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Coding Corner

Health care professionals can decrease the potential for claim denials with UnitedHealthcare by utilizing our coding corner training courses.

To help decrease the potential for claim denials, we encourage you to utilize these valuable coding resources. We created this information with the Optum® Payment Integrity provider education team of certified coders, nurses, physicians and qualified health care practitioners.

Featured professional course

The Injection or Infusion and E/M Unbundling course covers guidance to help prevent unbundling of an injection or infusion service (e.g., therapeutic, hydration, acupuncture, trigger-point procedures, arthrocentesis, vaccinations, etc.), and an evaluation and management (E/M) service.

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Featured facility course

The Acute Kidney Injury (AKI) Clinical Criteria course can help you better understand the clinical criteria we use to validate a diagnosis of AKI or acute renal failure (ARF) with tubular necrosis.

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Anesthesia and Integral Services Unbundling
Covers the guidelines and policies to help prevent unbundling of anesthesia and integral services, such as pre-or post-operative evaluation and management (E/M) services, procedures related to venous or airway access, and postoperative pain management.

Anesthesia Upcoding and Pricing Modifiers
Covers the documentation elements that help prevent upcoding of time-based anesthesia services, including guidance for applying modifiers for pricing (AA, AD, QK, QX, QY, QZ), physical status (P1-P5) and altered circumstances (22, 23, 47, 59, etc.)

Moderate Sedation Upcoding
Covers the documentation elements that help prevent upcoding of time-based moderate conscious sedation services (99151-99157, G0500).

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Complex Repair Upcoding
Covers the documentation elements to help prevent upcoding of surgical wound repairs, including guidelines for classifying and reporting simple (12001-12021), intermediate (12031-12057) and complex (13100-13153) repairs based on complexity, location and size.

Laser Psoriasis Treatment Upcoding
Covers the documentation elements such as total treatment area, technique and applicable conditions to help prevent upcoding of laser psoriasis treatments (96920-96922).

Mohs Surgery Coding
Covers documentation elements that help prevent upcoding of Mohs micrographic surgery (17311-17315), including criteria and guidance to select accurate codes for initial and subsequent stages and additional blocks. Also explains when Mohs codes are appropriate instead of separate surgery and pathology codes.

Mohs Surgery Unbundling
Covers guidance to help prevent unbundling of Mohs micrographic surgery (17311-17315) and surgical pathology services (88300-88309, 88329-88332) reported for the same tissue specimen by the same provider.

Other Repair Coding and Unbundling
Covers documentation elements to help prevent upcoding or unbundling of integumentary system repairs such as transfers, grafts and flaps (14000-14302, 15570-15731, 15740-15777) for closure of a defect created by an incision, excision or trauma.

Photochemotherapy Upcoding
Covers documentation elements (e.g., photosensitive chemicals, light rays, severity of dermatoses, length of direct supervision, etc.) to help prevent upcoding of photochemotherapy services (96910, 96912, 96913).

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Acute Congestive Heart Failure (CHF) Clinical Criteria
Covers the clinical criteria UnitedHealthcare uses to validate a diagnosis of acute or acute on chronic congestive heart failure (CHF).

Acute Kidney Injury (AKI) Clinical Criteria
Covers the clinical criteria UnitedHealthcare uses to validate a diagnosis of acute kidney injury (AKI) or acute renal failure (ARF) with tubular necrosis.

Acute Kidney Injury (AKI) Coding Considerations
Covers the ICD-10-CM Coding Guidelines and guidance from the American Hospital Association® Coding Clinic on reporting and sequencing acute kidney injury (AKI) or acute renal failure (ARF) diagnoses.

Acute Myocardial Infarction Clinical Criteria
Covers the clinical criteria UnitedHealthcare uses to validate a diagnosis of acute myocardial infarction.

Acute Respiratory Failure Clinical Criteria
Covers the clinical criteria UnitedHealthcare uses to validate a diagnosis of respiratory failure.

Acute Respiratory Failure Coding Considerations
Covers the ICD-10-CM Coding Guidelines for reporting and sequencing respiratory failure diagnoses.

Blood Loss Anemia Clinical Criteria and Coding Consideration
Covers the clinical criteria UnitedHealthcare uses to validate a diagnosis of blood loss anemia, including coding guidance from the ICD-10-CM Coding Guidelines and the American Hospital Association Coding Clinic.

