CODING MANUAL

For Hospitals and Other Healthcare Institutions

Effective: 2020 Draft Submitted for 2018 Code Sets

 Table of Contents
CODING GUIDELINES ........................................................................................................................................................ 5

1. CHAPTER ONE ................................................................................................................................................................... 6

STATEMENT OF CODING ETHICS...................................................................................................................................................6

2. CHAPTER TWO .................................................................................................................................................................. 8

CODING TERMS ........................................................................................................................................................................8

3. CHAPTER THREE .............................................................................................................................................................. 14

HEALTH DATA ELEMENTS FOR STANDARDIZATION .........................................................................................................................14

CODE SETS FOR REPORTING AND CLAIMING FOR ADMISSION, WITH EFFECTIVE OR SERVICE DATES: ...........................................................14

4. CHAPTER FOUR ............................................................................................................................................................... 15

CODING CONVENTIONS............................................................................................................................................................15

CODING DIAGNOSTIC GUIDELINES .................................................................................................................................. 25

1. CHAPTER ONE: OFFICIAL CODING GUIDELINES FOR FY 2018 ........................................................................................... 26

THE ICD-10-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING FOR FY 2018 ..........................................................................26
COVID-19 CODING .............................................................................................................................................................26

CODING PROCEDURAL GUIDELINES ................................................................................................................................ 29

1. CHAPTER ONE: INTRODUCTION ...................................................................................................................................... 30

CURRENT PROCEDURAL TERMINOLOGY (CPT©) 4TH EDITION 2018 ..................................................................................................30

2. CHAPTER TWO: TERMS AND GUIDELINES........................................................................................................................ 32

PROCEDURE CODING TERMS AND GUIDELINES .............................................................................................................................32

3. CHAPTER THREE: MODIFIERS .......................................................................................................................................... 40

MODIFIERS ............................................................................................................................................................................40
GUIDELINES ON CORRECT AND INCORRECT USAGE OF MODIFIERS.....................................................................................................43

4. CHAPTER FOUR: UNLISTED PROCEDURE ......................................................................................................................... 48

UNLISTED PROCEDURE OR SERVICE CODES ...................................................................................................................................48

5. CHAPTER FIVE: ADD- ON CODES ...................................................................................................................................... 49

ADD – ON CODES ...................................................................................................................................................................49

6. CHAPTER SIX: TIME ......................................................................................................................................................... 50

TIME ....................................................................................................................................................................................50

7. CHAPTER EIGHT: E/M ...................................................................................................................................................... 53

EVALUATION & MANAGEMENT .................................................................................................................................................53

INSTRUCTIONS FOR SELECTING A LEVEL OF E/M SERVICE................................................................................................................59

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8. CHAPTER EIGHT: TELEMEDICINE...................................................................................................................................... 64

TELEMEDICINE AND TELEPHONE SERVICES [NEVER TO BE CODED TOGETHER] .............................................................................64

9. CHAPTER NINE: ANESTHESIA ........................................................................................................................................... 65

ANESTHESIA ..........................................................................................................................................................................65

10. CHAPTER TEN: SURGERY ............................................................................................................................................... 66

SURGERY.............................................................................................................................................................................66

11. CHAPTER ELEVEN: RADIOLOGY ..................................................................................................................................... 75

RADIOLOGY GUIDELINES (INCLUDING NUCLEAR MEDICINE AND DIAGNOSTIC ULTRASOUND) ...............................................................75

12. CHAPTER TWELVE: PATHOLOGY & LABORATORY .......................................................................................................... 78

PATHOLOGY & LABORATORY ..................................................................................................................................................78

13. CHAPTER THIRTEEN: MEDICINE ..................................................................................................................................... 81

MEDICINE ...........................................................................................................................................................................81

14. CHAPTER FOURTEEN: CATEGORY II CODES .................................................................................................................... 83

CATEGORY II (A0021-V5364) ...............................................................................................................................................83

15. CHAPTER FIFTEEN: CATEGORY III CODES ....................................................................................................................... 84

CATEGORY III CODES (0019T-0259T).....................................................................................................................................84

16. CHAPTER SIXTEEN: COVID CPT CODES ........................................................................................................................... 85

ALL CPT CODES ARE INCLUDED IN THE DRG FOR PAYMENT. ..........................................................................................................85

17. CHAPTER SEVENTEEN: OBSERVATION CODES ................................................................................................................ 86

OBSERVATION CODES ............................................................................................................................................................86

DATA STANDARDS ........................................................................................................................................................ 89

1. CHAPTER CHAPTER 1 ....................................................................................................................................................... 90

PLACE-OF-SERVICE CODES / ENCOUNTER CODES FOR CLAIMS .........................................................................................................90

CURRENT DENTAL TERMINOLOGY ................................................................................................................................... 94

1. CHAPTER ONE ................................................................................................................................................................. 95

CANADIAN DENTAL ASSOCIATION (CDA) CURRENT DENTAL TERMINOLOGY (CDT) .............................................................................95

INTERNATIONAL REFINED DIAGNOSIS RELATED GROUPS [IRDRG] .................................................................................. 96

1. CHAPTER ONE ................................................................................................................................................................. 97

