illness and injury codes, as discussed in the previous chapter, cannot describe medical necessity for these visits of apparently healthy workers. Instead, a subset of ICD-9-CM codes, called V codes, describes the medical necessity of preventive and administrative care. b. V codes are a separate section of the tabular index of the ICD-9-CM Manual, Volume 1. Like the injury and illness codes, additional digits add specificity to the code. c. Two V codes commonly describe medical necessity for preventive exams by OEM physicians. Use these codes only as the primary (i.e., first-listed) code for the visit. (1) V70.5 codes for health exams of a defined population such as groups of workers in medical surveillance programs. This code has special Department of Defense extenders that add more detail, for instance to code for a pre-deployment health assessment (see Table 2-3). (2) V68.09 encounters are for administrative purposes such as the issuance of a medical certification, rating, or statement. Medical certificates are most often part of an examination or physical and do not receive a separate code. However, when no medical indication for the encounter exists, the patient’s reason for the encounter was solely to obtain a medical certificate, no other code more appropriately reflects the primary reason for the encounter, and the provider does not evaluate or treat any symptoms, conditions, or diseases, use V68.09. Table 2- 3: DoD Extenders for V70.5 Extender V70.5_0 V70.5_1 V70.5_2 V70.5_3 V70.5_4 V70.5_5 V70.5_6 V70.5_7 V70.5_8 V70.5_9 V70.5_A V70.5_B V70.5_C V70.5_D V70.5_E V70.5_F V68.09

Purpose Armed Forces Medical Exam Aviation exam Periodic Health Assessments Occupational exam Pre-deployment related encounter Intra-deployment related encounter Post-deployment related encounter Duty status determination Special Program Accession encounter Separation/Retirement Exam Health Exam of defined subpopulations Abbreviated Sep/Retirement Exam PRT Screening Pre-Deployment Assessment Initial Post-Deployment Assessment Post-Deployment Health Reassessment Issuance of Medial Certificate

Description Pre-enlistment general exam

Includes initial certifying and recurring exams Not Pre-deployment assessment

Includes return to work and disability evaluation Prior to service entry to officer programs School physicals, etc. Partial exam updating complete exam within a defined period Identified conditions are secondary codes Identified conditions are secondary codes Identified conditions are secondary codes Identified conditions are secondary codes Use only as primary code, do not use in conjunction with V70.x

d. Visits including preventive counseling and education, such as a reproductive hazard evaluations, also require V codes to describe medical necessity of the education or counseling provided. These codes are secondary codes to the appropriate primary diagnostic or V codes. Table 2-4 provides some helpful secondary V codes for describing these visits. Table 2- 4: Secondary V Codes for OEM Education and Counseling V Code V65.49_6 V65.49_5 V62.1_0 V62.2 V15.84 V15.85

Education Topic Occupational exposure education Travel medicine education Occupational stress education Dissatisfaction w/employment Exposure to Asbestos Exposure to Hazardous Body Fluid

V15.3 V15.86 V72.0 V65.43 V65.3 V22.2 V26.49 V82.89

Exposure to Irradiation Exposure to Lead Eye & Vision (SCP) Injury Prevention Nutritional Counseling Pregnancy Incidental Reproductive concerns/hazard Submarine Pressure Screening

e. Table 2-5 summarizes diagnostic coding of hearing tests performed in conjunction with the Hearing Conservation Program. Civilian ICD-9-CM coding guidelines limit both V70 and V72 codes to first-listed status and use of code V70.5 therefore typically should exclude V72. However, the Department of Defense wishes to identify the specific type of hearing conservation program exam performed and has issued superseding guidance to report both codes for hearing conservation program exams. Table 2- 5: V Codes for Hearing Conservation Program Exams Encounter Type ICD-9-CM Codes Military accession exam – no abnormalities V70.5_8 and V72.1* Military accession exam - abnormalities V70.5_8 and V72.1* plus 794.15** Baseline exam - no abnormalities V70.5_3 and V72.1* Baseline exam – abnormalities V70.5_3 and V72.1*, plus 794.15** Annual exam - no identified STS V70.5_3 and V72.1* Annual exam - initial STS V70.5_3 and V72.1* plus 794.15** Annual exam - previously confirmed PTS V70.5_3 and 388.1X* or 389.XX* Follow-up 1 or 2 for STS 794.15** Termination exam V70.5_9 and V72.1* * 4th and 5th digits and applicable DoD extender code required to indicate a specific condition or encounter **For non-professionals (e.g., technicians, nurses, volunteers). Physicians or audiologists may diagnose noise-induced hearing loss.

f. For individuals receiving occupational audiology evaluation after an abnormal screening evaluation, V code extenders in Table 2-6 apply. Table 2- 6: V Code Extenders for Occupational Audiology Evaluations Encounter Type Examination of Ears and Hearing Hearing Examination Following Failed Hearing Screening Hearing Examination Following Failed Hearing Screening, Otoscopic Exam Done Hearing Examination Following Failed Hearing Screening, Otoscopic Exam Not Done Other Examination of Ears and Hearing Other Examination of Ears and Hearing, Otoscopic Exam Done Other Examination of Ears and Hearing, Otoscopic Exam Not Done

ICD-9-CM Code V72.1* V72.11* 0 V72.11* 1 V72.11* 2 V72.19* 0 V72.19* 1 V72.19* 2

g. For individuals receiving immunizations as required by medical surveillance, V codes in Table 2-7 apply. Table 2-7: V Codes for Immunizations IMMUNIZATIONS Vaccine or Medication Name Anthrax B-12 Chicken Pox(Varivax) Varicella Depo Provera 150mg

Admin CPT 90471 / 2 90772

CPT HCPCS 90581 J3420

90471 / 2 90772

90716 J1055

ICD9 V03.89 266.2 or per Dr order V05.4 V25.49

Depo Provera 50mg DTaP < 7 years DT, Pediatric, <7 years Flu Shot, split virus 6-35 months of age

