PCA CPP cheat sheet

ICD-10-CM Official Guidelines for Coding and Reporting are organized by section: Chapter-specific guidelines (Section I.C) take precedence over general conventions (Section I.A) when they conflict.

The coding conventions in the Tabular List-Includes, Excludes1, Excludes2, Code first, Use additional code, Code also-carry different legal weight: Excludes1 means the two conditions cannot be reported together; Excludes2 means both may be reported if documented.

CPT guidelines are published with each code section and are binding for correct use; the AMA's CPT Assistant and AHA Coding Clinic are the recognized interpretive authorities for CPT and ICD-10-CM/ICD-10-PCS respectively.

HIPAA Administrative Simplification (45 CFR Parts 160/162) designates ICD-10-CM, ICD-10-PCS, CPT/HCPCS Level II, and NDC as the standard code sets for the transactions they serve.

The False Claims Act (31 U.S.C. §§3729–3733) imposes treble damages plus per-claim penalties for knowingly submitting false claims; 'knowingly' includes deliberate ignorance and reckless disregard, not just intent.

The Anti-Kickback Statute (42 U.S.C. §1320a-7b(b)) is a criminal statute covering remuneration intended to induce referrals of federally payable items or services; the physician self-referral law (Stark, 42 U.S.C. §1395nn) is civil and applies to designated health services.

The OIG Compliance Program Guidance for Individual and Small Group Physician Practices lists seven elements, including written policies, a designated compliance officer, training, and auditing/monitoring.

Medical necessity documentation must support the level of service, not merely the diagnosis; auditors apply the 'if it wasn't documented, it wasn't done' rule, so undocumented services are non-billable.

ICD-10-CM codes are 3–7 characters: the first character is alphabetic (except U), the second is numeric, and characters 3–7 may be alphabetic or numeric; a 7th character is required only where the Tabular List specifies it.

Placeholder 'X' is used only to fill empty characters so a required 7th character lands in the correct position (e.g., T-codes and obstetric codes); it is never used as a trailing filler.

Sequencing rule: the principal/first-listed diagnosis is the condition chiefly responsible for the encounter; etiology codes are sequenced before manifestation codes when the Alphabetic Index directs 'code first.'

Excludes1 notes are absolute: a code cannot be reported with an Excludes1-referenced code because the two conditions cannot occur together (e.g., congenital vs. acquired forms).

Laterality and episode-of-care characters must match documentation; for injuries, the 7th character A = initial encounter, D = subsequent encounter, S = sequela.

Signs and symptoms that are integral to a confirmed diagnosis are not coded separately; if no diagnosis is established, code the signs/symptoms to the highest degree of certainty.

Diabetes coding follows the combination-code logic: most diabetic manifestations (e.g., diabetic neuropathy, CKD, retinopathy) have a single combination code; 'code also' the manifestation only when the Index directs it.

Chapter 15 (Pregnancy, childbirth, puerperium) requires an O code as first-listed for most obstetric encounters, plus a Z3A code (weeks of gestation) when applicable.

Office/outpatient E/M (99202–99215) may be leveled by either total time on the date of the encounter or medical decision making (MDM); the two methods are alternatives, not additive.

Total time for office/outpatient E/M includes all time personally spent by the reporting physician/NP/PA on the date of the encounter, including pre-visit chart review and post-visit documentation-not just face-to-face time.

MDM has three elements-number and complexity of problems addressed, amount/complexity of data reviewed, and risk of complications/morbidity/mortality; the level is set by the two elements met in the highest two of three.

Problem complexity in MDM is stratified as minimal, low, moderate, or high; a single stable chronic illness is low, an acute uncomplicated illness is low, and an acute illness with systemic symptoms can be moderate.

Risk in MDM is stratified as minimal, low, moderate, or high; prescription drug management is moderate risk, while decision for emergency major surgery or drug therapy requiring intensive monitoring is high risk.

Prolonged services (99417 for office/outpatient) are reported only when total time exceeds the highest-level threshold by at least 15 minutes; time is cumulative, not per-unit rounding.

Hospital inpatient/observation E/M levels are based on MDM or time, with time defined as unit/floor time; critical care (99291/99292) requires the patient to be critically ill and time is reported in 30-minute increments after the first hour.

