CASCC cheat sheet

ICD-10-CM official guidelines are updated annually on October 1; the current fiscal year's guidelines govern discharges/encounters on or after that date.

HIPAA requires covered entities to use code sets (ICD-10-CM/PCS, CPT, HCPCS) for electronic transactions; non-covered entities may still be contractually bound.

The False Claims Act imposes liability for knowingly submitting false claims; 'knowingly' includes deliberate ignorance or reckless disregard.

The Anti-Kickback Statute prohibits remuneration for referrals of items/services covered by federal health care programs; safe harbors provide protection.

The Physician Self-Referral (Stark) Law prohibits referrals of designated health services to entities with which the physician has a financial relationship, unless an exception applies.

The OIG Work Plan outlines audit targets; providers should monitor it for enforcement priorities.

Medical record documentation must support the medical necessity of services billed; lack of documentation can result in recoupment.

Advance Beneficiary Notice (ABN) is used when Medicare may deny a service as not reasonable and necessary; it shifts liability to the patient if properly executed.

Wound repair codes (12001-13160) are selected by length, complexity (simple, intermediate, complex), and site; multiple wounds are summed by complexity group.

Lesion excision codes (11400-11646) include margins and simple closure; intermediate or complex closures are separately reportable with modifier 59 or XS if distinct.

For musculoskeletal procedures, the surgical package includes the procedure, local anesthesia, and typical postoperative care; E/M on the same day may require modifier 24 or 57.

Arthroscopic surgery codes are site-specific and include limited debridement; meniscectomy and chondroplasty at the same compartment may be bundled.

Fracture care codes (e.g., 25600-25620) include application of cast/splint and follow-up; casting done for initial treatment is not separately billed.

Skin grafts (15100-15157) are coded by type, size, and site; the donor site is separately reportable when applicable.

Breast procedures (e.g., mastectomy, lumpectomy) have specific codes; reconstruction may be separately coded depending on timing and medical necessity.

Use modifier 50 for bilateral procedures when the code is not inherently bilateral; otherwise use RT/LT modifiers.

Anesthesia codes (00100-01999) are time-based; report base units plus time units (1 unit per 15 minutes) and modify with physical status (P1-P6).

Anesthesia time begins when the anesthesia provider starts preparing the patient and ends when the patient is safely transferred to post-anesthesia care.

Qualifying circumstances (99100-99140) may be reported with anesthesia codes when documented; extreme age, emergency, or comorbidity may apply.

Monitored anesthesia care (MAC) is reported with the same anesthesia codes as general anesthesia, with modifier QS when appropriate.

Pain management injections (e.g., 62320-62327 for spinal, 64400-64530 for peripheral) include fluoroscopy/CT guidance when performed; do not separately bill guidance unless distinct.

Implantable drug delivery system refills (62368) and programming (62369-62370) are distinct services; refill includes access and drug.

Postoperative pain blocks (e.g., 64400-64450) performed by the surgeon may be separately reportable with modifier 59 if distinct from the surgical procedure.

Anesthesia for procedures not covered by a specific anesthesia code may use unlisted code 01999; document clearly.

Radiology codes are divided by modality (e.g., X-ray, CT, MRI, ultrasound) and include both technical and professional components; modifier 26 for professional, TC for technical.

Global services include both components; when only one component is provided, append modifier 26 or TC accordingly.

CT and MRI codes often include contrast; when contrast is used, select the appropriate code (with or without contrast) and do not separately bill contrast unless code descriptor allows.

Radiology guidance (e.g., 77001-77022) is reported separately only when not included in the primary procedure; check bundling edits.

Interventional radiology procedures (e.g., 36000-36500) include access, catheter placement, and injection; additional selective catheterization may be separately coded.

For diagnostic ultrasound, codes 76700-76770 are complete exams; limited exams (76705) require documentation of limited study.

Nuclear medicine codes (78000-79999) include radiopharmaceutical; do not separately bill the radiopharmaceutical unless specified.

When multiple imaging studies are performed, use modifier 59 or XS to indicate distinct services if appropriate.

Pathology codes (80000-89999) include both professional and technical components; modifier 26/TC may apply for split billing.

Surgical pathology (88300-88309) is coded by specimen type and complexity; multiple specimens may be billed separately with modifier 59 if distinct.

Clinical laboratory tests are often paneled (e.g., 80053 comprehensive metabolic panel); do not unbundle components unless medically necessary and documented.

When a lab test is performed in-house, use the appropriate CPT code; for referred tests, use the reference lab's code and follow payer rules.

Immunohistochemistry (88342-88343) is coded per antibody; multiple antibodies may be separately billed with modifier 59 if distinct.

Flow cytometry (88182-88189) codes include interpretation; do not separately bill interpretation unless distinct.

Molecular pathology codes (81161-81479) are specific to gene/mutation; use the most specific code and document the method.

Specimen collection (e.g., 36415 venipuncture) may be separately billable; check payer policies for bundling.

E/M codes (99202-99499) are selected by site, patient type (new/established), and medical decision making or time; documentation must support the level.

Prolonged services (99415-99417) may be reported with E/M when time thresholds are met; check payer-specific rules.

Vaccinations (90460-90474) include counseling for children; administration codes (90471-90474) are separate and depend on route and number of components.

Physical therapy and occupational therapy codes (97161-97546) are time-based and require documentation of skilled services and functional goals.

Dialysis codes (90935-90999) include physician supervision; monthly capitation codes (90951-90970) apply for outpatient dialysis.

Chemotherapy administration codes (96401-96549) are distinct from the drugs; use appropriate code for method (infusion, injection) and duration.

Psychiatric services (90785-90899) have specific time and documentation requirements; interactive complexity (90785) may be added when applicable.

Ancillary services such as respiratory therapy (94002-94799) are billed when medically necessary and not included in another service.

Modifier 25 indicates a significant, separately identifiable E/M service by the same physician on the same day as a procedure; documentation must support the E/M.

Modifier 59 is used to indicate distinct procedural services; it should not be used to bypass bundling edits when services are integral.

Modifier 26 and TC split professional and technical components; use only when the provider furnishes one component.

Modifier 50 (bilateral) is used when a procedure is performed bilaterally and the code is not inherently bilateral; do not use with codes designated as bilateral.

Modifier 51 (multiple procedures) is used for additional procedures; some payers prefer 59 or XS for distinct services.

Modifier 24 indicates an unrelated E/M service during a postoperative period; documentation must show the service is unrelated to the surgery.

Modifier 57 indicates an E/M service that resulted in the decision for surgery; used for major procedures (90-day global).

Modifier 76 (repeat procedure by same physician) and 77 (repeat by another physician) are used for repeat procedures on the same day.

ASCs are paid under the ASC Payment System based on the ASC-covered surgical procedure list; not all CPT codes are payable in the ASC setting.

ASC facility fees include nursing, supplies, and equipment; physician professional fees are billed separately.

Multiple procedures in the ASC are subject to multiple procedure reduction; the highest valued procedure is paid at 100%, others at 50% (unless exempt).

Implantable devices used in ASC procedures may be separately reimbursed if on the ASC device list; otherwise included in facility fee.

Claims must include appropriate HCPCS/CPT codes, modifiers, and diagnosis codes; NCCI edits apply to ASC claims.

The ASC must report the appropriate site of service (POS 24 for ASC) on claims.

Bilateral procedures in ASC may be subject to special payment rules; use modifier 50 when applicable.

For services not covered by Medicare, ASCs may bill patients directly; provide advance notice and follow state laws.