PURPOSE AND SCOPE OF IR DRG ..............................................................................................................................................97

PURPOSE ..............................................................................................................................................................................97
SCOPE ..................................................................................................................................................................................97

2. CHAPTER TWO ................................................................................................................................................................ 98

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 IR-DRG STANDARD DEFINITIONS ..............................................................................................................................................98

ENHANCED AMBULATORY PATIENT GROUPS [EAPG] .................................................................................................. 100

1. CHAPTER ONE ............................................................................................................................................................... 101

PURPOSE AND SCOPE OF EAPG ..............................................................................................................................................101

SCOPE ................................................................................................................................................................................101

2. CHAPTER TWO .............................................................................................................................................................. 102

EAPG STANDARD DEFINITIONS ...............................................................................................................................................102

CODING REFERENCES, POLICIES, PROCESSES, AUDIT & ARBITRATION .......................................................................... 104

1. CHAPTER ONE ............................................................................................................................................................... 105

CODING REFERENCES ............................................................................................................................................................105

2. CHAPTER TWO .............................................................................................................................................................. 106

CODING POLICIES .................................................................................................................................................................106

3. CHAPTER THREE ............................................................................................................................................................ 108

CODING PROCESSES ..............................................................................................................................................................108

4. CHAPTER FOUR ............................................................................................................................................................. 112

CODING AUDIT.....................................................................................................................................................................112

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Coding Guidelines

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1. Chapter One
Statement of Coding Ethics
1.1.1 Introduction

1.1.1.1 The DoH Standards of Ethical Coding are based on the American Health Information
Management Association's (AHIMA's) Code of Ethics. Both sets of Ethical principles reflect
expectations of professional conduct for coding professionals involved in diagnostic and/or
procedural coding or other health record data abstraction.
1.1.1.2 The AHIMA Code of Ethics (available on the AHIMA web site) is relevant to all AHIMA
members and credentialed HIM professionals, coding staff, coding auditors, coding
educators, clinical documentation improvement (CDI) professionals, managers responsible
for decision making processes and operation as well as HIM/, regardless of their professional
functions, the settings in which they work, or the populations they serve. Coding is one of the
cores HIM functions, and due to the complex regulatory requirements affecting the health
information coding process, coding professionals are frequently faced with ethical challenges.
The AHIMA Standards of Ethical Coding are intended to assist coding professionals and
managers in decision-making processes and actions, outline expectations for making ethical
decisions in the workplace, and demonstrate coding professionals' commitment to integrity
during the coding process, regardless of the purpose for which the codes are being reported.
They are relevant to all coding professionals and those who manage the coding function,
regardless of the healthcare setting in which they work or whether they are AHIMA members
or non-members.
1.1.1.3 These Standards of Ethical Coding have been revised in order to reflect the current
healthcare environment and modern coding practices.

1.1.2 Standards of Ethical Coding

1.1.2.1 Coding professionals should:

1.1.2.2 Apply accurate, complete, and consistent coding practices that yield quality data.
1.1.2.3 Gather and report all data elements (e.g. diagnosis and procedure codes, present on
admission indicator, discharge status) required for internal and external reporting purposes
(e.g. reimbursement and other administrative uses, population health, quality and patient
safety measurement and research) completely and accurately, in accordance with regulatory
and documentation standards and requirements and applicable data set definitions.
1.1.2.4 Assign and report, only the codes and data that are clearly and consistently supported by
health record documentation in accordance with the applicable code set and abstraction
conventions and requirements.

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 1.1.2.5 Query and/or consult as needed with the provider (physician or other qualified healthcare
practitioner) for clarification and additional documentation prior to code assignment when
there is conflicting, incomplete, or ambiguous information in the health record regarding a
significant reportable condition or procedure or other reportable data element dependent on
health record.
1.1.2.6 Refuse to participate in, support, or change reported codes or the narratives titles, billing
data, clinical documentation practices, or any coding related activities intended to
misrepresent data and their meaning that do not comply with requirements.
1.1.2.7 Refuse to participate in or support coding or documentation practices intended to
inappropriately increase payment, qualify for insurance policy coverage, or skew data by
means that does not comply with DOH regulations and official rules and guidelines.
1.1.2.8 Facilitate and advocate interdisciplinary collaboration with healthcare professionals in the
pursuit of accurate, complete and reliable coded data and in situations that support ethical
coding practices.
1.1.2.9 Advance coding knowledge and practice through continuing education.
1.1.2.10 Refuse to participate in and/or conceal unethical coding, abstraction practices, query
practices or any inappropriate activities related to coding.
1.1.2.11 Always maintain and protect the confidentiality of the health record information and refuse
to access protected health information not required for coding-related activities (examples of
coding-related activities include completion of code assignment, other health record data
abstraction, coding audits and educational purposes).
1.1.2.12 Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding
practices, and fosters trust in professional activities.