A problem-oriented E/M code should not be reported with a preventive medicine visit for the same patient on the same day unless a significant, separately identifiable problem is documented; append modifier 25 to the problem-oriented E/M.

The global surgical package includes pre-operative evaluation, the surgical procedure, and routine post-operative care; for major surgery the global period is 90 days, for minor surgery 0 or 10 days.

Modifier 57 is used on an E/M code when the decision for surgery is made on the same day as a major procedure; modifier 25 is used for a separately identifiable E/M on the same day as a minor procedure.

Bundling: the National Correct Coding Initiative (NCCI) Procedure-to-Procedure edits prohibit reporting a column-two code with a column-one code unless an appropriate modifier (e.g., 59, XS, XU) is supported by documentation.

Modifier 59 (and the more specific X{EPSU} modifiers) should be used only to identify a distinct, separately identifiable service, not to unbundle services that are integral to the primary procedure.

Surgical code selection depends on the approach (open, percutaneous, endoscopic, laparoscopic), the extent of the procedure, and the anatomic site; the most specific code supported by the operative report is required.

Multiple procedures on the same day are typically reported with modifier 51 on the secondary procedure for payers that accept it; Medicare generally applies multiple-procedure reduction automatically.

Wound repair codes (12001–13160) are selected by wound length, anatomic site group, and complexity (simple, intermediate, complex); multiple wounds in the same group are summed before code selection.

Bilateral procedures are reported with modifier 50 when the code is eligible; otherwise report the code twice with modifiers RT and LT as payer rules require.

Radiology codes are divided into diagnostic (70010–76499), nuclear medicine (78000–79999), and radiation oncology (77261–77799); the professional component is billed with modifier 26 and the technical component with modifier TC.

When a procedure is split between a physician and a facility, the physician bills the professional component (26) and the facility bills the technical component (TC); billing the global code requires providing both components.

Laboratory codes in the 80000–89999 range are typically billed by the performing laboratory; the professional interpretation of a clinical lab test is generally not separately payable unless a specific code exists (e.g., 93000 for ECG with interpretation).

Organ- or disease-oriented panels (80047–80076) must be ordered and reported as a panel; individual component tests should not be unbundled from a panel.

Pathology codes distinguish surgical pathology (gross and microscopic examination, 88300–88309 by specimen complexity) from cytopathology (88104–88199) and molecular pathology (81105–81479).

Medicine codes include immunization administration (90460–90474), which is reported with the vaccine product code; administration code selection depends on route, number of components, and patient age.

Cardiovascular medicine codes such as stress tests (93015–93018) have global, professional, and technical components; interpretation-only services use modifier 26.

Sleep medicine, physical medicine, and psychotherapy codes frequently require time-based documentation; when a code is time-based, the time must be documented in the record.

HCPCS Level II codes are five-character alphanumeric codes (A0000–V9999) used for items and services not represented in CPT, including drugs, supplies, durable medical equipment, and prosthetics.

The HCPCS Level II code set is maintained by CMS and updated quarterly; the annual update is effective January 1, with quarterly updates in April, July, and October.

J-codes are used for injectable drugs and biologicals that are not described by a specific CPT code; the billing unit is usually per 1 mg, 10 mg, or per vial, as stated in the code descriptor and must be converted from the dose administered.

Durable medical equipment (E-codes) must meet the DME definition: durable, used for a medical purpose, not useful in the absence of illness, and used in the home; prosthetics (L-codes) and orthotics have separate coverage rules.

Modifiers used with HCPCS Level II include KX (documentation on file), GA (waiver of liability on file), GY (statutorily excluded), and GZ (not reasonable and necessary).

The Advanced Beneficiary Notice (ABN, Form CMS-R-131) is used to notify a Medicare beneficiary that an item or service may be denied as not medically necessary; the correct modifier depends on whether the ABN was signed.

HCPCS Level II 'C' codes are used for hospital outpatient prospective payment system items and services, while 'Q' codes are temporary codes assigned by CMS.

Drug waste for single-dose vials may be billable with the JW modifier when the discarded amount is documented and the payer permits it.

Anatomical position: body erect, palms forward; directional terms include anterior/ventral, posterior/dorsal, superior/cranial, inferior/caudal, medial, lateral, proximal, and distal.

Body planes: sagittal divides left and right, coronal (frontal) divides anterior and posterior, transverse divides superior and inferior.