90772 90471 / 2 90471 / 2 90471 / 2

J1051 90700 90702 90657

Per Dr order V06.1 V06.5 V04.81

Flu Shot , split virus >3 years 90471 / 2 90658 V04.81 Flu Mist (intranasal) 90473 90660 V04.81 Hep A, 1-18 yrs, 2 Dose Sch. 90471 / 2 90633 V05.3 Hep A, Adult 90471 / 2 90632 V05.3 Hep B, 0-19 years, 3 Dose Sch. 90471 / 2 90744 V05.3 Hep B, Adult, 20+ 90471 / 2 90746 V05.3 HPV – Gardasil V04.89 90471 / 2 90649 V05.8 Twinrix, Hep A & Hep B, adult 90471 / 2 90636 V06.8 HIB (3 dose vaccine) PRP-OMP 90471 / 2 90647 V03.81 IPV (Polio) IM or SUBQ 90471 / 2 90713 V04.0 JEV (Japanese Encephalitis Virus) 90471 / 2 90735 V05.0 Meningococcal (2-10 yrs old) Menemune 90471 / 2 90733 V03.89 Meningococcal (10 yrs/ older) Menactra con 90471 / 2 90734 V03.89 MMR 90471 / 2 90707 V06.4 MMRV (ProQuad) 90471 / 2 90710 V06.8 Pediarix (DTaP, IPV, Hep B) 90471 / 2 90723 V06. 8 Pneumoccal, conj. <5 years 90471 / 2 90669 V03.82 Pneumovax, Adult or immunosuppressed patient 90471 / 2 90732 V03.82 PPD Placement (TB test) ------86580 V74.1 PPD – Read NEGATIVE -----------V74.1 PPD—Read POSITIVE 795.5 Rabies IM 90471 / 2 90675 V04.5 Rotavirus 3 dose sched., live, for Oral use 90473 90680 V04.89 Synagist (per 100mg vial) 90772 90378 V04.82 Td, Adult >7 90471 / 2 90718 V06.5 Tdap IM > 7 years and older V06.1 90471 / 2 90715 V06.8 Tetanus toxoid 90471 / 2 90703 V03.7 Typhoid IM (ViCPs) 90471 / 2 90691 V03.1 Typhoid Oral 90473 90690 V03.1 Yellow Fever 90471 / 2 90717 V04.4 Zoster (Shingles) SUBQ 90471 / 2 90736 V05.8 PRESERVATIVE FREE (PF) Flu Shot, split virus 6-35 months of age, PF 90471 / 2 90655 V04.81 Flu Shot, split virus >3, PF 90471 / 2 90656 V04.81 Tetanus and Diptheria toxoids(Td) age >7, PF 90471 / 2 90714 V06.5 *** Administration codes*** if inj and oral/nasal given concurrent always list inject first. If you administer more than one each additional injectable would be coded as a 90472 Use 90473 if you give an oral or a nasal with NO OTHER VACCINE If you administer more than one oral or nasal then ADD 90474 IMMUNE GLOBULINS Immune Globulin (Ig) IM 90772 90281 V04.89 Respiratory syncytial virus immune globulin (RSV-IgIM) PER UNIT 90772 90378 V04.82 50mg each Tetanus Immune Globulin (TIg)IM 01 PFS 90772 90389 V03.89 Rabies Immune Globulin (Rig-HT), HT 10 1vi 90772 90376 V04.5 SHOT TRANSCRIPTION ON TO SPECIAL FORM – such as PH731/State SchPE Form etc. Special Reports / Forms 99080 V68.09 SMALLPOX VACCINE *only given at NMCP, Boone and Sewells Point Smallpox $202/vial 90471 / 2 V04.1 Dr. supervised Grp Edu Svsc (DOD required briefing) Dr. supervised Provision Edu Supplies (Mandatory Tri-fold) 99071 Dr. service: smallpox review/reporting of status (scrn form 99071 clearance w/ reporting) Special Foam Dressing, wound cover, 16 sq. inch or less, adhes (per unit A6212 – usually 6 given –) Purell 99070 Other Therapies; Non-MD Patient Education and Counseling S9445 Non-MD Instruction for Patients 99071 ADVERSE EFFECTS – Nurses use if initiating VAERS Special Reporting (VAERS reporting) Patient Education-Medication Adverse Event

Diptheria 99080 E948.5 Mix (combination) 99080 E948.9 Pertussis 99080 E948.6 Tetanus 99080 E948.4 Measles 99080 E949.4 Lymes Vac 99080 E948.8 Mumps 99080 E949.6 Polio 99080 E949.5 Rabies 99080 E949.1 Typhoid 99080 E948.1 Yellow fever 99080 E949.3 Smallpox 99080 E949.0 Bacterial, other and unspecified 99080 E948.8 Other-unspec vaccines and biological substances 99080 E949.9 When filing a VAERS one must use the 99080, V65.49 with the appropriate E code. VACCINATION REFUSAL Vaccination not carried out, unspecified reason



Vaccination not carried out because of acute illness



Vaccination not carried out because of chronic illness or condition



Vaccination not carried out because of immune compromised state



Vaccination not carried out because of allergy to vaccine or component



Vaccination not carried out because of caregiver refusal



Vaccination not carried out because of patient refusal



Vaccination not carried out for religious reasons



Vaccination not carried out because patient had disease being vaccinated against



Vaccination not carried out for other reason



CHAPTER THREE: CPT CODING FOR PRIVILEGED PROVIDER SERVICES 3-1. CATEGORIES OF E&M SERVICES PERTINENT TO OEM a. Evaluation and management (E&M) codes are the subset of CPT codes that quantify the work done by the privileged provider during (or associated with) a patient visit. E&M codes, CPT procedure codes, and HCPCS Level II codes together determine the reimbursement for the patient visit. For specialties such as OEM that are less procedure-oriented, E&M codes are the largest contributor to reimbursement. b. Different categories of E&M codes apply to different types of visits. Table 3-1 outlines the E&M categories pertinent to OEM clinics. Table 3- 1: E&M Categories Used in OEM Category/Subcategory Problem-Oriented Services □ New Patient □ Established Patient □ Consultation Preventive Medicine Services □ New Patient □ Established Patient Preventive Medicine Counseling Services □ Individual Counseling □ Group Counseling Case Management Services □ Case Management, each 15 minutes □ Team Conferences □ Telephone Calls (Privileged Providers only) Prolonged Services □ Direct Patient Contact □ Without Direct Patient Contact Special Services □ Work-Related or Medical Disability Evaluation *Precludes use of 99080 CPT procedure code

Code Numbers 99201-99205 99211-99215 99241-99245 99381-99387 99391-99397 99401-99404 99411-99412 T1016 99361-99362 99441-99443 99354-99355 99358-99359 99455-99456*