1.1.3 Resources

1.1.3.1 AHIMA Code of Ethics (2019)available at:

http://www.ahima.org/downloads/AHIMACodeofEthicsPrinciplesFINALApprovedApril292019.pd f

1.1.3.2 Standards of Ethical Coding (2016) available at:

http://bok.ahima.org/CodingStandards#.XlZkWmgzZPY
1.1.3.3 ICD-10-CM Official Guidelines for Coding and Reporting:
https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf

https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

1.1.3.4 AHIMA’s Practice Brief - Data Quality Management Module (2015): Available at -
https://library.ahima.org/PB/DataQualityModel#.XlZkDGgzZPY

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2. Chapter Two
Coding Terms
2.1.1 Definitions

2.1.1.1 Acute Condition – An acute condition is a type of illness or injury that ordinarily lasts less than
three months, was first noticed less than 3 months before the reference data of the interview
and was serious enough to have had an impact on behavior or having a short and relatively
severe course. (Pregnancy is also considered to be an acute condition despite lasting longer
than three months.)
2.1.1.2 Autopsy – The post-mortem examination of a body, including the internal organs and
structures after dissection, to determine the cause of death or the nature of pathological
changes.
2.1.1.3 Chronic Condition – Condition/s that are not cured once acquired (such as heart disease,
diabetes, and hypertension) and are considered chronic.
2.1.1.4 Coding Books, Alphabetical – An alphabetical index to diseases with corresponding ICD codes.
2.1.1.5 Coding Books, Tabular – A numerical list of the ICD disease code numbers.
2.1.1.6 Complication (diagnosis) – In coding, a complication generally refers to a misadventure of a
medical or surgical procedure, an adverse outcome from therapy. In medicine, an additional
problem that arises following a procedure, treatment or illness and is secondary to it. A
complication complicates the situation.
2.1.1.7 Co-morbidity (diagnosis) – Co-morbidities are conditions that exist at the same time as the
principal condition in the same patient (for example hypertension is a co-morbidity of
ischemic heart disease or diabetes), e.g. two or more co-existing medical conditions or
disease processes that are additional to an initial diagnosis.
2.1.1.8 Diagnosis – See sub section below
2.1.1.9 Discharge Summary – Generally a transcribed document that is a concise summary of the
patient’s course in the hospital to include: reason for admission, principal diagnoses,
additional diagnoses, significant findings, operations and procedures performed,
consultations, medications and other treatments, condition at discharge, discharge
instructions and medications with follow up required.
2.1.1.10 DRG – refers to the International Refined Diagnosis Related Groups (IR-DRG), as developed by
3M. The Definitions Manual may be obtained directly from 3M.
2.1.1.11 EAPG- Enhanced Ambulatory Patient Grouping, as developed by 3M. The Definitions Manual
may be obtained directly from 3M.

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 2.1.1.12 Etiology (diagnosis) – The cause or origin of a disease.
2.1.1.13 Face Sheet – Generally a form that is placed at the front of the inpatient admission that
documents the demographic information for the patient at the time of the admission, the
admission and discharge dates as well as a list of diagnoses and procedures that are relevant
to that admission.
2.1.1.14 Guidelines - Set of rules that have been developed to accompany and complement the
official conventions and instructions provided within the ICD-10-CM and Current Procedural
Terminology. The instructions and conventions of the classification take precedence over
guidelines. These include the coding and sequencing instructions. Adherence to these
guidelines when assigning diagnosis and procedure codes is required.
2.1.1.15 History Of (diagnosis) – A diagnosis of a condition that is no longer active, however does
impact the current visit of the patient in terms of length of stay, follow-up considerations
and/or residual effects. Examples of important history conditions for coding are cancers,
organ replacements, traumas with residual effects such as amputations.
2.1.1.16 ICD-10-CM – International Classification of Diseases, 10th Revision, Clinical Modification. This
is a clinical modification of the World Health Organization’s ICD 10 coding system. The term
“clinical” is used to emphasize the modification intent; namely to serve as a useful tool in the
area of classification of morbidity data for indexing medical records.
2.1.1.17 Manifestation (diagnosis) – The visible expression of a disease, for example shortness of
breath for a patient with congestive heart failure.
2.1.1.18 Maternal Death – Is defined by the WHO as the death of a woman while pregnant or within
42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy,
from any cause related to or aggravated by the pregnancy or its management.
2.1.1.19 Miscarriage – Loss of the products of conception from the uterus before the fetus is viable,
before 22 weeks gestation; spontaneous abortion. (After 22 weeks this is a stillborn.) 1
2.1.1.20 Morbidity – A diseased condition or state; the incidence or prevalence of a disease or of all
diseases in a population.
2.1.1.21 Mortality – In coding this means “death” as in the mortality rate or death rate.
2.1.1.22 Neonate –For coding purposes this refers to the time period from birth through to the 28th
day.