The four main tissue types are epithelial, connective, muscle, and nervous; the four abdominopelvic quadrants are RUQ, LUQ, RLQ, and LLQ.

The skeletal system has 206 bones in the adult; the axial skeleton (80 bones) includes the skull, vertebral column, and rib cage, and the appendicular skeleton (126 bones) includes the limbs and girdles.

The cardiovascular system: the right heart pumps deoxygenated blood to the lungs via the pulmonary circuit; the left heart pumps oxygenated blood to the body via the systemic circuit.

Prefixes and suffixes commonly tested: -ectomy (removal), -otomy (incision), -ostomy (creation of an opening), -plasty (repair), -scopy (visual examination), -algia (pain), -itis (inflammation), -megaly (enlargement).

The respiratory system's conducting zone includes the nose, pharynx, larynx, trachea, bronchi, and bronchioles; gas exchange occurs in the alveoli of the respiratory zone.

The nervous system is divided into the central nervous system (brain and spinal cord) and peripheral nervous system (somatic and autonomic, the latter split into sympathetic and parasympathetic).

The revenue cycle sequence: scheduling/registration → eligibility verification → coding and charge capture → claim submission → payer adjudication → remittance posting → denial management → patient collections.

CMS-1500 is the claim form for non-institutional (physician) services; the UB-04 (CMS-1450) is used for institutional claims.

The Explanation of Benefits (EOB) and the 835 Electronic Remittance Advice (ERA) report payer adjudication; the 837P is the electronic claim transaction for professional claims.

Medicare Physician Fee Schedule payment = (Work RVU × Work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × Conversion Factor; the conversion factor is updated annually.

The Medicare Administrative Contractor (MAC) processes Part A and Part B claims; Medicare Advantage plans are paid by CMS and administer benefits through private insurers.

Coordination of benefits (COB) determines which payer is primary; for Medicare, the Medicare Secondary Payer rules determine whether Medicare pays first, second, or not at all.

Denials should be categorized (eligibility, coding, medical necessity, timely filing) and tracked with a denial rate metric; timely filing limits are typically 90–365 days depending on the payer.

Clean claim rate, days in accounts receivable (A/R), and first-pass resolution rate are key revenue cycle KPIs; a clean claim requires complete, accurate, and compliant data at first submission.

The ICD-10-CM Official Guidelines are organized by section; chapter-specific guidelines (Section I.C) take precedence over general conventions (Section I.A) when the two conflict.

Excludes1 notes mean the two conditions cannot be reported together; Excludes2 notes mean both may be reported if documented.

CPT guidelines are binding for correct code use; the AMA's CPT Assistant and AHA Coding Clinic are recognized interpretive authorities for CPT and ICD-10-CM/ICD-10-PCS, respectively.

HIPAA Administrative Simplification (45 CFR Parts 160/162) designates ICD-10-CM, ICD-10-PCS, CPT/HCPCS Level II, and NDC as standard code sets for the transactions they serve.

The False Claims Act (31 U.S.C. §§3729–3733) imposes treble damages plus per-claim penalties for knowingly submitting false claims; 'knowingly' includes deliberate ignorance and reckless disregard, not just intent.

The Anti-Kickback Statute (42 U.S.C. §1320a-7b(b)) is criminal and covers remuneration intended to induce referrals of federally payable items; the physician self-referral law (Stark, 42 U.S.C. §1395nn) is civil and applies to designated health services.

The OIG Compliance Program Guidance for Individual and Small Group Physician Practices lists seven elements, including written policies, a designated compliance officer, training, and auditing/monitoring.

Medical necessity documentation must support the level of service, not merely the diagnosis; auditors apply the rule that undocumented services are non-billable.

ICD-10-CM codes are 3–7 characters: the first character is alphabetic (except U), the second is numeric, and characters 3–7 may be alphabetic or numeric; a 7th character is required only where the Tabular List specifies it.

The placeholder 'X' fills empty characters so a required 7th character lands in the correct position; it is never used as a trailing filler.

Sequencing rule: the principal/first-listed diagnosis is the condition chiefly responsible for the encounter; etiology codes are sequenced before manifestation codes when the Alphabetic Index directs 'code first.'