3-2. PROBLEM-ORIENTED SERVICES a. OEM practices that provide acute care use the same evaluation and management (E&M) codes as primary care clinics. The problem-oriented E&M codes represent five different levels of complexity based on the intensity of care. The provider, not AHLTA, selects the appropriate E&M code level for the patient visit. The five levels of service are minimal, problem focused, expanded problem focused, detailed, and comprehensive. Privileged providers typically do not use the minimal level unless their documentation is deficient. A privileged provider is an independent practitioner who is granted permission to provide medical, dental, and other patient care in the granting facility, within defined limits, based on the individual’s education, licensure, experience, competence, ability, health, and judgment. Resident physicians are not independent practitioners but are included as privileged providers for coding purposes. Chapter 4 addresses use of the minimal level of service code by support staff. b. Three key components, history, exam, and medical decision making, determine the appropriate E&M level for a problem-oriented visit. Only documented services contribute to the level of complexity. c. Four contributory factors can increase the E&M level of an encounter in certain circumstances: nature of presenting illness, coordination of care, counseling, and time. If more than 50% of the visit is spent counseling or coordinating care, these factors become a key component of the E&M level. If time is a key component for the encounter, document the counseling topics or coordination of care that occurred and include the total face-to-face time plus the

counseling/coordinating time. This time does not include resident or support staff time with the patient. Prolonged time is described by the -21 modifier only for the highest level (i.e., comprehensive or 99215) E&M services, or by an additional prolonged services E&M code for other levels (see section 3-5). Reporting any code that is measured by time only must be supported within the providers’ documentation by time in and time out per DoD Coding Guidelines and must also show how much time was spent directly counseling/coordinating care within the time in and time out span. (For example, time in 1300; time out 1415 – 50 minutes spent counseling/coordinating care for pt on ….) d. Problem-oriented E&M codes distinguish between services provided in consultation, to a new patient, and to an established patient. New patient and consult visits receive a higher reimbursement than established patient visits for the same level of complexity. CPT defines a new patient as one who has not received any professional services from the physician (or another physician in the same practice group) within the past 3 years. New patient visits require documentation of all three key components (history, exam, and medical decision-making), whereas established patient visits require only two of the three key components. e. Content of documentation, not volume, determines the E&M code. The component with the lowest level of documentation determines the E&M level. By knowing the elements required to code each component to a higher level of service, you can ensure that your documentation accurately reflects your workload. Templates, in particular, can ensure that you do not lose an E&M level by failing to document services that you performed. f. Each of the three key components depends on specific elements to determine its level of complexity. Documentation of the history of present illness; review of systems; and past medical, family, and social history determines the level of complexity for the history component. Occupational history is part of social history for coding purposes. Appendix A provides expanded information on the history component. The physical exam component depends on the number of organ systems and body areas evaluated. Appendix B provides expanded information on the physical exam component. Medical decision-making complexity depends on the Table of Risk (Appendix C). g. After determining the level of complexity for each of the three key components, find the final E&M level for the visit in Appendix D. Again, remember that the lowest complexity component drives the level of service. If three components are completed for an established patient, the E&M level is the middle complexity component (i.e., drop the lowest component since it is not required).

3-3. PREVENTIVE MEDICINE SERVICES a. The E&M codes for Preventive Medicine Services describe routine examinations performed in the absence of patient complaints or symptoms. These services include medical surveillance exams, disability evaluations, and fitness for duty determinations. Age, rather than documented complexity of care, determines the E&M level for preventive medicine services. Like E&M coding for problem-oriented visits, preventive services codes also distinguish between new and established patients. b. Note that if an employee raises a specific complaint during a medical surveillance exam, the visit may constitute both a problem-oriented and preventive services visit if the complaint requires significant time and resources for its evaluation and management. In this case, document the problem-oriented visit separately from the preventive visit with a second SOAP (Subjective, Objective, Assessment, and Plan) note and code to reflect both services provided. Use a preventive services E&M code linked to the appropriate ICD-9-CM V code. Then, use a problemoriented service E&M with modifier -25 linked to the injury and illness ICD-9-CM code

describing the symptom, sign, or diagnosis. Table 3-2 provides guidance in differentiating problem-oriented, preventive medicine, and combined visits.

Table 3- 2: Differentiating Preventive Medicine Visits from Problem-Oriented Visits Preventive Medicine Visit Chief complaint


System review, Past/family/social history Examination Assessment and Plan

Healthy patient No complaints Insignificant/trivial problem Not problem oriented No present illness described Pertinent risk factors assessed Comprehensive system review, Comprehensive PFSH Based on age, risk factors Screening for ancillary services Plan typically counseling, anticipatory guidance, risk factor reduction

Problem-Oriented Visit Chief complaint specified

Preventive Medicine Visit with Problem Healthy patient with significant complaint

Limited to presenting problem

Include history related to age/gender and present illness

Pertinent to presenting problem

Comprehensive system review/PFSH + data specific to presenting problem

Appropriate to presenting problem Medical decision-making reflected in assessment, Ancillary services ordered for specific medical problem

Age and risk factor based exam + eval of presenting problem Screening + medical decision making

c. Code diagnoses, symptoms, or signs discovered during a preventive services visit but not requiring significant time and resources as secondary ICD-9-CM codes.

3-4. PREVENTIVE MEDICINE COUNSELING SERVICES a. A frequent service of OEM clinics is counseling individuals and groups of patients. As an example of this service, consider an industrial operation that potentially exposes an individual employee or group of employees or non-employees to overexposure of toxins, fumes, or physical hazards. An employee may be educated about the signs and symptoms that he or she might experience in the event of an overexposure. This service is preventive counseling. b. A common coding error is using a preventive medicine, individual, or group counseling code rather than an education code when a condition, symptom, or disease exists. Using the previous example, if the OEM staff educates employees following an overexposure, this is a problemoriented visit rather than preventive counseling. c. Levels for these E&M codes depend on the amount of time that the provider spends with the individual or group. d. ICD-9-CM codes for these encounters are V codes described in Chapter 2.

3-5. CASE MANAGEMENT SERVICES a. Case management codes report coordination of care with other providers or employers without a patient encounter on that day. Medical team conferences by the provider with an interdisciplinary team of health professionals receive an E&M code. Note, however, that the provider must be responsible for direct care of the patient and for supervising health care services needed by the patient. Therefore, these codes do not apply to conferences involving an employee who has not been under the provider’s care (e.g., team review of worker’s comp claim). b. Do not code site visits that are not associated with care of an individual patient. However, if the walk-through occurs in conjunction with individual patient care (e.g., to clarify reasonable

accommodation in a fitness for duty evaluation) and as part of an interdisciplinary team, case management E&M codes apply. c. Time determines the appropriate level of case management E&M code. Code 99361 reflects a 30-minute team conference while code 99362 reflects a 60-minute team conference.