Encephalopathy Clinical Criteria
Covers the clinical criteria UnitedHealthcare uses to validate a diagnosis of encephalopathy.

Encephalopathy Coding Considerations
Covers the ICD-10-CM Coding Guidelines and guidance from the American Hospital Association Coding Clinic on reporting and sequencing encephalopathy diagnoses.

Facility Billing and Review Process
Covers the UnitedHealthcare facility billing process, including administrative scope and process, governing resources, guidelines and factors that may impact Diagnoses Related Group (DRG) assignment.

Heart Failure Coding Considerations
Covers the ICD-10-CM Coding Guidelines and guidance from the American Hospital Association Coding Clinic on reporting and sequencing heart failure (HF) diagnoses.

Malnutrition and Marasmus Clinical Criteria
Covers the clinical criteria UnitedHealthcare uses to validate a diagnosis of malnutrition or marasmus.

Malnutrition and Marasmus Coding Considerations
Covers the ICD-10-CM Coding Guidelines and guidance from the American Hospital Association Coding Clinic on reporting and sequencing malnutrition and marasmus diagnoses.

Myocardial Infarction Coding Considerations
Covers the ICD-10-CM Coding Guidelines and guidance from the American Hospital Association Coding Clinic on reporting and sequencing myocardial infarction diagnoses.

Pneumonia Clinical Criteria
Covers the clinical criteria UnitedHealthcare uses to validate pneumonia diagnoses.

Pneumonia Coding Considerations
Covers the ICD-10-CM Coding Guidelines for reporting and sequencing pneumonia diagnoses.

Sepsis-2 Clinical Criteria
Covers the clinical criteria UnitedHealthcare uses to validate sepsis diagnoses utilizing Sepsis-2 criteria for Kentucky Medicaid cases, California cases with discharge dates prior to Nov. 1, 2019, and all other cases (except for New York) with discharge dates prior to Jan. 1, 2019.

Sepsis-3 Clinical Criteria
Covers the clinical criteria UnitedHealthcare uses to validate sepsis diagnoses utilizing Sepsis-3 criteria for California cases with discharge dates on or after Nov. 1, 2019, and all other cases (except for Kentucky Medicaid and New York) with discharge dates on or after Jan. 1, 2019.

Sepsis Clinical Criteria - State of New York Only
Covers the clinical criteria UnitedHealthcare uses to validate sepsis diagnoses for cases in New York.

Sepsis Coding Considerations
Covers the ICD-10-CM Coding Guidelines for reporting and sequencing sepsis diagnoses.

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Advance Care Planning Upcoding and Unbundling
Covers the documentation elements that help prevent upcoding of advance care planning (ACP) services (99497 and 99498), unbundling ACP and critical care (99291 and 99292) or cognitive care (99483) services.

Critical Care Upcoding
Covers the guidelines to define critical care services (99291 and 99292) and documentation elements to help prevent upcoding these time-based services.

Hospital Observation E/M Upcoding (Prior to Jan. 1, 2023)
Covers criteria and guidelines effective up to Jan. 1, 2023, to help prevent upcoding of hospital observation evaluation and management (E/M) services. Note: Codes 99217-99220 and 99224-99226 were deleted effective Jan. 1, 2023.

Hospital Inpatient or Observation E/M Upcoding
Covers the CPT® changes effective Jan. 1, 2023, for hospital evaluation and management (E/M) services, including revised time and medical decision making (MDM) code selection criteria for initial (99221-99223), subsequent (99231-99233) and same day admit/discharge (99234-99236) codes. Also covers documentation elements to help prevent upcoding these services or time-based hospital discharge codes (99238-99239).

Nursing Facility E/M Unbundling
Covers guidelines to help prevent unbundling of nursing facility evaluation and management (E/M) services (99304‒99316) and other E/M services or procedures such as continuous inhalation treatment (94644).

Nursing Facility E/M Upcoding
Covers the CPT changes effective Jan. 1, 2023, for nursing facility (NF) evaluation and management (E/M) services, including revised time and medical decision making (MDM) code selection criteria for initial (99304-99306) and subsequent (99307-99310) codes. Also covers documentation elements to help prevent upcoding of these services or time-based NF discharge codes (99315, 99316).