Excludes1 notes are absolute: a code cannot be reported with an Excludes1-referenced code because the two conditions cannot occur together (e.g., congenital vs. acquired forms).

Laterality and episode-of-care characters must match documentation; for injuries, the 7th character A = initial encounter, D = subsequent encounter, S = sequela.

Signs and symptoms integral to a confirmed diagnosis are not coded separately; if no diagnosis is established, code the signs/symptoms to the highest degree of certainty.

Diabetes coding follows combination-code logic: most diabetic manifestations (e.g., diabetic neuropathy, CKD, retinopathy) have a single combination code; 'code also' the manifestation only when the Index directs it.

Chapter 15 (Pregnancy, childbirth, puerperium) requires an O code as first-listed for most obstetric encounters, plus a Z3A code (weeks of gestation) when applicable.

Office/outpatient E/M (99202–99215) may be leveled by either total time on the date of the encounter or medical decision making (MDM); the two methods are alternatives, not additive.

Total time for office/outpatient E/M includes all time personally spent by the reporting physician/NP/PA on the date of the encounter, including pre-visit chart review and post-visit documentation-not just face-to-face time.

MDM has three elements-number and complexity of problems addressed, amount/complexity of data reviewed, and risk of complications/morbidity/mortality; the level is set by the two elements met in the highest two of three.

Problem complexity in MDM is stratified as minimal, low, moderate, or high; a single stable chronic illness is low, an acute uncomplicated illness is low, and an acute illness with systemic symptoms can be moderate.

Risk in MDM is stratified as minimal, low, moderate, or high; prescription drug management is moderate risk, while decision for emergency major surgery or drug therapy requiring intensive monitoring is high risk.

Prolonged services (99417 for office/outpatient) are reported only when total time exceeds the highest-level threshold by at least 15 minutes; time is cumulative, not per-unit rounding.

Hospital inpatient/observation E/M levels are based on MDM or time, with time defined as unit/floor time; critical care (99291/99292) requires the patient to be critically ill and is reported in 30-minute increments after the first hour.

A problem-oriented E/M code should not be reported with a preventive medicine visit for the same patient on the same day unless a significant, separately identifiable problem is documented; append modifier 25 to the problem-oriented E/M.

The global surgical package includes pre-operative evaluation, the surgical procedure, and routine post-operative care; for major surgery the global period is 90 days, for minor surgery 0 or 10 days.

Modifier 57 is used on an E/M code when the decision for surgery is made on the same day as a major procedure; modifier 25 is used for a separately identifiable E/M on the same day as a minor procedure.

Bundling: the National Correct Coding Initiative (NCCI) Procedure-to-Procedure edits prohibit reporting a column-two code with a column-one code unless an appropriate modifier (e.g., 59, XS, XU) is supported by documentation.

Modifier 59 (and the more specific X{EPSU} modifiers) should be used only to identify a distinct, separately identifiable service, not to unbundle services that are integral to the primary procedure.

Surgical code selection depends on the approach (open, percutaneous, endoscopic, laparoscopic), the extent of the procedure, and the anatomic site; the most specific code supported by the operative report is required.

Multiple procedures on the same day are typically reported with modifier 51 on the secondary procedure for payers that accept it; Medicare generally applies multiple-procedure reduction automatically.

Wound repair codes (12001–13160) are selected by wound length, anatomic site group, and complexity (simple, intermediate, complex); multiple wounds in the same group are summed before code selection.

Bilateral procedures are reported with modifier 50 when the code is eligible; otherwise report the code twice with modifiers RT and LT as payer rules require.

Radiology codes are divided into diagnostic (70010–76499), nuclear medicine (78000–79999), and radiation oncology (77261–77799); the professional component is billed with modifier 26 and the technical component with modifier TC.

When a procedure is split between a physician and a facility, the physician bills the professional component (26) and the facility bills the technical component (TC); billing the global code requires providing both components.

Laboratory codes in the 80000–89999 range are typically billed by the performing laboratory; the professional interpretation of a clinical lab test is generally not separately payable unless a specific code exists.

Organ- or disease-oriented panels (80047–80076) must be ordered and reported as a panel; individual component tests should not be unbundled from a panel.

Pathology codes distinguish surgical pathology (gross and microscopic examination, 88300–88309 by specimen complexity) from cytopathology (88104–88199) and molecular pathology (81105–81479).