3-6. PROLONGED SERVICES a. Prolonged provider services occur when the care provided requires at least 30 minutes more than usual. Use these secondary E&M codes only in conjunction with a problem-oriented, preventive service, or special service E&M code. Prolonged services can occur either with direct, face-to-face patient contact or without. Episodes of prolonged service without direct patient contact must occur either before or after direct patient care (within one week). A frequent use of prolonged services codes in OEM is the description of time required for record review before or after a disability evaluation or reproductive hazard evaluation. b. Code prolonged services with direct patient contact as 99354 for 30 to 60 minutes and add 99355 for each additional 30 minutes. Code prolonged services without direct patient contact as 99358 for 30 to 60 minutes and add 99359 for each additional 30 minutes.

3-7. SPECIAL SERVICES a. Work-related disability examinations fall under special E&M services. These exams include a history and exam appropriate to the employee’s condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of a treatment plan; and completion of documentation including reports and certificates. b. If the provider is treating the employee, code 99455 applies. If the provider is not treating the employee, code 99456 applies. c. Do not use CPT procedure code 99080 (Special paperwork) in conjunction with these special services E&M codes since completion of certificates and reports is integral to the special services E&M code.

3-8. CPT PROCEDURE CODES a. Specific procedures performed during a problem-oriented or preventive services visit receive additional CPT procedure codes (and therefore additional workload credit). Frequent omission of these procedure codes leads to lost workload credit. Only code those procedures actually performed in (not ordered by) the occupational health clinic. b. Table 3-3 outlines some of the more common procedural codes used in conjunction with OEM problem-oriented and preventive visits. Table 3- 3: Common CPT Procedural Codes for OEM Procedure Problem-Oriented Visits Application of modality, hot or cold packs Educational Materials given to pt. IV Infusion, first hour IV Infusion, each additional hour Orthotic mgmt and training; ea 15 min Tetanus/Diphtheria Vaccine (IM)

Code 97010 99071 90765 90766 97760 90718

Use with Tetanus Vaccine (Admin) Venipuncture (Code Specimen Handling Also) Laceration Repair face/ear/nose/lip/eyelid; <2.5 cm Laceration Repair face/ear/nose/lip/eyelid; 2.6-7.5 cm Laceration Repair scalp/neck/trunk/ext; <2.5 cm Laceration Repair scalp/neck/trunk/ext; 2.6-5.0 cm Preventive Visits Venipuncture Spirometry Tympanometry Visual acuity EKG Immunizations, PPD placement Guaiac Test Dip Stick Urinalysis Audiometry

90471 36415 12001 12002 12011 12013

36415 94010 92567 99173 93000 (global) 93005 (tracing only) 93010 (interpretation and report only) 90465–90749 86580 82270 81002 Screening, Pure tone, air only, 92551 Pure tone (threshold), air only, 92552 Testing of groups, 92559

c. Immunizations given at point of service (i.e., in the clinic performing the physical) are coded on the same encounter as the physical. d. Electrocardiograms have a global code (93000) used when the tracing, interpretation, and report are completed in the same clinic. In this case, the technician performing the test should be included as an additional provider. If the tracing and interpretation/report are performed in separate clinics, the clinic performing the tracing codes 93005 for the tracing only. The provider privileged to interpret and report the ECG/EKG then uses 93010 upon completing the EKG report to code the professional component. Interpretation without a written report does not receive a separate CPT procedure code, but is part of the medical decision-making complexity in determining the E&M code for the visit. e. Table 3-4 provides CPT codes describing special services that may apply to OEM providers. As CPT codes, they confer additional workload credit if coded when applicable. Table 3- 4: Special Procedure Codes for OEM Special Services Pertinent to OEM Services provided in office at times other than regularly scheduled office hours Service provided on emergency basis in office which disrupts scheduled services Medical testimony Special reports such as insurance forms

CPT Code 99050 99058 99075 99080

3-9. OTHER SERVICES a. Telephone calls between a privileged provider and patient constitute episodes of care per military coding guidance. Privileged providers may choose from the three E&M codes for telephone calls (99441, 99442, and 99443). Non-privileged providers may choose from the three CPT codes for telephone calls (98966, 98967, and 98968). Classification of a call is based on its duration. Documentation of the call must contain evidence of medical decision making by a privileged provider directly responsible for the management of the patient’s care. Do not code telephone calls for provider–provider coordination, leaving messages on answering machines, or speaking with a Commander about an active duty member. This military-specific guidance on telephone calls differs from civilian CPT guidance.

b. Routine audiograms for the hearing conservation program may occur in conjunction with a medical surveillance exam. In this case, the preventive services E&M for the surveillance exam includes the professional service (i.e., interpretation of the audiogram) and the additional CPT procedure code for the audiogram should be included with this visit. If a technician performs an audiogram without an associated preventive services visit, use 99499 in the E&M field as a placeholder and code the CPT procedure code. If an audiologist evaluates a patient but performs no procedure, use problem-oriented E&M codes based on the history, exam, and medical decisionmaking documented in the medical record.

CHAPTER FOUR: CODES FOR SUPPORT STAFF SERVICES AND SUPPLIES 4-1. OCCUPATIONAL HEALTH NURSES AND TECHNICIANS a. Support staff are normally restricted to using E&M code 99211 to document face-to-face encounters in which no procedure is performed (e.g., counseling or education) or code 99499 when a procedure is performed (e.g., audiogram, EKG). 99499 can also report other unique military data collection (e.g., technician review of a DD 2795). b. Nurse telephone triage is assessment of a caller’s medical condition using a protocol approved by the medical staff to provide non-privileged provider healthcare advice. Military coding guidance considers this service administrative overhead and assigns no RVUs for this function. Although collection of nurse telephone triage data is not required and not recommended, E&M code 99499 and the appropriate ICD-9-CM diagnostic code facilitates AHLTA documentation of the encounter. c. Telephone calls solely for reporting test results are a continuation of the visit at which the provider ordered the test. Append documentation to the AHLTA record of that visit. Do not document telephone calls for administrative issues, such as reminding patients of appointments. d. Add occupational health nurses and technicians involved in a patient visit as additional providers for that visit. This documentation supports the necessity of staff in operation of the clinic. e. Do not code the following clinic services: • • • •