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2.1.1.23 Neoplasm – any new and abnormal growth; specifically, a new growth of tissue in which the
growth is uncontrolled and progressive. An abnormal growth of tissue. The word neoplasm is
not synonymous with cancer. A neoplasm may be benign or malignant or of uncertain
behavior. The word neoplasm literally means a new growth, from the Greek neo-, new +
plasma, that which is formed, or a growth = a new growth.
2.1.1.24 Newborn – for coding purposes a newborn is only coded with the live born infant codes (Z38)
with 4th digit to signify whether born in or outside of the hospital. Generally, codes from
Chapter 16 should be sequenced as the principal/first-listed diagnosis on the newborn
record, with the exception of the appropriate Z38 code for the birth episode, followed by
codes from any other chapter that provide additional detail.
2.1.1.25 Operative Report – is a summary report, generally typed, that describes the events occurring
during the operation of the patient.
2.1.1.26 Ambulatory – a patient who receives medical services in a clinic, ambulatory care or
emergency department without occupying an inpatient bed overnight.
2.1.1.27 Pediatric – Infants, children, and adolescents. The age limit of such patients ranges from 12 to
21 with the average age limit being 17 or 18 years of age. A medical practitioner who
specializes in this area is known as a pediatrician.
2.1.1.28 Perinatal - For coding and reporting purposes the perinatal period is defined as before birth
through to the 28th day following birth.
2.1.1.29 Post-mortem Examination – an examination of a body of a patient after death; not an
autopsy.
2.1.1.30 Procedure, Principal –Is defined as the procedure performed for definitive treatment, rather
than one performed for diagnostic or exploratory purposes or was necessary to take care of a
complication. If there are two or more therapeutic procedures, then it is the one most
related to the principal diagnosis. If all procedures are diagnostic, then it is the one most
related to the principal diagnosis. If there is more than one, then it is the most resource
intensive. The hierarchy is as follows:
I. Therapeutic
II. Related to Principal Diagnosis
III. Most resource intensive
IV. If there is more than one procedure to be reported in a hospital or ambulatory visit, then the
procedures need to be sequenced as principal or secondary for reporting purposes.
2.1.1.31 Procedure, Secondary – All other significant procedures are to be reported as secondary
procedures. A significant procedure is one that is surgical in nature or carries a procedural
risk or carries an anesthetic risk or requires specialized training.

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 2.1.1.32 Provider - the term provider is used throughout the guidelines to mean physician or any
qualified health care practitioner who is legally accountable for establishing the patient’s
diagnosis.
2.1.1.33 Residual Condition – In coding this refers to the on-going effect of a previous illness or injury.
For example, a patient who had a CVA (cerebrovascular accident) in the past and has a
residual condition of aphasia.
2.1.1.34 Rule-Out Diagnosis – When a physician is performing tests on a patient to determine the final
diagnosis, he may be working on a suspected diagnosis that he is attempting to “rule-out” or
prove right or wrong. Sometimes the “rule-out” diagnosis is still the final diagnosis because
the tests aren’t yet conclusive, and the true diagnosis hasn’t been determined.
2.1.1.35 Sequela (late effect code)– A sequela is defined as residual effects (results produced) after
termination of the acute phase of the illness or injury. Late effects are classified by the
residues (nature of late affect) and by the cause of the late effect.
2.1.1.36 Stillbirth – The delivery of a dead infant, at least 22 weeks gestation. 2
2.1.1.37 Symptom (diagnosis) – Any subjective evidence of a patient’s disease or condition, such as a
fever is a symptom of a urinary tract infection.
2.1.1.38 Unspecified (diagnosis) – In coding, this occurs when a physician fails to be as specific in his
diagnosis as the coding system is, for example listing hypertension as a diagnosis and not
specifying whether it is benign or malignant.
2.1.1.39 Underlying Cause of Death – When the immediate cause of death is a symptom or a
manifestation of a diagnosis, the underlying cause of death is the diagnosis responsible for
the symptom or manifestation that lead to the death. For example, cardiopulmonary arrest
due to myocardial infarction or respiratory failure due to acute pneumonia. The World
Health Organization (WHO) defines the underlying cause of death as the disease or injury
that initiated the train of events (circumstances) leading directly to the death.
2.1.1.40 Versus Diagnosis – In coding this refers to a situation where the physician has not yet
determined which diagnosis is responsible for the condition of the patient and has two or
more choices that are equally valid.
2.1.1.41 Visit Reason (diagnosis) – Generally visit reasons are used for ambulatory visits. They can be
symptoms or diagnoses or other reasons for contact with healthcare professionals, for
example a follow up for healed fracture of the foot.

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 2.1.1.42 X, W or Y-Code – Specific ICD-10-CM codes used to identify the external cause of injury,
poisoning and other adverse effects, never coded as a principal or stand-alone.
2.1.1.43 Z-Code – In ICD-10-CM, are used in classifying supplementary factors that are influencing the
patient’s health status and/or contact with health services. An example is the outcome of
delivery codes in the Z38 category or personal history of cancer in the Z85 category. (See Z
Code Tables in Chapter 21)