Medicine codes include immunization administration (90460–90474), which is reported with the vaccine product code; administration code selection depends on route, number of components, and patient age.

Cardiovascular medicine codes such as stress tests (93015–93018) have global, professional, and technical components; interpretation-only services use modifier 26.

Sleep medicine, physical medicine, and psychotherapy codes frequently require time-based documentation; when a code is time-based, the time must be documented in the record.

HCPCS Level II codes are five-character alphanumeric codes (A0000–V9999) used for items and services not represented in CPT, including drugs, supplies, durable medical equipment, and prosthetics.

The HCPCS Level II code set is maintained by CMS and updated quarterly; the annual update is effective January 1, with quarterly updates in April, July, and October.

J-codes are used for injectable drugs and biologicals that are not described by a specific CPT code; the billing unit is usually per 1 mg, 10 mg, or per vial, as stated in the code descriptor and must be converted from the dose administered.

Durable medical equipment (E-codes) must meet the DME definition: durable, used for a medical purpose, not useful in the absence of illness, and used in the home; prosthetics (L-codes) and orthotics have separate coverage rules.

Modifiers used with HCPCS Level II include KX (documentation on file), GA (waiver of liability on file), GY (statutorily excluded), and GZ (not reasonable and necessary).

The Advanced Beneficiary Notice (ABN, Form CMS-R-131) is used to notify a Medicare beneficiary that an item or service may be denied as not medically necessary; the correct modifier depends on whether the ABN was signed.

HCPCS Level II 'C' codes are used for hospital outpatient prospective payment system items and services, while 'Q' codes are temporary codes assigned by CMS.

Drug waste for single-dose vials may be billable with the JW modifier when the discarded amount is documented and the payer permits it.

Anatomical position: body erect, palms forward; directional terms include anterior/ventral, posterior/dorsal, superior/cranial, inferior/caudal, medial, lateral, proximal, and distal.

Body planes: sagittal divides left and right, coronal (frontal) divides anterior and posterior, transverse divides superior and inferior.

The four main tissue types are epithelial, connective, muscle, and nervous; the four abdominopelvic quadrants are RUQ, LUQ, RLQ, and LLQ.

The skeletal system has 206 bones in the adult; the axial skeleton (80 bones) includes the skull, vertebral column, and rib cage, and the appendicular skeleton (126 bones) includes the limbs and girdles.

The cardiovascular system: the right heart pumps deoxygenated blood to the lungs via the pulmonary circuit; the left heart pumps oxygenated blood to the body via the systemic circuit.

Prefixes and suffixes commonly tested: -ectomy (removal), -otomy (incision), -ostomy (creation of an opening), -plasty (repair), -scopy (visual examination), -algia (pain), -itis (inflammation), -megaly (enlargement).

The respiratory system's conducting zone includes the nose, pharynx, larynx, trachea, bronchi, and bronchioles; gas exchange occurs in the alveoli of the respiratory zone.

The nervous system is divided into the central nervous system (brain and spinal cord) and peripheral nervous system (somatic and autonomic, the latter split into sympathetic and parasympathetic).

The revenue cycle sequence: scheduling/registration → eligibility verification → coding and charge capture → claim submission → payer adjudication → remittance posting → denial management → patient collections.

CMS-1500 is the claim form for non-institutional (physician) services; the UB-04 (CMS-1450) is used for institutional claims.

The Explanation of Benefits (EOB) and the 835 Electronic Remittance Advice (ERA) report payer adjudication; the 837P is the electronic claim transaction for professional claims.

Medicare Physician Fee Schedule payment = (Work RVU × Work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × Conversion Factor; the conversion factor is updated annually.

The Medicare Administrative Contractor (MAC) processes Part A and Part B claims; Medicare Advantage plans are paid by CMS and administer benefits through private insurers.

Coordination of benefits (COB) determines which payer is primary; for Medicare, the Medicare Secondary Payer rules determine whether Medicare pays first, second, or not at all.

Denials should be categorized (eligibility, coding, medical necessity, timely filing) and tracked with a denial rate metric; timely filing limits are typically 90–365 days depending on the payer.

Clean claim rate, days in accounts receivable (A/R), and first-pass resolution rate are key revenue cycle KPIs; a clean claim requires complete, accurate, and compliant data at first submission.