TB test reading Patient who presents for an order for pregnancy test only Blood pressure checks per patient request Patient who presents to pick up a prescription refill

f. CPT procedure codes for support staff include those in Table 4-1. Use these codes whenever applicable. Either support staff or providers can enter these codes. Each clinic should develop a consistent procedure to ensure that coding for these services occurs. If the procedure does not occur in conjunction with a privileged provider visit, support staff uses the 99499 E&M placeholder in AHLTA. The health and behavior assessment, for instance, is applicable to an occupational health nurse’s encounter with a patient with a needle-stick injury. Table 4- 1: CPT Codes for Support Staff Description of procedure Education for patient self-management by non-privileged provider □ Individual □ 2-4 Patients □ 5-8 Patients Conveyance of specimen for transfer from provider’s office to laboratory Health and behavior assessment (i.e. Needlesticks) □ Initial assessment □ Reassessment Educational Materials given to pt (by provider or support staff) Group counseling (60 min) Case Management Services □ Telephone Calls (Non-Privileged Providers only)

CPT Code 98960 98961 98962 99000 96150 96151 99071 99412 98966-98968

4-2. HCPCS LEVEL II CODES a. HCPCS Level II contains the codes for most durable medical equipment and supplies. Do not code for equipment issued with the expectation that the patient will return it. Table 4-2 lists some

commonly used equipment and supplies. Again, develop consistent procedures to ensure maximal coding of services provided. Table 4- 2: HCPCS Level II Supply Codes Commonly Used in OEM Supply Albuterol, inhalation solution, 1 mg Ankle Orthosis (elastic) prefabricated Ankle Orthosis (pneumatic/stirrup style) Ankle/Foot Orthosis, static (adjustable)

Code J7611 L1901 L4350 L4396

Benadryl, up to 50 mg


Cane, all materials, fixed or adjustable Ceftriaxone Sodium, per 250 mg (Rocephin) Cervical Orthosis (foam collar) Crutches, underarm, pair (not wood) Crutches, underarm, pair (wood) Elbow Orthosis (elastic/neoprene) Elbow Orthosis; adjust. locking joints (Any type) Finger splint, static Foot Drop Splint, Recumbent Positioning Device Full Leg Orthosis (pneumatic) Gauze (non-adhesive) 16 sq. inch or less Generic Splint Supply Hand Orthosis (metacarpal fracture orthosis) Hand/Finger Orthosis w/o joints Ice Cap or Collar *only if sutures done elsewhere

E0100 J0696 L0120 E0114 E0112 L3701 L3760 Q4049 L4398 L4370 A6216 A4570 L3917 L3923 E0230

Supply Ice Pack (not cap or collar) Kenalog, per 10 mg Knee Immobilizer, (canvas) prefabricated Knee Orthosis (pneumatic) Knee Orthosis w/ joints (elastic) prefabricated Leg; Walking Boot (pneumatic) Lidocaine/Marcaine Injection Light compression bandage, elastic Nitroglycerin, each Normal Saline Solution (up to 1 Liter) Phenergan (up to 50 mg) Ringer's Lactate (up to 1 Liter) Shoulder Orthosis, double shoulder (elastic) Shoulder Orthosis, hard plastic, stabilizer Shoulder Orthosis, single shoulder (elastic) Suture Removal Kit* Toradol, per 15 mg Upper Ext Fracture Orthosis (w/ wrist) Wrist Orthosis, (elastic) prefabricated Wrist/Hand/Finger Orthosis (any type)

Code A9999 J3301 L1830 L4380 L1810 L4360 J3490 A6450 J3490 J7030 J2550 J7120 L3652 L3677 L3651 S0630 J1885 L3984 L3909 L3911

b. HCPCS Level II also encompasses some privileged provider services not included in the CPT procedure codes. Table 4-3 provides some common examples. Table 4- 3: HCPCS Level II Service Codes Commonly Used in OEM Service Smoking cessation counseling □ 3-10 minutes □ 10+ minutes Digital Rectal Exam for Prostate Cancer Screening Pap smear collection

HCPCS Code G0375 G0376 G0102 Q0091

CHAPTER FIVE: AHLTA AND CODING 5-1. AHLTA CODING FEATURES a. Although AHLTA boasts automated coding features, correct output requires correct input. Understanding how these features work is one element necessary to ensure accurate coding. Coupled with development of consistent clinic-based procedures to coordinate the coding efforts of providers and support staff, this knowledge can lead to coding success. b. AHLTA has two specific coding features: a look-up for ICD-9-CM, CPT, and HCPCS Level II codes and an E&M code calculator. In addition to the specific coding features, customized templates and clinic lists can assist you in maximizing your coding accuracy and efficiency. c. AHLTA look-up features use keywords to offer codes that are potentially applicable to the patient visit. They do not contain the full information that is available in the coding manuals. In addition, the look-up functions are separate for each coding system (ICD-9-CM, CPT, and HCPCS), requiring you to know what type code you need d. An alternative to using the look-up feature is to develop clinic lists of commonly used codes. This document contains most commonly used codes for OEM practice. Entry of these codes into lists of clinic favorites allows rapid retrieval of codes without using the look-up feature. For best coding accuracy, refer to a coding manual rather than the look-up if the code is not available here. e. The E&M code calculator uses information from the AHLTA note to generate a suggested E&M Level code. The default E&M category is “outpatient services” (i.e., problem-oriented). Since age alone determines E&M levels for preventive services, simply changing to the correct category usually leads to a correct code suggestion (unless the patient’s birth date is incorrect in DEERS). f. The E&M code calculation for problem-oriented visits is more complicated. The calculator uses information entered using the MEDCIN tree (i.e., check boxes on AHLTA) to determine which elements of history and exam were completed, and uses the ICD-9-CM, CPT, and HCPCS codes to rate the medical decision making complexity. If you document elements of the history and exam using free text, the E&M code calculator does not recognize that you documented them and will undercode the visit. Therefore, if you choose to use free text for documentation in AHLTA, you should override the E&M code calculator on every visit. g. Support staff can document subjective and objective information for the provider in AHLTA. When the provider takes ownership of documentation entered by support staff, these elements become part of the provider’s documentation and taking ownership indicates agreement with the information contained. If the provider takes ownership of the documentation, these elements are recognized by the E&M code calculator.

5-2. TEMPLATES a. AHLTA template capabilities include subjective and objective information templates created by individual users, AIM forms created by specialty leaders, and encounter templates that encompass all aspects of the encounter including reason for visit, subjective and objective data, procedures, orders, and coding. b. Navy occupational medicine has used the Medical Matrix and PC Matrix to standardize medical surveillance and certification exams. The Navy Environmental Health Center is in the process of developing and validating AHLTA encounter templates against PC Matrix 9. These validated templates are located in Enterprise/Occupational and Environmental Medicine ending with MHJ. Note that templates in this folder starting with ENC are older templates and are not validated (see Figure 5-1). Not all stressors are available at this time.