Pediatric and Neonatal Critical and Intensive Care Unbundling
Covers guidance to help prevent unbundling of pediatric and neonatal critical and intensive care services (99468-99476, 99477-99480) with other evaluation and management (E/M) services or procedures considered inclusive to the critical or intensive care.

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General Lab Billing Guidance
Covers multiple UnitedHealthcare policies for reporting lab services, including criteria on intent to order, date of service, place of service and Clinical Laboratory Improvement Amendments (CLIA) certification. Also reviews the appropriate use of modifiers for reporting repeat or distinct procedures (91, 59, XE, XS, etc.) and professional or technical components (26, TC).

Genomic Panel, Molecular Pathology and PLA Code Unbundling
Covers guidance to help prevent unbundling of genetic testing services (e.g., Tier 1 and Tier 2 molecular pathology, genomic sequencing procedures, other molecular multianalyte assays, proprietary laboratory analyses and unlisted codes). Also reviews the MolDx program (administered by Palmetto GBA) to register tests.

Organ or Disease-Oriented Lab Panel Unbundling
Covers guidelines to help prevent unbundling from billing individual component codes that make up a laboratory panel (80047–80081) or reporting panel codes with overlapping components.

Presumptive and Definitive Drug Test Unbundling
Covers guidelines to help prevent unbundling of presumptive and/or definitive drug tests, as well as specimen validity testing for the same date. Also covers exceeding Medically Unlikely Edit (MUE) values for these services.

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Obstetrical Services Unbundling     
Covers guidance to help prevent unbundling of services that are included in the global obstetrical (OB) package (e.g., related to antepartum care, delivery and postpartum care), such as evaluation and management (E/M) services, ultrasounds and labor/delivery procedures.

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2021 Evaluation and Management (E/M) Changes
Covers the CPT changes that became effective Jan. 1, 2021, for office or other outpatient E/M services (99201–99215). Includes revised time and medical decision making (MDM) criteria.

Allergen Injection and E/M Unbundling
Covers the guidelines for appropriately billing a separate E/M service with an allergen injection service (95115 and 95117) to help prevent unbundling.

Cardiovascular and E/M Service Unbundling
Covers guidance to help prevent unbundling of evaluation and management (E/M) services and cardiovascular procedures, such as electrocardiograms (ECGs), stress testing, catheter placement and more.

Chemotherapy Administration and E/M Unbundling
Covers guidelines to help prevent unbundling of evaluation and management (E/M) services and chemotherapy administration services (96401–96549) in office and facility settings.

Injection or Infusion and E/M Unbundling
Covers guidance to help prevent unbundling of an injection or infusion service (e.g., therapeutic, hydration, acupuncture, trigger-point procedures, arthrocentesis, vaccinations, etc.), and an evaluation and management (E/M) service.

Multiple E/M Service Unbundling
Covers guidelines to help prevent unbundling of multiple evaluation and management (E/M) services when reported by the same group physician (e.g., same specialty and group practice) for the same patient and same date of service.

Office E/M Upcoding
Covers documentation elements to help prevent upcoding of office or other outpatient evaluation and management (E/M) services (99202–99215), including time and medical decision making (MDM) criteria for code selection.

Preventive Services and E/M Unbundling
Covers guidance to help prevent unbundling of help preventive evaluation and management (E/M) services (99381–99387, 99391–99397, G0101, G0402, G0438, G0439, G0468) and a problem-oriented E/M service performed on the same date.

Prolonged E/M Service Upcoding and Unbundling
Covers documentation elements to help prevent upcoding of time-based prolonged services without direct patient contact (99358, 99359). Also includes guidance to help prevent unbundling of services that may be inclusive if reported on the same date.

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Ophthalmology Exam Upcoding & Unbundling
Covers documentation elements to help prevent upcoding of ophthalmological and visual field exams (92002, 92004, 92012, 92014) and guidance to help prevent unbundling of these services and evaluation and management (E/M) services.

Ophthalmology Procedure Upcoding and Unbundling
Covers documentation elements to help prevent upcoding of cataract removal (66982–66984, 66987–66989, 66991), vitrectomy (67036–67043) and retinal detachment (67101–67113) procedures. Also includes guidance to help prevent unbundling of ophthalmological services.

