Code Detail Pane

The Code Detail pane contains referential and payment information in separate tabs. The tabs vary depending upon the type of code selected.

CDM Code Reference tab

The CDM Code Reference tab allows you to identify if codes are already included in your CDM and view if they're active and available for use in the CDM.

Detail tab

The Detail tab is visible by default, and it’s the first tab on the left. The information it contains varies by code type.

CPT/HCPCS code detail:

  • Code Type
  • Plain English Descriptions
  • Long Description
  • Medium Description
  • Consumer Friendly Description
  • Effective Date
  • Deleted Date

Inclusion Terms and Instructional Notes are included on the ICD-10 CM Code Detail tab.

All of the information in the tab applies to the Date Of Service indicated on the Search pane. If a code is deleted as of that date, Deleted displays in red font and all replacement codes are listed.

Add On tab

The Add On tab shows related codes for common add on services related to the code. Codes on this tab can be billed in conjunction with the primary code selected if add on services were provided and documented.

Ambulance tab

The Ambulance tab includes information from the Ambulance Fee Schedule as determined by the ZIP code of a facility.

  • Ambulance Base Rate
  • Ambulance Rural Ground Miles 1-17
  • Ambulance Rural Base Rate/Lowest Quartile
  • Ambulance Rural Base Rate/Rural Mileage
  • Ambulance RVU
  • Ambulance Urban Base Rate/Urban Mileage

Anesthesia tab

The Anesthesia tab contains information from the American Society of Anesthesiologists (ASA).

Information on the tab for procedures (CPT codes) that typically require anesthesia:

  • Anesthesia code appropriate for the procedure
  • Primary Code - yes or no
  • Long Desc
  • ASA RVG Units
  • Conversion Factor
  • Add On
  • Comments
  • Instructions

APC Info tab

The Medicare Ambulatory Payment Classifications (APC) tab includes:

  • APC Group Status Indicators
  • National and Wage Adjusted Payment Rates
  • Relative Weights and Co-pay

The additional table in the tab includes:

  • Composite complexity adjustment when the code is billed as primary
  • Secondary for codes that have complexity adjustments

If a code can group to multiple APCs, the APC Info tab displays the history for all applicable APCs, with active APCs at the top.

ASC tab

The Ambulatory Surgery Center (ASC) tab includes:

  • Payment indicator
  • ASC Notes
  • Multi Proc Disc
  • Payment weight
  • ASC wage index used for the calculation
  • National and adjusted payment amounts based on your facility's ASC wage index

Medicaid PTP Hospital tab

The sections of the Medicaid PTP Hospital tab contain the Correct Coding Initiative Procedure to Procedure rules related to the CPT/HCPCS code being reviewed for Facility billing.

CCI (PTP) Physician tab

The sections of the CCI (PTP) Physician tab contain the Correct Coding Initiative Procedure to Procedure rules related to the CPT/HCPCS code being reviewed for Physician billing.

CPT/HCPCS Codes tab

The CPT/HCPCS Codes tab populates only when searching the Revenue Codes dataset and lists all CPT/HCPCS codes that may fall into the revenue code selected.

CPT to ICD-10-PCS tab

The CPT to ICD-10-PCS tab provides a crosswalk from CPT codes selected to possible ICD-10-PCS Procedure codes.

CPT to ICD-9 Px tab

Note

This tab is hidden by default. Contact your account manager to add this tab to your view.

Most users now see the CPT to ICD-10-PCS tab instead of the CPT to ICD-9-Px tab. By default, this tab is hidden but can be revealed for a single user or an entire facility.

Devices tab

The Devices tab shows all the devices that are mapped to the selected CPT/HCPCS code. Information includes:

  • Model Number
  • UPN (if available)
  • Device Name
  • Manufacturer
  • Manufacturer Subdivision
  • CPT/HCPCS mapped
  • Multiple HCPCS Device - Yes indicates that the product contains two or more devices, each with a separate HCPCS code.

Device Dependent tab

The Device Dependent tab shows codes that are on the device-intensive procedure list and have a date of service prior to January 1, 2015.

Devices listed on the Related Devices tab are maintained by Vitalware and based on reasonableness (for dates of service after January 1, 2015). This proprietary list does not represent any official payer claim edits in effect on or after January 1, 2015.