Figure 5-1: Identifying validated encounter templates


Not validated

c. Currently, merging templates for workers enrolled in more than one surveillance program can only occur at the individual clinic level. Figures 5-2 through 5-12 outline this somewhat cumbersome process.

Figure 5-2: Open the Template Management function

1) Click Template Management, under Tools folder

Figure 5-3: Search for the required templates

Click “Search”

Figure 5-4: Search for enterprise level templates

1) OEM

2) Enterprise

3) Search

Figure 5-5: Select and merge the templates

2) Click Merge

1) Hold and click each program to merge

Figure 5-6: Removed merged template note then add…

(1) (2)

Figure 5-7: From Forms and Notes Template…

Figure 5-8: Again from OEM enterprise

1) 2)


Figure 5-9: S/O Templates

• •

Hold and click on appropriate S/O templates (Begin with SOOEM-) *Include Standard Matrix Questions! Click “Add Items” Click “Done”

Figure 5-10: Save merged templates 5) “Save”

• • • •

Owner type: “Clinic” Clinic: Choose appropriate clinic Specialty: optional EM Category: optional, “Preventive Medicine Services”

Figure 5-11: Name merged templates

1) Change name - Choose consistent naming strategy: E.g. “FF_RESP_HAZ”

2) “Save”

Figure 5-12: Close template manager and use template

5-3. SCREENSHOTS a. The first step in accurate AHLTA coding occurs before the provider sees the patient. When scheduling appointments or entering telephone consults, the appointment is designated as “count” or “non-count.” Only “count” visits contribute to workload credit. Figure 5-13 and 5-14 show proper selection of a count visit to a privileged provider. Non-count visits document services provided by support staff using the 99211 or 99499 placeholder E&M codes.

Figure 5-13: Correct selection of a “count” visit when creating an appt.

If you don’t get option for “Yes”, have PAS user make changes to your clinic profile

Figure 14: Selection of Count Visit in Disposition Module


b. Although the first step in coding is documentation, a full demonstration of documentation in AHLTA is beyond the scope of this document. The first screen for entry of codes is the Assessment and Plan Module. Enter ICD-9-CM codes (Figure 5-15 through 5-16), including injury and illness, V codes, and E codes, here along with CPT procedure codes and HCPCS Level II codes. This module contains the look-up features.

Figure 5-15: ICD-9-CM code entry

ICD-9: Ideally entered before orders/procedures so that they are “associated”

Figure 5-16: E Code prompt in disposition module

c. Enter E&M codes in the Disposition Module. This module contains the E&M coding calculator. For problem-oriented visits, remember that the E&M code calculator only recognizes information entered via the MEDCIN tree. Even if you used the MEDCIN tree, confirm the E&M code calculation according to the guidance provided in this manual. Clicking on each key component on the E&M calculator will provide additional detail about what elements have been included in the calculation. You can upgrade a component if you entered additional elements using free text.

Figure 5-17: Changing Service Type to Preventive Service

Figure 5-18: E&M Calculator for Problem-Oriented Visit

d. For combined preventive services and problem-oriented visits, remember to enter a secondary E&M code with a -25 modifier (Figure 5-19).

Figure 5-19: Additional E&M coding

CHAPTER SIX: SCENARIOS Scenario: A 40-year-old explosives handler returns to your clinic for a biennial surveillance exam. The clinic staff draws blood and takes the specimen to the lab. They also perform an EKG, which you interpret and comment on in your note, an audiogram, and a visual acuity screening. No additional problems arise during the visit. Coding: ICD-9-CM: Occupational Exam V70.5_3 CPT: EKG tracing and report 93000 Venipuncture 36415 Transport specimen 99000 Pure tone audiogram 92552 Visual acuity 99173 E&M: Preventive Services, 40-64, est 99396 Scenario: A 25-year-old worker not previously known to your clinic cuts his right hand with a non-powered hand tool. You document the location and mechanism of the injury, and the time at which it occurred. You also note that he has no known drug allergies and had his last tetanus shot more than five years ago. Clinic staff has recorded his blood pressure, pulse, respirations, and temperature. You describe the 3 cm laceration that requires sutures, but does not damage any tendons. You repair the laceration and order a tetanus immunization that he receives in the occupational health clinic. He also receives educational materials about signs and symptoms of infection. Coding: ICD-9-CM: Open wound of hand, without complication 882.0 E Code: Cause – Other hand tool/implement E920.4 CPT: Laceration repair, 2.6-5cm 12013 Td Vaccine 90718 Td Admin 90471 Educational Materials 99071 E&M: Problem-Oriented Visit, New Patient 99201-25 History component: Expanded problem focused Exam Component: Problem focused* Medical decision making: Low *Note that the documentation of the exam limits this from being a 99202. Scenario: A 60-year-old laboratory technician who is a military beneficiary known to your clinic presents for annual surveillance for animal-associated diseases. He is diabetic, hyperlipidemic, and smokes. Although he denies any symptoms associated with the rodents that he works with, he does note that he has had waxing and waning dull substernal chest pain since eating a large sausage dinner last night. He has no pain currently. Clinic staff placed a tuberculin skin test two days prior to the visit. You get an EKG in the clinic, which is normal, do a thorough cardiovascular and respiratory exam, and note that the PPD is negative. While the clinic staff draws blood to check troponin levels, you contact the patient’s primary care physician and arrange further evaluation and care. You spend 45 minutes coordinating care without direct patient contact. Coding: ICD-9-CM: Occupational exam V70.5_3 Pericardial pain 786.51 CPT: EKG 93000 E&M: Preventive services, 40-64, est. 99396 Problem-oriented 99214-25 History: Detailed Exam: Detailed Medical Decision Making: Moderate Prolonged services 99358

Scenario: A 32-year-old family practice nurse who is a government service employee presents for an accidental needle stick during a routine blood draw in her clinic. The Occupational Health Nurse performs a problem oriented assessment of the wound and no physician intervention is needed for closure, etc. OHN proceeds to document a brief clinical history on the patient as well as known risk factors of the “needle” that punctured her finger. OHN reviews all risks with the patient as well as signs and symptoms to look for to show infection and/or possible adverse affect. OHN spends 30 minutes counseling the patient on health and behavior risk factors involved in a needle stick injury and answers all questions/concerns of the patient. Coding: ICD-9-CM: Open Wound Finger, Uncomplicated 883.0 Accidents by needle stick E920.5 CPT: Needle stick HRA Counseling 96150 x 2* E&M: Unlisted E/M Service 99499 *Note 96150 is a time based code, use units of service for every 15 minute interval.

