How to determine the number of Dx during E & M visit

Number of Diagnoses and/or Management Options

The number of possible diagnoses and/or the number of management options that must be considered is based on:

** The number and types of problems addressed during the encounter;

** The complexity of establishing a diagnosis; and

** The management decisions that are made by the physician.


In general, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnosed tests performed may be an indicator of the number of possible diagnoses. Problems that are improving or resolving are less complex than those problems that are worsening or failing to change as expected. Another indicator of the complexity of diagnostic or management problems is the need to seek advice from other health care professionals.

Some important points that should be kept in mind when documenting the number of diagnoses or management options are:

** For each encounter, an assessment, clinical impression, or diagnosis should be documented which may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation:

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is:

- Improved, well controlled, resolving, or resolved; or

- Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

** The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.

** If referrals are made, consultations requested, or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom advice is requested.

What is INTERNATIONAL CLASSIFICATION OF DISEASES DIAGNOSIS AND PROCEDURE CODES

The use of ICD-9-Clinical Modification (CM) diagnosis and procedure codes is limited to billing for inpatient E/M services on inpatient claims. All other provider types should continue to use CPT codes to bill for E/M services.

The compliance date for implementation of the International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/ PCS) is for services provided on or after October 1, 2015, for all Health Insurance Portability and Accountability Act covered entities. ICD-10-CM/PCS is a replacement for ICD-9-CM diagnosis and procedure codes. The Implementation of ICD-10-CM/PCS will not impact the use of CPT and alpha-numeric Healthcare Common Procedure Coding System codes.


All providers billing for inpatient services provided to inpatient beneficiaries will use ICD-10-CM diagnosis codes instead of ICD-9-CM diagnosis codes for services furnished on or after October 1, 2015. ICD-10-CM/PCS will enhance accurate payment for services rendered and facilitate evaluation of medical processes and outcomes. The new classification system provides significant improvements through greater detailed information and the ability to expand  in order to capture additional advancements in clinical  medicine.

ICD-10-CM/PCS consists of two parts:

** ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings.

Diagnosis coding under this system uses 3 – 7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and

** ICD-10-PCS – The procedure classification system developed by the Centers for Medicare & Medicaid Services for use in the U.S. for billing inpatient hospital claims for inpatient services ONLY. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.

CPT code G0475 coved ICD 10 code and denial codes

Billing Requirements

Effective for claims with dates of service on or after April 13, 2015, MACs will recognize new HCPCS code G0475 (HIV antigen/antibody, combination assay, screening) as a new covered service for HIV screening.

NOTE: HCPCS G0475 will appear in the January 1, 2017, CLFS; in the January 1, 2016, Integrated Outpatient Code Editor (IOCE); in the January 2016 Outpatient Prospective Payment System (OPPS); and in the January 1, 2016, Medicare Physician Fee Schedule (MPFS). HCPCS Code G0475 will be effective retroactive to April 13, 2015, in the IOCE and OPPS.

For services from April 13 - September 30, 2015, inclusive, the diagnosis codes are:

ICD-9 Code Descriptor
V22.0 Supervision of normal first pregnancy
V22.1 Supervision of other normal pregnancy
V23.9 Supervision of unspecified high-risk pregnancy
V69.8 Other problems related to lifestyle
V73.89 Special screening examination for other specified viral diseases
V69.2 High risk sexual behavior
Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester
Z34.01 Encounter for supervision of normal first pregnancy, first trimester
Z34.02 Encounter for supervision of normal first pregnancy, second trimester
Z34.03 Encounter for supervision of normal first pregnancy, third trimester
Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester
Z34.81 Encounter for supervision of other normal pregnancy, first trimester
Z34.82 Encounter for supervision of other normal pregnancy, second trimester
Z34.83 Encounter for supervision of other normal pregnancy, third trimester
Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester
Z34.92 Encounter for supervision of normal pregnancy, second trimester
Z34.93 Encounter for supervision of normal pregnancy, third trimester
O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester
O09.91 Supervision of high risk pregnancy, unspecified, first trimester
O09.92 Supervision of high risk pregnancy, unspecified, second trimester
O09.93 Supervision of high risk pregnancy, unspecified, third trimester
Z72.89 Other problems related to lifestyle
Z11.4 Encounter for screening for human immunodeficiency virus [HIV]
Z72.51 High risk heterosexual behavior
Z72. 52 High risk homosexual behavior
Z72.53 High risk bisexual behavior

On professional claims, the place of service must be either 81 (independent laboratory) or 11 (office).