  • Code and long description
  • Device Intensive - yes or no
  • Device Overrides Edit - yes or no
  • Start and End Date of Device Code
  • Notes regarding the date of service

Related procedures listed on the Related Procedures tab are maintained by Vitalware and based on reasonableness (for dates of service after January 1, 2015). This proprietary list does not represent any official payer claim edits in effect on or after January 1, 2015.

  • Code and long description
  • Device Intensive Procedure - yes or no
  • Device Overrides Edit - yes or no
  • Start and End Date of Code
  • Notes regarding the date of service

Dates of Service prior to January 1, 2015 have a Device Dependent tab and list codes that reflect the CMS procedure to device edits for the date of service used in the search.

DME Fee Sched tab

The Durable Medical Equipment (DME) Fee Sched tab data includes:

  • Jurisdiction
  • Category
  • Payment amount based upon reported modifiers
  • Floor and ceiling amounts

Fac Fee Schedule tab

For dates of service on or after January 1, 2018, the Fac Fee Schedule tab contains the national payment amount based on the date of service indicated in the search criteria, or a local payment indicator for those codes that are priced individually by each MAC.

For dates of service prior to January 1, 2018, the tab contains the locality-specific payment rates based upon the facility and the date of service indicated in the search criteria.

Fac SAF Analytics tab

The Fac SAF Analytics tab (Facility Standard Analytical File) displays statistics about the code selected in relation to its use in the facility setting.

The SAF file contains detailed claims information about health care services rendered to Medicare beneficiaries in the outpatient setting. Information is aggregated from the most recent four quarters of data available for CMS and is updated on a quarterly basis.

The data is separated into three sections, collapsed by default. Expand the sections by clicking on the caret icon.

The Diagnosis Medicare Outpatient section contains statistics about the ICD-10-CM codes most frequently billed with the CPT/HCPCS code being reviewed.

The CPT/HCPCS Medicare Outpatient section contains statistics about other CPT/HCPCS codes that are most frequently billed with the CPT/HCPCS code being reviewed.

The Rev Code Medicare Outpatient section contains:

  • RevCode Billed Count - The number of times the revenue code was billed with the CPT/HCPCS being reviewed based on the SAF data.

  • Total CPT/HCPCS Billed Count - The total number of times the CPT/HCPCS code being reviewed was billed.

  • Percent RevCode Billed - The percentage of times that the revenue code was billed with the CPT/HCPCS being reviewed.

Note

The percentage totals may not add up to 100% for the following reasons:

  • Code pairings less than 2% are not displayed.
  • We cannot display claims information in which fewer than 11 claims are found in the data.

Guidelines tab

The Guidelines tab contains the official CPT guidelines as published by the AMA. Click the caret to expand or contract the Guidelines Replaced, Guidelines, Guidelines Deleted, Coding Tips, and Citation sections.

LCD/Articles tab

The LCD/Articles tab contains all Local Coverage Determinations and Articles for a particular Contractor related to the code selected. The tab defaults to the state and contractor set up for your facility.

  • Change the state, provider type, and contractor in the dropdown fields to research LCDs and Articles related to the code from other Medicare Contractors.
  • Click the LCD or Article ID hyperlink to open the document in a new tab.
  • Click the Contractors icon to access the contractor information.

Alt Code Relationships tab

The Alt Code Relationships tab shows CPT/HCPCS to CPT/HCPCS relationships, including Medicare Alternate, suggested replacements for deleted codes, Radiological S&I relationships, and recommendations to ensure complete and accurate billing for procedures that require additional codes. It contains:

  • The type of code-to-code relationships and effective dates.
  • The type of provider that applies to this relationship in the fields FAC, PRO and ASC Applicable, along with guidelines.

MLN Matters tab

The MLN Matters tab contains links to all MedLearn Matters articles that relate to the code selected. The MLN Article Number hyperlink opens the article in a new tab. You have the option to open a PDF version of the article in a browser tab.

Modifiers tab

The Modifiers tab includes information on which modifiers are applicable to the selected code for the billing type: facility, professional, or ASC.

MUEs tab

The MUEs tab contains the Medically Unlikely Edit information for the code you selected. It includes:

  • Type of MUE - DME, Facility or Professional
  • MUE Value
  • Adjudication Indicator
  • Rationale
  • Adjudication Indicator Definition

NCD tab

The NCD tab contains a list of all National Coverage Determination documents that contain the code you selected.

NDC tab

The NDC tab shows a list of National Drug Codes mapped to the CPT/HCPCS code selected and are generally for injectable drugs. The list is not all inclusive, as many over the counter (OTC) drugs are not listed. The NDC number hyperlink opens a new tab at the top of the page and contains a crosswalk to the drugs assigned to it.