Appendix A – Problem-Oriented Provider Services: History Component Problem Focused* At least 1: Location Quality Severity Duration Timing Context Modifying factors Assoc/signs/symptoms

Exp Problem Focused* At least 1: Location Quality Severity Duration Timing Context Modifying factors Assoc/signs/symptoms

Detailed* At least 4: or At least 3: Location Chr DX Quality Chr DX Severity Chr DX Duration Timing Context Modifying factors Assoc/signs/symptoms

Comprehensive* At least 4: or At least 3: Location Quality Chr DX Severity Chr DX Duration Chr DX Timing Context Modifying factors Assoc/signs/symptoms





At least 1 required: Constitutional Eyes ENT/mouth CV Resp GI GU Musc Skin/Breast Neuro Psych Endo Hem/lymph Allergy/Immuno No PFSH

At least 2 required: Constitutional Eyes ENT/mouth CV Resp GI GU Musc Skin/Breast Neuro Psych Endo Hem/lymph Allergy/Immuno At least 1: Past Medical Family History Social History

At least 10 required: Constitutional Eyes ENT/mouth CV Resp GI GU Musc Skin/Breast Neuro Psych Endo Hem/lymph Allergy/Immuno At least 2: Past Medical Family History Social History


*Marked column farthest left identifies complexity level of history component.

Appendix B – Problem-Oriented Provider Services: Physical Exam Component Organ System/Body Area Constitutional □ 3 of 7 vital signs □ General appearance Eyes □ Conjunctivae/lids □ Pupils/irises □ Optic discs/posterior segments Ears/nose/throat/mouth □ External ears/nose □ Otoscopic exam □ Hearing assessment □ Nasal mucosa/septum/turbinates □ Lips/teeth/gums □ Oropharynx Neck □ External neck □ Thyroid Cardiovascular □ Heart palpation □ Heart auscultation □ Carotid arteries □ Abdominal aorta □ Femoral arteries □ Pedal pulses □ Extremity edema/varicosities Respiratory □ Respiratory effort □ Chest percussion □ Chest palpation □ Auscultation Breasts □ Inspection □ Palpation Gastrointestinal/Abdomen □ Palpation including masses/tenderness □ Liver/spleen □ Hernia □ Anus/perineum/rectum when indicated □ Fecal occult blood when indicated Genitourinary – Male □ Scrotal contents □ Penis □ Prostate Genitourinary – Female □ External genitalia/vagina □ Urethra □ Bladder □ Cervix □ Uterus □ Adnexa Musculoskeletal □ Gait and station □ Digits/nails □ Extremities/joints Skin □ Inspection □ Palpation Neurologic □ Cranial nerves □ Deep tendon reflexes □ Sensation Psychiatric □ Judgment/insight □ Orientation □ Memory □ Mood/affect Hematologic/lymphatic/immunologic □ Neck nodes □ Axillary nodes □ Groin nodes □ Other nodes

Problem Focused

1-5 elements from any area or system

Expanded Problem Focused

At least 6 elements from any area or system



At least 2 elements from each of 6 areas/systems

Perform all elements in at least 9 areas/systems



At least 12 elements in 2 or more areas/systems

Document at least 2 elements in each of the areas/systems

Appendix C – Problem-Oriented Provider Services: Medical Decision-Making Table of Risk Type of decision making Minimal

Number of diagnoses and/or risk of complications •

One stable chronic illness

Acute, uncomplicated illness or injury

Non-invasive diagnostic procedures (e.g., EEG, ECG, ultrasound, etc)

Physiologic tests not under stress

Low risk of complications, morbidity or mortality

Non-cardiovascular imaging studies without IV or intrathecal contrast (e.g., upper GI, barium enema, etc)

Skin biopsy

Superficial needle biopsy

Arterial puncture

Data to be obtained/reviewed requiring at least 10 minutes of physician time


Non-invasive/minimally invasive lab tests (e.g., urinalysis, venipuncture, etc)

Management options selected •

Rest, gargles

Elastic bandages, superficial dressings

Rest, exercise, diet, stress management

Medication management with minimal risk

Referrals without detailed discussion or care plan

Referrals with detailed discussion/care plan

Medication management with moderate risk (e.g., digoxin, warfarin)

Three or more self-limited problems

One or more chronic mild problems with ongoing activity (active problem)

Physiological tests under stress

Endoscopy for average risk patient (e.g., stable vitals, non-critical illness)

Two or three stable chronic illnesses or problems requiring evaluation

Discussion for psychotherapy and/or counseling

Deep needle/incisional biopsy

Interventional cardiovascular or radiologic procedure for average risk patient

Arranging hospitalization for non-critical illness/injury

Percutaneous removal of body cavity fluid

Referral for comprehensive pain management rehabilitation

IV contrast imaging

• Moderate

One self-limited/minor problem (e.g., contusion, insect bite, etc.) One or two self-limited problems


Diagnostic procedures/tests ordered and/or amount of data to be obtained or reviewed

New illness, injury or problem with uncertain prognosis

Acute illness with systemic symptoms

Moderate risk of complications, morbidity or mortality (i.e., uncertain prognosis, possibility of prolonged functional impairment)

Therapeutic or diagnostic spinal/nerve injections

One or more acute or chronic severe problems with ongoing activity

Data to be obtained/reviewed requiring at least 20 minutes of physician time

Four or more stable chronic problems requiring evaluation

Intra-arterial cerebral angiography (excludes MRA)

Acute, complicated injury

At least one problem posing imminent threat to life or bodily function

Endoscopy for high risk patient (e.g., therapeutic endoscopy for bleeding, unstable vital signs, critical illness)

Abrupt change in bodily function (e.g., seizure, CVA, acute mental status change)

High risk of complications, morbidity, or mortality (i.e., possibility of significant prolonged functional impairment)

Interventional cardiovascular or radiologic procedure for high risk patient (e.g., unstable condition)

Emergency hospitalization

Medications requiring intensive monitoring (e.g., initiation of IV heparin, IV antiarrhythmics; antineoplastics)