2.1.2 Diagnosis

2.1.2.1 Principal Diagnosis Inpatients:

Condition established, after study, to be chiefly responsible for occasioning the admission of the
patient to the healthcare facility including a suspected diagnosis or a rule-out diagnosis and is
based on the patient’s presenting history and physical and the physician’s review of symptoms.
2.1.2.2 Principal Diagnosis Outpatients:
▪ The condition or problem that is the reason the patient presented to healthcare and the clinician’s
assessment of these presenting symptoms/problems and corresponds to the tests or services
provided.
▪ Or a symptom where the underlying causes has yet to be determined.
▪ Or the reasons why the patient presented to healthcare
2.1.2.3 Secondary Diagnosis Inpatients:
▪ All conditions that co-exist at the time of admission, including chronic conditions, or develop
subsequently, which affect the treatment received and/or the length of stay, that affect patient care
in terms of requiring: Clinical evaluation, therapeutic treatment, diagnostic procedures, extended
length of hospital stay, increased nursing care and/or monitoring; excluding diagnoses that refer to
an earlier episode that have no bearing on the current hospital stay.
▪ External causes of injury, poisoning or adverse effect are coded as supplementary codes to the
diagnosis codes of the actual condition.
2.1.2.4 Secondary Diagnosis Outpatients:
▪ All co-existing conditions, including chronic conditions that exist at the time of the Encounter or visit
and require or affect patient management; excluding diagnoses that have no bearing on the current
encounter.
▪ External causes of injury, poisoning or adverse effect are coded as supplementary codes to the
diagnosis codes of the actual condition.
2.1.2.5 Admitting Diagnosis:
▪ The diagnosis that the physician identifies at time of Inpatient admission or Emergency Department
visit. This diagnosis may differ from the Principal diagnosis.

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2.1.3 References

▪ National Center for Health Statistics, USA

▪ National Health Interview Survey, USA
▪ European Observatory on Health Care Systems
▪ ICD-10-CM Official Guidelines for Coding and Reporting
▪ Encoding Software - 3M™ Codefinder
▪ American Hospital Association (AHA) Coding Clinic®
▪ American Hospital Association (AHA) Coding Clinic® for HCPCS,
▪ Health Information Management: Concepts, Principles, and Practice, 5th Ed., AHIMA
▪ Elsevier’s Anatomy Plates
▪ Anatomy and Physiology, publisher of choice
▪ Dorland’s Medical Dictionary
▪ The Merck Manual of Diagnosis and Therapy, edited by M. H. Beers, MD and R. Berkow, MD, Merck
Research Laboratories
▪ Current Procedural Terminology, 4th Edition, 2018 Code set American Medical Association
▪ Canadian Dental Codes (USCLS)

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 3. Chapter Three
Health Data Elements for Standardization
Refer to the DOH Data Elements Common Type Schema as well as the validation rules on the DOH website at
https://doh.gov.ae/en/Shafafiya

Code Sets for reporting and claiming for admission, with effective or service dates:
3.2.1 Diagnostic Coding:

▪ ICD-9-CM 2008 effective 01 January 2008

▪ ICD -9-CM 2011 effective 15 October 2012
▪ ICD-10-CM 2015 (2016) effective 01 January 2017
▪ ICD-10-CM 2018 effective XX XXX 2020

3.2.2 Procedure Coding:

▪ CPT 4th Edition 2008 effective 01 January 2008

▪ CPT 4th Edition 2011 effective 15 October 2012
▪ CPT 4th Edition 2018 effective XX XXX 2020

3.2.3 Consumable Coding:

▪ HCPCS 2008 effective 01 January 2008

▪ HCPCS 2011 effective 15 October 2012
▪ HCPCS 2018 effective XX XXX 2020

3.2.4 Dental Coding:

▪ Canadian Dental Codes (CDA) 2008 effective 01 January 2008

▪ Canadian Dental Codes (CDA 2011 effective 15 October 2012
▪ Canadian Dental Codes (CDA XXXX) effective XX XXX 2020

3.2.5 IRDRG Version:

▪ IR-DRG v2.2 – effective 01 January 2018

▪ IR-DRG v.2.3 - effective 15 October 2012
▪ IR-DRG v. 3.01- effective 01 January 2017
▪ IR-DRG v 3.3- effective XX XXX 2020

3.2.6 EAPG Version:

▪ EAPG v3.14 – effective XX XXX 2020

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4. Chapter Four
Coding Conventions
4.1.1 Section One: General

4.1.1.1 Includes: An includes note appears immediately under a three-digit code title to further
define, or give examples of, the content of the category.
4.1.1.2 Excludes: An exclude note under a code indicates that the terms excluded from the code are
to be coded elsewhere. In some cases, the codes for the excluded terms should not be used
in conjunction with the code from which it is excluded. An example of this is a congenital
condition excluded from an acquired form of the same condition. The congenital and
acquired codes should not be used together. In other cases, the excluded terms may be used
together with an excluded code. An example of this is when fractures of different bones are
coded to different codes. Both codes may be used together if both types of fractures are
present.
4.1.1.3 Inclusion terms: List of terms is included under certain four- and five-digit codes. These terms
are the conditions for which that code number is to be used. The terms may be synonyms of
the code title, or, in the case of “other specified” codes, the terms are a list of the various
conditions assigned to that code. The inclusion terms are not necessarily exhaustive.
Additional terms found only in the index may also be assigned to a code.
4.1.1.4 “Other” Codes: Codes titled “other” or “other specified” (usually a code with a fourth digit or
fifth digit for diagnosis codes) are for use when the information in the medical record
provides detail for which a specific code does not exist. Index entries with NEC in the line
designate “other” codes in the tabular. These index entries represent specific disease entities
for which no specific code exists, so the term is included within an “other” code
4.1.1.5 “Unspecified” Codes: Codes titled “unspecified” are for use when the information in the
medical record is insufficient to assign a more specific code.
4.1.1.6 Etiology/Manifestation Convention: Appears as “code first”, “use additional code” and “in
diseases classified elsewhere” notes.
▪ Certain conditions have both an underlying etiology and multiple body system manifestations due
to the underlying etiology. For such conditions, the coding convention requires that the
underlying condition be sequenced first, followed by the manifestation. Wherever such a
combination exists, there is a “use additional code” note at the etiology code and a “code first”
note at the manifestation code.
▪ In most cases the manifestation codes will have in the code title “in diseases classified
elsewhere”. Codes with this title are a component of the etiology/manifestation convention. The
code title indicates that it is a manifestation code. “In diseases classified elsewhere” codes are

