Coding Corner

Anesthesia and Integral Services Unbundling
Explain CMS and UnitedHealthcare policies to help avoid unbundling of anesthesia and integral services.

Anesthesia Upcoding and Pricing Modifiers
Identify accurate reporting of anesthesia time and correct use of anesthesia pricing modifiers to help avoid upcoding of anesthesia services. 

Moderate Sedation Upcoding
Identify documentation elements that offset potential upcoding of time-based moderate conscious sedation services.

Complex Repair Upcoding
Identify documentation elements that offset potential upcoding of complex repairs. Provides criteria and guidance for reporting simple, intermediate, and complex surgical repairs for closure of a defect created by an incision, excision or trauma.

Laser Psoriasis Treatment Upcoding
Identify documentation elements that offset potential upcoding of laser psoriasis treatment services. Provides criteria and guidance to support accurate code selection and identify differences in laser psoriasis treatment codes.

Mohs Surgery Coding
Focus is to identify documentation that offset potential upcoding of Mohs surgery procedures. Addresses when Mohs codes are appropriate instead of separate surgery and pathology codes. Provides criteria and guidance to help support accurate code selection for initial and subsequent stages and additional blocks.

Mohs Surgery Unbundling
Identify documentation elements that offset potential unbundling of Mohs procedures and surgical pathology or biopsy codes. Provides criteria and guidance to clarify when these services are separately reportable by the same provider. 

Other Repair Coding and Unbundling
Identify documentation elements that offset potential upcoding or unbundling of integumentary system repairs such as transfers, grafts, and flaps for closure of a defect created by an incision, excision or trauma.

Photochemotherapy Upcoding
Identify documentation elements that offset potential upcoding of photochemotherapy services. Provides criteria and guidance to help support accurate code selection and distinguish phototherapy and photochemotherapy services.

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

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

Acute Kidney Injury (AKI) Coding Considerations
Focus is on the ICD-10-CM Coding Guidelines and guidance from the AHA Coding Clinic for ICD on reporting and sequencing of acute kidney injury (AKI) or acute renal failure (ARF) diagnoses.

Acute Myocardial Infarction Clinical Criteria
Focus is on the clinical criteria used by UnitedHealthcare to validate a diagnosis of acute myocardial infarction.

Acute Respiratory Failure Clinical Criteria
Focus is on the clinical criteria used by UnitedHealthcare to validate a diagnosis of respiratory failure.

Acute Respiratory Failure Coding Considerations
Focus is on the ICD-10-CM Coding Guidelines for reporting and sequencing of respiratory failure diagnoses.

Blood Loss Anemia Clinical Criteria and Coding Consideration
Focus is on the clinical criteria used by UnitedHealthcare to validate a diagnosis of blood loss anemia and coding guidance from the ICD-10-CM Coding Guidelines and the AHA Coding Clinic for ICD-10-CM.

Encephalopathy Clinical Criteria
Focus is on the clinical criteria used by UnitedHealthcare to validate a diagnosis of encephalopathy.

Encephalopathy Coding Considerations
Focus is on the ICD-10-CM Coding Guidelines and guidance from the AHA Coding Clinic for ICD on reporting and sequencing of encephalopathy diagnoses.

Facility Billing and Review Process
Focus is on the UnitedHealthcare facility billing process including our administrative scope and process, governing resources and guidelines and factors that may impact DRG assignment.

Heart Failure Coding Considerations
Focus is on the ICD-10-CM Coding Guidelines and guidance from the AHA Coding Clinic for ICD on reporting and sequencing of heart failure (HF) diagnoses.

Malnutrition and Marasmus Clinical Criteria
Focus is on the clinical criteria used by UnitedHealthcare to validate a diagnosis of malnutrition or marasmus.

Malnutrition and Marasmus Coding Considerations
Focus is on the ICD-10-CM Coding Guidelines and guidance from the AHA Coding Clinic for ICD on reporting and sequencing of malnutrition and marasmus diagnoses.

Myocardial Infarction Coding Considerations
Focus is on the ICD-10-CM Coding Guidelines and guidance from the AHA Coding Clinic for ICD-10-CM on reporting and sequencing of myocardial infarction diagnoses.

Pneumonia Clinical Criteria
Focus is on the clinical criteria used by UnitedHealthcare to validate pneumonia diagnoses.

Pneumonia Coding Considerations
Focus is on the ICD-10-CM Coding Guidelines for reporting and sequencing of pneumonia diagnoses.