If claims are received for screenings that exceed the maximum number allowed per year, the claim line item will be denied with the following remittance codes:

** Claim Adjustment Reason Code (CARC) 119: “Benefit maximum for this time period or occurrence has been reached.”

** Remittance Advice Remark Code (RARC) N386: “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination
as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp on the CMS website. If you do not have web access, you may contact the contractor to request a copy of the NCD.” and


** Group Code: CO (Contractual Obligation).

Note that the next eligible date for the service will be provided on all Common Working File (CWF) provider query screens (HUQA, HIQA, HIQH, ELGA, ELGH, and PRVN).
Claims with HCPCS Code G0475 for beneficiaries between the ages of 15 and 65 without regard to risk must also be submitted with a primary diagnosis code of either V73.89 (ICD- 9) or Z11.4 (ICD-10). If that primary code is not present, the line item will be denied using the following messages:

** CARC 167 – “This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information
REF), if present.”

** RARC N386 – “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or
service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp on the CMS website. If you do not have web access, you may contact the contractor to request a copy of the NCD.”

** Group Code: CO (Contractual Obligation).

Claims with HCPCS Code G0475 for beneficiaries less than age 15 or greater than age 65 with increased risk must also be submitted with a primary diagnosis code of either V73.89 (ICD-9) or Z11.4 (ICD-10) and a secondary diagnosis code that denotes the high risk. The ICD-9 secondary codes are V69.2 or V69.8. The ICD-10 secondary diagnosis codes are Z72.51, Z72.89, Z72.52, or Z72.53. If that secondary code is not present, the line item will be denied using the following messages:

** CARC 6: “The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment Information REF), if present.”

** RARC N129: “Not eligible due to the patient’s age.”

** Group Code: CO (Contractual Obligation).

Effective for claims with dates of service on or after April 13, 2015, MACs will deny lineitems on claims for pregnant beneficiaries denoted by a secondary diagnosis code above denoting pregnancy, if HCPCS Code G0475, HIV screening, or CPT code 80081, obstetric panel, and primary diagnosis code V73.89/ Z11.4, as appropriate, are not present on the claim. Such line item denials will result in the following remittance messages:

** CARC 11: “The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information
REF), if present.

** RARC N386 – “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item
or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp on the CMS website. If you do not have web access, you may contact the contractor to request a copy of the NCD.”

** Group Code: CO (Contractual Obligation).

Institutional claims for G0475 submitted on Types of Bill (TOB) 12X, 13X, 14X, 22X, and 23X will be paid based on the CLFS with dates of service on or after January 1, 2017. MACs will apply their pricing to claims with dates of service of April 13, 2015, through December 31, 2016. Such claims submitted on TOB 85X will be paid based on reasonable cost for dates of service beginning with April 13, 2015.

• Persons who have acquired or request testing for other sexually transmitted infectious diseases;

• Persons with a history of blood transfusions between 1978 and 1985;

CPT CODE G4076 denial and covered DX part 2

Change Request (CR) 9434 announces that the Centers for Medicare & Medicaid Services (CMS) has determined that, effective for dates of service on or after July 9, 2015, evidence is sufficient to add Human Papillomavirus (HPV) testing under specified conditions. Make sure that your billing staffs are aware of this change.


Medicare covers a screening pelvic examination and Pap test for all female beneficiaries at 12- or 24-month intervals, based on specific risk factors; however, current Medicare coverage does not include the HPV testing.