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Always Therapy Service Required Modifiers
Covers qualified therapist criteria and discipline-specific modifiers (GN, GO, GP, CO and CQ) for Always Therapy Services as designated by CMS.

Occupational Therapy Evaluation Upcoding
Covers documentation elements to help prevent upcoding of occupational therapy (OT) evaluations (97165-97167) and guidance for reporting OT services, including qualified professionals, plan of care criteria and required modifiers (GO, CO).

Physical Therapy Evaluation Upcoding
Covers documentation elements to help prevent upcoding of physical therapy (PT) evaluations (97161-97164) and guidance on reporting PT services, such as qualified professionals, plan of care criteria and required modifiers (GP, CQ).

Speech Language Pathology Service Unbundling
Covers guidance to help prevent unbundling of speech language pathology (SLP) and other services. Also includes elements for reporting SLP services, such as qualified professionals, plan of care criteria, required modifiers and related Smart Edits.

Time-Based Therapy Procedure Upcoding
Covers documentation elements to help prevent upcoding of time-based physical therapy procedures (97110–97150, 97530–97542) and guidance on required modifiers and maximum frequency per day (MFD) limits.

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Casting, Splinting and Strapping Procedure Unbundling
Covers guidelines to help prevent the unbundling of cast, splint or strapping procedures and other musculoskeletal procedures, vein destruction or ablation procedures, and evaluation and management (E/M) services. Also reviews modifiers (54, 55, 56) used to report a split surgical package.

Cerumen Removal and E/M Unbundling
Covers the criteria for reporting unilateral or bilateral cerumen (ear wax) removal procedures (69209, 69210 and G0268), and guidelines for reporting a distinct evaluation and management (E/M) service for the same session.

Exceeding Medically Unlikely Edit Values
Covers guidelines and policies to avoid reporting units of service that exceed the limits set by the CMS Medically Unlikely Edit (MUE) tables or the UnitedHealthcare Maximum Frequency Per Day (MFD) policies.

Global Surgery Package Unbundling
Covers guidance for separately reporting services, such as evaluation and management (E/M) visits performed during the global period (000, 010, 090, etc.) of a procedure subject to the CMS Global Surgical Package concept.

Musculoskeletal Procedure Upcoding and Unbundling
Covers criteria to help prevent upcoding of musculoskeletal system procedures (e.g., injections, implant removals, etc.), including guidance to help prevent unbundling of services or procedures that may be inclusive if reported on the same date.

Osteopathic Manipulative Treatment Coding
Covers documentation elements that help prevent upcoding of osteopathic manipulative treatment (OMT) services (98925-98929) and guidance to help prevent unbundling of OMT and evaluation and management (E/M) services.

Procedure-to-Procedure Code Pair Unbundling
Covers guidance to help prevent unbundling of procedure code pairs identified by National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits and circumstances for using an appropriate modifier (e.g., 59, XE, XP, etc.) to override an edit.

Transthoracic Echocardiogram Upcoding
Covers documentation elements to help prevent upcoding of transthoracic echocardiogram (TTE) studies (93306-93308).

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Diagnostic Radiology and E/M Unbundling
Covers guidelines to help prevent unbundling of evaluation and management (E/M) services and diagnostic radiology services (70000-75999, 78000-79999), such as computerized tomography (CT), magnetic resonance imaging (MRI) X-ray and more.

IMRT Unbundling and Exceeding MUE/MFD Values
Covers guidelines to help prevent unbundling of an intensity-modulated radiation therapy (IMRT) plan and related radiation therapy services. Also includes an overview of exceeding medically unlikely edit (MUE) limits for these services.

Myocardial Perfusion Imaging (MPI) Unbundling
Covers guidance to help prevent unbundling of MPI procedures (78451, 78452) and related services, such as 3D rendering services (76376, 76377) and various cardiac blood pool imaging studies (78472, 78473, 78481, 78483, 78494).

Radiology and E/M Unbundling
Covers guidance to help prevent unbundling of an evaluation and management (E/M) service and a radiology service (76000-77999) such as computed tomography (CT), fluoroscopic guidance, ultrasound imaging services, etc.