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 never permitted to be used as first listed or principal diagnosis codes. They must be used in
conjunction with an underlying condition code and they must be listed following the underlying
condition.
▪ There are manifestation codes that do not have “in diseases classified elsewhere” in the title. For
such codes a “use additional code” note will still be present and the rules for sequencing apply.
▪ In addition to the notes in the tabular, these conditions also have a specific alphabetical index
entry structure. In the index both conditions are listed together with the etiology code first
followed by the manifestation codes in brackets. The code in brackets is always to be sequenced
second.
▪ The most commonly used etiology/manifestation combinations are the codes for diabetes
mellitus, category E10-E13. For each code under category E10-E13. There are additional codes
with the note for the manifestation that are specific for that particular diabetic manifestation, the
specific 4th-6th digits should be specified. Should a patient have more than one manifestation of
diabetes, more than one code from category E10-E13 may be used with as many manifestation
codes as are needed to fully describe the patient’s complete diabetic condition. The category
E10-E13 diabetes codes should be sequenced first, followed by the manifestation codes.
▪ “Code first” and “Use additional code” notes are also used as sequencing rules in the
classification for certain codes that are not part of an etiology/manifestation combination.
4.1.1.7 Level of Detail in Diagnostic Coding:
▪ Diagnosis codes must be used at the highest number of digits available, at the greatest specificity
available.
▪ A three-digit code is to be used only if it is not further subdivisions. If fourth- and fifth-digit
subcategories are provided, they must be assigned.
4.1.1.8 Signs and Symptoms: Codes that describe symptoms and signs, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive diagnosis has not been
established by the care provider.
4.1.1.9 Conditions that are an integral part of the disease process: Signs and symptoms that are
integral to the disease process should not be assigned as additional codes unless otherwise
instructed by the coding books.
4.1.1.10 Conditions that are not an integral part of a disease process: Additional signs and symptoms
that may not be associated routinely with a disease process should be coded when present.
4.1.1.11 Multiple coding for a single condition: In addition to the etiology/manifestation convention
that requires two codes to fully describe a single condition that affects multiple body
systems, there are other single conditions that also require more than one code. “Use
additional code” notes are found in the tabular at codes that are not part of an
etiology/manifestation pair where a secondary code is useful to fully describe a condition.

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 ▪ The sequencing rule is the same as the etiology/manifestation pair - “use additional code”
indicates that a secondary code should be added.
▪ Multiple codes may be needed for sequelae (late effects), complication codes and obstetric codes
to more fully describe a condition.
4.1.1.12 Acute and Chronic Conditions: If the same condition is described as both acute (subacute)
and chronic and separate subentries exist in the Alphabetic Index at the same indentation
level, code both and sequence the acute (subacute) code first.
4.1.1.13 Combination Codes:
▪ A combination code is a single code used to classify two diagnoses or a diagnosis with an associated
secondary process (manifestation) or a diagnosis with an associated complication.
▪ Combination codes are identified by referring to sub term entries in the Alphabetic Index of the ICD-
10-CM and by reading the inclusion and exclusion notes in the Tabular List of the ICD 10 CM.
▪ Assign only the combination code when that code fully identifies the diagnostic conditions involved
or when the Alphabetic Index in the ICD-10-CM so directs.
▪ NOTE: Multiple coding must not be used when the classification provides a combination code that
clearly identifies all of the elements documented in the diagnosis. However, if the combination
code lacks the necessary specificity in describing the manifestation or complication, then an
additional code should be used as a secondary code.
4.1.1.14 Sequelae (Late Effects):
▪ A late effect is the residual effect (condition produced) after the acute phase of an illness or injury
has terminated. There is no time limit on when a late effect code can be used. The residual
condition may appear early, such as in cerebrovascular accident cases, or it may occur months or
years later, such as that due to a previous injury.
▪ Coding of late effects generally requires two codes sequenced with the condition or nature of the
late effect first and the late effect code second.
▪ An exception to the above is in those instances where the code for the late effect is followed by a
manifestation code identified in the Tabular List in the ICD-10-CM or where the late effect code has
been expanded (at the 4th and 5th digit levels) to include the manifestation(s).
▪ The code for the acute phase of an illness or injury that led to the late effect is never used with a
code for the late effect.
4.1.1.15 Impending or Threatening Condition: Code any condition described at the time of discharge
as “impending” or “threatened” as follows:
▪ If it did occur, code as confirmed diagnosis.
▪ If it did not occur, reference the Alphabetic Index in the ICD-10-CM to determine if the condition
has a subentry term for “impending” or “threatened” and also reference main term entries for
“impending” or “threatened”.
▪ If the sub terms are listed, assign the given code.