Sepsis-2 Clinical Criteria
Focus is on the clinical criteria used by UnitedHealthcare to validate sepsis diagnoses utilizing Sepsis-2 criteria for KY Medicaid cases, CA cases with discharge dates prior to November 1, 2019, and all other cases (except NY state) with discharge dates prior to January 1, 2019.

Sepsis-3 Clinical Criteria
Focus is on the clinical criteria used by UnitedHealthcare to validate sepsis diagnoses utilizing Sepsis-3 criteria for CA cases with discharge dates on or after November 1, 2019, and all other cases (except NY state and KY Medicaid) with discharge dates on or after January 1, 2019.

Sepsis Clinical Criteria - State of New York Only
Focus is on the clinical criteria used by UnitedHealthcare to validate sepsis diagnoses for state of NY cases only.

Sepsis Coding Considerations
Focus is on the ICD-10-CM Coding Guidelines for reporting and sequencing of sepsis diagnoses.

Advance Care Planning Upcoding and Unbundling
Identify documentation elements that offset potential upcoding of time-based advance care planning services and unbundling of advance care planning and other evaluation and management services.

Critical Care Upcoding
Identify documentation elements that offset potential upcoding of time-based critical care services.

Hospital Observation E/M Upcoding (prior to 1/1/2023)
Focus is on criteria and guidelines to support accurate reporting of initial, subsequent and discharge observation evaluation and management (E/M) services (CPT 99217-99220, 99224-99226).

Hospital Inpatient or Observation E/M Upcoding
Focus is on criteria and guidelines to support accurate reporting of initial, subsequent and discharge (including same day admission and discharge) hospital evaluation and management (E/M) services (CPT 99221-99223, 99231-99239).

Nursing Facility E/M Unbundling
Focus is on guidelines and policies to help identify services that may be included and are not separately reportable with nursing facility evaluation and management (E/M) services.

Nursing Facility E/M Upcoding
Focus is on criteria and guidelines to support accurate code selection for initial, subsequent and discharge nursing facility evaluation and management (E/M) services.

Pediatric and Neonatal Critical and Intensive Care Unbundling
Interpret when it is appropriate to bill pediatric and neonatal critical and intensive care services with other services provided on the same date to offset potential unbundling.

General Lab Billing Guidance 
Summarize UnitedHealthcare policy guidance to support correct use of modifiers for reporting repeat lab services and professional or technical components, and specific lab claim requirement such as intent to order, date of service, place of service and CLIA requirements.

Genomic Panel, Molecular Pathology and PLA Code Unbundling
Summarize guidance from CPT, CMS and UnitedHealthcare policies to support proper use of genetic testing codes and to help avoid unbundling of lab services.

Organ or Disease-Oriented Lab Panel Unbundling
Summarize individual components that are included in laboratory panel codes and guidelines from CPT, CMS and UnitedHealthcare policies to help prevent  unbundling of laboratory panels.

Presumptive and Definitive Drug Test Unbundling
Summarize guidelines from CPT, CMS and UnitedHealthcare policies to support correct reporting of presumptive and/or definitive drug tests as well as specimen validity testing for the same date to help avoid unbundling of lab services.

Obstetrical Services Unbundling                                                  
Focus is on identifying which obstetrical (OB) services are included in the global OB package and when it is appropriate to bill OB services with other services provided on the same date or during the same time frame to avoid potential unbundling.

2021 Evaluation and Management (E/M) Changes
Identify documentation elements that offset potential upcoding of high level new and established patient E/M service codes when documentation supports a lower level service code. 

Allergen Injection and E/M Unbundling
Interpret when it is appropriate to bill a separate E/M service with an allergen injection service to avoid potential unbundling.   

Cardiovascular and E/M Service Unbundling
Interpret when it is appropriate to bill a separate E/M with a cardiovascular service to avoid potential unbundling.  

Chemotherapy Administration and E/M Unbundling
Interpret when it is appropriate to bill a separate E/M with a chemotherapy code, e.g., chemotherapy administration service, to avoid potential unbundling.

Injection or Infusion and E/M Unbundling
Focus is on helping providers understand when it is appropriate to bill a separate E/M with an injection or infusion service such as acupuncture, trigger-point procedures, arthrocentesis, vaccinations, etc., to avoid potential unbundling.

Multiple E/M Service Unbundling 
Identify guidelines to support the correct use of multiple E/M codes for the same patient and same date of service to avoid potential unbundling. 

Office E/M Upcoding 
Identify documentation elements that offset potential upcoding of high level new and established patient E/M service codes when documentation supports a lower level service code.

Preventive Services and E/M Unbundling 
Identify when it is appropriate to bill a separate E/M when billing for preventive E/M services to avoid potential unbundling.  