Surgery or procedure with ASA 2* or higher risk status

Decision not to resuscitate or to deescalate care because of poor prognosis

Mechanical ventilator management

Appendix D – Problem-Oriented Provider Services: Final E&M Selection History

Problem Focused


Problem Focused

Medical Decisionmaking E&M Code


99201/ 99241

New Patient/Consult Requires all 3 components - choose lowest column Expanded Detailed Comprehensive Comprehensive Problem Focused Expanded Detailed Comprehensive Comprehensive Problem Focused Minimal Low Medium High

99202/ 99242

99203/ 99243

99204/ 99244

99205/ 99245

Established Patient Requires at least 2 components or choose lowest column Problem Expanded Detailed Comprehensive Focused Problem Minimal Focused Problem Expanded Detailed Comprehensive Physician Focused Problem may not Focused be Minimal Low Medium High present 99211





OH Exam Type


Description Surveillance exams from Sections 4-6 of Matrix (excludes exams below) Respirator, Food Service, Childcare Worker

Diagnosis (ICD-9) Code(s)

(Matrix 700 series except exams directly below)

Vehicle Exam

Commercial Driver, Explosive Handler/Vehicle Operator, Forklift, Weight Handling Equipment Operator

Primary V70.5_3 Secondary Diagnosis codes for pertinent medical problems

Fitness for Duty

Evaluation of worker to assess fitness to return to work

Primary V70.5_7 Secondary Diagnosis codes for pertinent medical problems

Disability Evaluation

Evaluation leading to impairment/disability rating (Usually complex, detailed)

Primary V70.3 Secondary Diagnosis codes for pertinent medical problems.

Reproductive Toxicity Evaluation

Assessing/communicating reproductive risks in a job

Primary V70.5_7 Secondary V22.2

Evaluation for workrelatedness and/or impairment

Primary V70.5_7 Secondary Diagnosis codes for pertinent medical problems.

Military physicals including PEB exams (Not separation/ retirement)

Primary V70.5_0 - Periodic Exam V70.5_1 - Flight Physical; or V70.5_7 - PEB Exam Secondary Diagnosis codes for pertinent medical problems.

Military Separation or Retirement Exam


Primary V70.5_9 Secondary Diagnosis codes for pertinent medical problems

MSC Physical Exams

Military Sealift Command pre-employment or periodic exams

Primary V70.5_3 – Pre-employment V70.5_2 - Periodic Secondary Diagnosis codes for pertinent medical problems

Military pre- and postdeployment health assessments

Primary V70.5_4 – Pre-deployment V70.5_6 - Post-deployment Secondary Diagnosis codes for pertinent medical problems

Hearing Loss Medical Evaluation

Military Physical Exam

Deployment Screenings

Secondary E&M Code

Procedure (CPT) Code(s)

Primary V70.5_3 Secondary V15 series describing stressor Primary V68.09 Secondary Diagnosis codes for pertinent medical problems


Primary E&M Code

G0102 Prostate Screening 93000 EKG w/interp 93005 EKG w/o interp G0375 Smok. Cess. (3-10) G0376 Smok. Cess. (11+) 94010 Spirometry 99173 Snellen Chart 36415 Venipuncture 99000 Specimen Handling

New Pt 99385 (18-39) 99386 (40-64) 99387 (65+) Established Pt 99395 (18-39) 99396 (40-64) 99397 (65+)

Treating provider 99455 Other than treating 99456 New Pt 99385 (18-39) 99386 (40-64) 99387 (65+) Established Pt 99395 (18-39) 99396 (40-64) 99397 (65+)

N/A Extensive Record Review 99358 for first hour + 99359 each additional ½ hr

G0102 Prostate Screening 93000 EKG w/interp 93005 EKG w/o interp G0375 Smok. Cess. (3-10) G0376 Smok. Cess. (11+) 94010 Spirometry 99173 Snellen Chart 36415 Venipuncture 99000 Specimen Handling

Special CaseCombined Problem and Preventive Visit

Patient appt for preventive exam, medical problem(s) requiring additional eval & management addressed

Primary V70.5_X Secondary Diagnosis codes for pertinent medical problems

Acute Care Visit

Patient problem possibly work-related

Primary Diagnosis code(s) pertinent to current visit Secondary E codes describing cause and place of injuries

Asbestos CXR F/U

Visit for follow-up of abnormal asbestos surveillance CXR

Confirmed Asbestosis 501 Non-specific CXR finding 793.1

Multiple Exams in same category

For example, multiple vehicular-type exams (e.g., DOT and forklift) Complicated – only use same V Code once.

Primary V70.5_X Secondary Diagnosis codes for pertinent medical problems

New Pt 99201_25 (PF 10 min) 99202_25 (EPF 20 min) 99203_25 (D 30 min) 99204_25 (C 45 min) 99205_25 (C 60 min) Established Pt 99212_25 (PF 10 min) 99213_25 (EPF 15 min) 99214_25 (D 25 min) 99215_25 (C 40 min)

New Pt 99201 (PF 10 min) 99202 (EPF 20 min) 99203 (D 30 min) 99204 (C 45 min) 99205 (C 60 min) Established Pt 99212 (PF 10 min) 99213 (EPF 15 min) 99214 (D 25 min) 99215 (C 40 min New Pt 99385 (18-39) 99386 (40-64) 99387 (65+) Established Pt 99395 (age 18-39) 99396 (40-64) 99397 (65+)

*See Superbill

Extensive Face to Face 99354 for first hour + 99355 each additional ½ hr


G0102 Prostate Screening 93000 EKG w/interp 93005 EKG w/o interp G0375 Smok. Cess. (3-10) G0376 Smok. Cess. (11+) 94010 Spirometry 99173 Snellen Chart 36415 Venipuncture 99000 Specimen Handling


Current Procedural Terminology (CPT ®). (2008, February 27). CPT® Category II codes. .American Medical Association. Retrieved April 9, 2008 from …. Department of Defense (DoD). (2007, March 1). Military Health System Coding Guidance: Professional Services and Specialty Coding Guidelines, Version 2.0. Unified Biostatistical .Utility. Retrieved April 9, 2007 from …. Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures. (2005, November 30). HCPCS Level II Coding Process & Criteria. Centers for Medicare & Medicaid .Services. Baltimore, MD. Retrieved April 9, 2007 from …. …. res113005.pdf The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). (2007, October 1). National Center for Health Statistics and the Centers for Medicare and Medicaid Services. Baltimore, MD. Retrieved November 1, 2007 from …. pOfPage TrailBlazer Health Enterprises, LLC. (2007). Evaluation and Management Documentation .Guidelines. Evaluation and Management (E/M) Services. Retrieved April 9, 2007 from %20Services/Default.aspx?


The Coding Book For Military Occupational And - Navy Medicine

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