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 ▪ If the sub terms are not listed, code the existing underlying condition(s) and not the condition
described as impending or threatened.
4.1.1.16 Documentation for BMI and Pressure Ulcer Stages:
▪ For the Body Mass Index (BMI) and pressure ulcer stage codes, code assignment may be based on
medical record documentation from clinicians who are not the patient’s provider (i.e., physician
or other qualified healthcare practitioner legally accountable for establishing the patient’s
diagnosis), since this information is typically documented by other clinicians involved in the care
of the patient (e.g., a dietitian often documents the BMI and nurses often documents the
pressure ulcer stages). However, the associated diagnosis (such as overweight, obesity, or
pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical
record documentation, either from the same clinician or different clinicians, the patient’s
attending provider should be queried for clarification.
▪ The BMI and pressure ulcer stage codes should only be reported as secondary diagnoses. As with
all other secondary diagnosis codes, the BMI and pressure ulcer stage codes should only be
assigned when they meet the definition of a reportable additional diagnosis (2018 ICD 10 Coding
Guidelines Section III. Reporting Additional Diagnoses).
4.1.1.17 Medical and Surgical Complications: If the physician has documented that the patient’s
diagnosis/condition is a complication of previous medical or surgical treatment, then it is to
be coded as a “complication” code.
▪ First search in the ICD-10-CM Tabular for the condition under the main term of “complication”
and follow any instructions as indicated. If the condition is not specified, then use a code from
the section “Complications of Surgical and Medical Care, Not Otherwise Specified”.
▪ Code also the specific complication documented.
▪ For quality purposes, it is important to be able to track Hospital-acquired infections by coding Y95
as a supplemental code as well as the relevant ICD-10-CM Complications of Surgical and Medical
Care NOS (T88.9) codes.
4.1.1.18 Newborns: When coding the birth of an infant, assign a code from category Z38, according to
the type of birth. A code from this series is assigned as a principal diagnosis and assigned only
once to a newborn at the time of birth. If the newborn is transferred to another institution,
the Z38 series is not used at the receiving hospital.
4.1.1.19 Signs and Symptoms: Codes that describe symptoms and signs, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive diagnosis has not been
established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Ill-
defined conditions (codes R00-R99) contain many, but not all codes for symptoms. Additional
signs and symptoms that may not be associated routinely with a disease process should be
coded when present.

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 4.1.2 Section Two: Admitting Diagnosis

▪ The admitting diagnosis that the physician identifies at the time of admission into an inpatient facility.
▪ This diagnosis may differ from the Principal diagnosis.
▪ The admitting diagnosis will generally be documented by the physician in the history and physical exam,
either on the form or in the progress notes or the orders. It may also be listed as an impression in the
patient assessment.
▪ If there are multiple admitting diagnoses, then pick the most resource intensive diagnosis for reporting
purposes.
▪ If the patient is admitted through the Emergency Room, then use the diagnosis that brought the patient to
the ER as the admitting diagnosis.

4.1.3 Section Three: Principal Diagnosis

4.1.3.1 Principal Diagnosis Inpatients:

Condition established, after study, to be chiefly responsible for occasioning the admission of the
patient to the healthcare facility including a suspected diagnosis or a rule-out diagnosis and is based
on the patient’s presenting history and physical and the physician’s review of symptoms.
4.1.3.2 Principal Diagnosis Ambulatory:
▪ The condition or problem that is the reason the patient presented to healthcare and the clinician’s
assessment of these presenting symptoms/problems and corresponds to the tests or services
provided.3 1 See Note
▪ Or a symptom where the underlying causes has yet to be determined.
▪ Or The reason why the patient presented to healthcare
▪ Note: For quality purposes, it is important to be able to track Hospital-acquired infections by coding
Y95 as a supplemental code as well as the relevant ICD-10-CM Complications of Surgical and Medical
Care NOS (T88.9) codes.
▪ The circumstances of the inpatient admission always govern the selection of the principal diagnosis.
The principal diagnosis is defined earlier as the “condition established after study to be chiefly
responsible for occasioning the admission of the patient to the hospital for care.”
4.1.3.3 Principal Diagnosis in Long Term Care
Condition established, after study, to be chiefly responsible for occasioning the admission to
and/or continuation of the long-term care encounter.