Prolonged E/M Service Upcoding and Unbundling
Focus is on criteria for reporting prolonged services without direct patient contact (99358, 99359) and identifying services that may be inclusive if reported on the same date.

Ophthalmology Exam Upcoding & Unbundling
Focus is to offset potential upcoding and/or unbundling of ophthalmological services such as general ophthalmological exams and visual field examination services. 

Ophthalmology Procedure Upcoding and Unbundling
Focus is to offset potential upcoding and/or unbundling of ophthalmological procedures such as cataract removal, vitrectomy, retinal detachment and other special ophthalmological services.

Always Therapy Service Required Modifiers 
Identify always therapy services as designated by CMS and on identifying the appropriate modifier required to indicate the discipline of the plan of care under which the service is provided.

Occupational Therapy Evaluation Upcoding
Identify documentation elements that offset potential upcoding of occupational therapy (OT) evaluations. Summarize guidance from CPT, CMS and UnitedHealthcare policies for reporting OT services, e.g., qualified professionals, plan of care and required modifiers.

Physical Therapy Evaluation Upcoding
Identify documentation elements that offset potential upcoding of physical therapy (PT) evaluations. Summarize guidance from CPT, CMS and UnitedHealthcare policies for reporting PT services, e.g., qualified professionals, plan of care and required modifiers.

Speech Language Pathology Service Unbundling
Identify documentation elements that offset potential unbundling of speech language pathology (SLP) procedures. Summarize guidance from CPT, CMS and UnitedHealthcare policies for reporting SLP services, e.g., qualified professionals, plan of care and required modifiers.

Time-Based Therapy Procedure Upcoding 
Identify documentation elements that offset potential upcoding of time-based therapy procedures. Summarize guidance from CPT, CMS and UnitedHealthcare policies for reporting PT services, e.g., qualified professionals, plan of care and required modifiers.

Casting, Splinting and Strapping Procedure Unbundling
Focus is on identifying services or procedures that may be inclusive to cast, splint, and strapping procedures if reported on the same date.

Cerumen Removal and E/M Unbundling
Identify documentation elements that offset potential unbundling of cerumen removal procedures when billing for an EM service performed at the same session.

Exceeding Medically Unlikely Edit Values
Identify how to avoid billing units of service that exceed Medically Unlikely Edit (MUE) or maximum frequency per day (MFD) values. Recall the CMS MUE program with guidance from CMS and UnitedHealthcare policies on appropriate use of modifiers to bypass MUEs.

Global Surgery Package Unbundling 
Summarize the CMS Global Surgical Package concept in relation to indicators “000”, “010”, “090” and related post-operative periods. Identify which services are included in the global surgery package and which may be separately reported. Apply appropriate use of modifiers within the global period.

Musculoskeletal Procedure Upcoding and Unbundling
Focus is on criteria for reporting musculoskeletal system procedures (e.g., injections, implant removals, etc.) and identifying services or procedures that may be inclusive if reported on the same date.

Osteopathic Manipulative Treatment Coding
Focus is on criteria for reporting osteopathic manipulative treatment (OMT) services and identifying services that may be inclusive to OMT if reported on the same date.

Procedure-to-Procedure Code Pair Unbundling
Explain the National Correct Coding Initiative (NCCI) PTP edit program. Identify unbundling of code pairs identified by PTP edits and understand when it is appropriate to use a modifier to override an edit.

Transthoracic Echocardiogram Upcoding
Identify documentation elements that offset potential upcoding of transthoracic echocardiogram (TTE) services.

CPT Category II Codes

Diagnostic Radiology and E/M Unbundling
Identify when it is appropriate to bill a separate E/M with a diagnostic radiology service, e.g., CT, MRI, X-Ray, etc. to avoid potential unbundling.

IMRT Unbundling and Exceeding MUE/MFD Values 
Interpret the principles of unbundling an IMRT plan which is not ordinarily billed with other related radiation therapy services performed prior to or as part of the development of the IMRT plan.  This course also covers exceeding MUE limits. 

Myocardial Perfusion Imaging (MPI) Unbundling
Identify documentation elements that offset potential unbundling of Myocardial Perfusion Imaging when  reporting codes for first pass studies, SPECT MUGA, and 3D rendering. Course includes an overview of associated NCCI PTP edits.  

Radiology and E/M Unbundling
Interpret when it is appropriate to bill a separate E/M when billing for a radiology service, e.g., therapeutic radiology, CT/Fluoroscopic guidance, and ultrasound imaging services to avoid potential unbundling.