The default tab columns are:

  • Code Source
  • Drug Name
  • NDC
  • CPT/HCPCS
  • CPT/HCPCS Description
  • Labeler Name
  • Pkg Size
  • Pkg UOM
  • Pkg Qty
  • Bill Units
  • ASP +6% Price
  • 340B Reimbursement
  • AWP Price
  • WAC Price

Primary Code tab

The Primary Code tab is visible when the code selected is considered add-on code that must be billed in conjunction with a primary code. The codes listed on the tab are eligible primary codes for the CPT code selected.

Pro Anesthesia Fee Schedule tab

The Pro Anesthesia Fee Schedule tab provides helpful information for anesthesia billing.

The anesthesia conversion factor is published by CMS and is used to compute allowable amounts for anesthesia services under CPT codes 00100 through 01999.

CMS base units is the anesthesia base unit published by CMS to compute allowable amounts for anesthesia services for CPT codes 00100 through 01999. Average billed time increments represent the average billed units per CPT code calculated from the most recent four quarters of data published in the Carrier LDS Standard Analytical file.

Pro Fee Schedule tab

The Pro Fee Schedule tab includes locality-specific payment information from the Medicare Physician Fee Schedule in relation to the selected code based upon the DOS indicated that include:

  • Status Code
  • Work RVU (Relative Value Units)
  • Non-Facility Practice Expense RVU
  • Non-Facility NA Indicator
  • Facility Practice Expense RVU
  • Facility NA Indicator
  • Malpractice RVU
  • Total Non-Facility RVU
  • Total Facility RVU
  • PRO Facility Price
  • PRO Office Price
  • Professional-Technical Component Indicator
  • Global Surgery
  • Preoperative Percentage (Modifier 56, 54 and 55)
  • Multiple Procedure Indicator
  • Bilateral Surgery Indicator
  • Assistant Surgery Indicator
  • Co-Surgeon Indicator (Modifier 62 and 66)
  • Endoscopic Base Codes
  • Team Surgeons Indicator (Modifier 66)
  • Conversion Factor
  • Physician Supervision of Diagnostic Procedures
  • Facility Practice Expense RVU Used for OPPS
  • Non-Facility Practice Expense RVU Used for OPPS
  • Malpractice RVU Used for OPPS

Pro SAF Analytics tab

The Pro SAF Analytics tab (Professional Standard Analytical File) displays statistics about the code selected in relation to its use in the professional setting. The SAF file contains detailed claims information about health care services rendered to Medicare beneficiaries.

Each file contains one year of claims information and the SAF is released bi-yearly. The data is separated into two sections:

  • Diagnosis Medicare Outpatient - Contains statistics about the ICD-10-Dx codes most frequently billed with the CPT/HCPCS code being reviewed.
  • CPT/HCPCS Medicare Professional - Contains statistics about other CPT/HCPCS codes that are most frequently billed with the CPT/HCPCS code being reviewed.

The percentage totals may not add up to 100% because code pairings of less than 2% are not displayed.

Revision History tab

The code Revision History is listed from newest to oldest in a stacked view.

Rev Codes tab

The Rev Codes tab includes two lists of revenue codes that might be appropriate for the CPT/HCPCS code being reviewed.

The Best Practices list provides a list of revenue codes that Vitalware has determined are most suitable for the selected code. In most cases, the appropriate revenue code is listed here. However, there may be instances where a facility's specific use call for a revenue code not listed.

The Rev Code Medicare Outpatient list provides:

– RevCode Billed Count represents the number of times the revenue code was billed with the CPT/HCPCScode based on the SAF data. – Total CPT/HCPCS Billed Count represents the total number of times the CPT/HCPCS code being reviewed was billed. – Percent Rev Code Billed is the percentage of times that the revenue code was billed with the CPT/HCPCS being reviewed. The percentage totals may not all add to 100%, as code pairings less than 2% are not displayed.

RS&I Relationship tab

The RS&I Relationship tab (Radiological Supervision and Interpretation Relationship) shows related RS&I codes when a procedure typically requires separately reportable radiological guidance or supervision and interpretation codes for complete reporting.

Transmittals tab

The Transmittals tab contains all transmittals that are related to the code selected.

Click the Transmittal hyperlink to open the document in a new tab. You have the option to open a PDF version of the document in a new browser tab.

Notes tab

The Notes tab allows you to add notes.