Section 1861(ddd) of the Social Security Act (the Act) (see http://www.ssa.gov/OP_Home/ssact/title18/1861.htm) states that CMS may add coverage of "additional reventive services" through the National Coverage Determination (NCD) process. The preventive services must meet all of the following criteria:

1. Reasonable and necessary for the prevention or early detection of illness or disability;

2. Recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF); and,

3. Appropriate for individuals entitled to benefits under Part A or enrolled under  Part B.

CMS has reviewed the USPSTF recommendations and supporting evidence for screening for cervical cancer with HPV co-testing, and has determined that the criteria were met. Therefore, effective for claims with dates of service on or after July 9, 2015, CMS will cover screening for cervical cancer with HPV co-testing under the following conditions:

CMS has determined that the evidence is sufficient to add HPV testing once every 5 years as an additional preventive service benefit under the Medicare program, for
asymptomatic beneficiaries aged 30 to 65 years in conjunction with the Pap smear test. CMS will cover screening for cervical cancer with the appropriate U.S. Food
and Drug Administration (FDA)-approved/cleared laboratory tests, used consistent with FDA-approved labeling, and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations.


A new Healthcare Common Procedure Coding System (HCPCS) code, G0476 (HPV combo assay, CA screen), Type of Service (TOS) 5 (diagnostic lab), has been created for this
benefit. This code will:

** Be effective retroactive back to the effective date of July 9, 2015;

** Be included in the January 2016, Integrated Outpatient Code Editor, Outpatient Prospective Payment System, and Medicare Physician Fee Schedule Database;

** Be MAC-priced from July 9, 2015, through December 31, 2016, and during this period code G0476 is paid only when it is billed by a laboratory entity; and,

** Beginning January 1, 2017, this will be priced and paid according to the Clinical Laboratory Fee Schedule (CLFS).

In addition, you should be aware of the following:

1. Your MACs will not apply beneficiary coinsurance and deductibles to claim lines containing HCPCS G0476, HPV screening;

2. Part B MACs shall only accept claims with a Place of Service Code equal to ‘81’, Independent Lab or ‘11’, Office; and

3. Effective for claims with dates of service on or after July 9, 2015, your MACs will deny  line-items on claims containing HCPCS G4076, HPV screening, when reported more  than once in a 5-year period [at least 4 years and 11 months (59 months total) must elapse from the date of the last screening]. The next eligible dates for this service are shown on all Common Working File (CWF) provider query screens (HUQA, HIQA, HIQH, ELGA, ELGH, and PRVN).

When denying a line-item on a claim for this requirement they will use the following messages:

** Claim Adjustment Reason Code (CARC) 119 – “Benefit maximum for this time period or occurrence has been reached;”

** Remittance Advice Remark Code (RARC) N386 – “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD;”

** Group Code “CO” if the claim contains a GZ modifier to denote a signed Advance Beneficiary Notice (ABN) is not on file or with Group Code "PR" (Patient
Responsibility) if the claim has a GA modifier to show a signed ABN is on file.

4. HCPCS Code G0476 will be paid only for institutional claims submitted on Type of Bill codes (TOB) 12X, 13X, 14X, 22X, 23X, and 85X. Institutional claims on other TOBs  will be returned to the provider.

5. Effective for claims with dates of service on or after July 9, 2015, your MACs will deny line-items on claims containing HCPCS G4076, HPV screening, when the beneficiary is less than 30 years of age or older than 65 years of age. When denying a line-item on claims for this requirement, they will use the following
messages:

** CARC 6 – “The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment Information REF), if present;”

** RARC N129 – “Not eligible due to the patient’s age;”

** Group Code “CO” if the claim contains a GZ modifier to denote a signed Advance Beneficiary Notice (ABN) is not on file or with Group Code "PR" (Patient
Responsibility) if the claim has a GA modifier to show a signed ABN is on file.



6. Effective for claims with dates of service on or after July 9, 2015, you must report the following diagnosis codes when submitting claims for HCPCS G0476:

** ICD-9 (for dates of service prior to October 1, 2015): V73.81, special screening exam, HPV (as primary), and V72.31, routine gynecological exam (as secondary)  ** ICD-10: Z11.51, encounter for screening for HPV, and Z01.411, encounter for gynecological exam (general)(routine) with abnormal findings, OR Z01.419, encounter for gynecological exam (general)(routine) without abnormal findings.

Effective on this date, your MACs will deny line-items on claims containing HCPCS Code G0476, HPV screening, when the claim does not contain these codes.
When denying a line-item on claim for this requirement, they will use the following messages:

** CARC 167 – “This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment
Information REF), if present;”

** RARC N386 – “This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular
item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD;” and

** Group Code CO.