3
Under DOH review and consideration due to CCSC reference material

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4.1.3.4 A symptom(s) followed by contrasting/comparative diagnoses: When a symptom(s) is
followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the
contrasting/comparative diagnoses should be coded as additional diagnoses.
4.1.3.5 Two or more interrelated Conditions: When there are two or more interrelated conditions
(such as diseases in the same ICD-10-CM chapter or manifestations characteristically
associated with a certain disease) potentially meeting the definition of principal diagnosis,
either condition may be sequenced first, unless circumstances of the admission, the therapy
provided, the Tabular List or the Alphabetic Index indicate otherwise.
4.1.3.6 Multiple Principal Diagnoses: In the unusual instance when two or more diagnoses equally
meet the criteria for principal diagnosis as determined by the circumstances of admission,
diagnostic work up and/or therapy provided, and the Alphabetic Index, Tabular List or
another coding guideline does not provide sequencing direction, any one of the diagnoses
may be sequenced first.
4.1.3.7 Contrasting/Comparative Diagnoses: In those rare instances when two or more contrasting
or comparative diagnoses are documented as “either/or” (or similar terminology), they are
coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the
circumstances of the admission. If no further determination can be made as to which
diagnosis should be principal, then either diagnosis may be sequenced first.
4.1.3.8 Symptom with Contrasting/Comparative Diagnoses: When a symptom is followed by
contrasting/comparative diagnoses, the symptom code is sequenced first. All the
contrasting/comparative diagnoses should be coded as additional diagnoses.
4.1.3.9 Original Treatment Cancelled: If the original treatment plan is not carried out, continue to
use the definition of principal diagnosis as above, when coding the visit, regardless of the
cancelled or delayed treatment. Use an additional code Z-code from the classifying
supplementary factors chapter to address the factors that influenced the treatment being
cancelled.
4.1.3.10 Complication as Principal Diagnosis: When the admission is for treatment of a complication
resulting from surgery or other medical care, the complication code is sequenced as the
principal diagnosis. An additional code for the specific complication should also be signed as
well as relevant T code.
4.1.3.11 “Possible” Diagnoses as Principal: If the diagnosis documented at the time of discharge is
qualified as “probable”, “suspected”, “likely”, “questionable”, “possible” or “still to be ruled
out”, or other similar terms indicating uncertainty, code the condition as if it existed or was
established. (This rule does not apply to a diagnosis of HIV. In order to add a code for HIV
there must be a definitive diagnosis or positive blood test for HIV also (see Official 2018
ICD10-CM Coding and Reporting Guidelines Section 8 D) (Code only confirmed cases of avian

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 influenza (codes J11.1) Influenza due to identified avian influenza virus) or novel H1N1
influenza virus (H1N1 J10 or swine flu, code J09.X2)
▪ This rule also does not apply to outpatient or ambulatory visits; see ambulatory visit section for more
details.)
4.1.3.12 Admission from Day Care/Surgery: When a patient is admitted directly from a day care or
day surgery visit:
▪ If the inpatient admission is for a complication of the day care or day surgery, assign the
complication as the principal diagnosis.
▪ If there is no complication or any other reason for the inpatient admission, assign the reason for the
day care or day surgery visit as the principal diagnosis.
▪ If the reason for the inpatient admission is another condition unrelated to the surgery, assign the
unrelated condition as the principal diagnosis.

4.1.4 Section Four: Secondary Diagnoses

4.1.4.1 Secondary Diagnosis Inpatients:

▪ All conditions that co-exist at the time of admission, including chronic conditions, or develop
subsequently, which affect the treatment received and/or the length of stay - that affect patient
care in terms of requiring: Clinical evaluation, therapeutic treatment, diagnostic procedures,
extended length of hospital stay, increased nursing care and/or monitoring; excluding diagnoses
that refer to an earlier episode that have no bearing on the current hospital stay.
▪ External causes of injury, poisoning or adverse effect are coded as supplementary codes to the
diagnosis codes of the actual condition.
4.1.4.2 Secondary Diagnosis Ambulatory/Outpatients:
▪ All co-existing conditions, including chronic conditions that exist at the time of the Encounter or
visit and require or affect patient management; excluding diagnoses that have no bearing on the
current encounter.
▪ External causes of injury, poisoning or adverse effect are coded as supplementary codes to the
diagnosis codes of the actual condition.
4.1.4.3 Secondary Diagnosis Long Term Care:
▪ For reporting purposes, the definition for secondary diagnosis is interpreted as additional
conditions that affect patient care in terms of requiring:
- clinical evaluation; or
- therapeutic treatment; or
- diagnostic procedures; or

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 - extended length of hospital stays; or increased nursing care and/or monitoring
4.1.4.4 For reporting purposes, the definition for secondary or other diagnoses is interpreted as
additional conditions that affect patient care in terms of requiring clinical evaluation; or
therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or
increased nursing care and /or monitoring.
4.1.4.5 The secondary diagnoses were defined earlier in this document as “all conditions that co-
exist at the time of admission, that develop subsequently, or that affect the treatment
received and/or the length of stay. Diagnoses that relate to an earlier episode, which have no
bearing on the current hospital stay are to be excluded.”
4.1.4.6 Previous Conditions - If the doctor includes a diagnosis on the face sheet, discharge summary
or discharge note it should normally be coded. Sometimes however, doctors list resolved
conditions or diagnoses and status-post procedures from previous admissions that have no
bearing on the current stay. Such conditions are not to be coded or reported for that visit.
However, history codes (Z80- Z87) should be used as secondary diagnoses if the historical
condition or family history has an impact on the current care or influences treatment. Z85
history of cancer codes should always be used if the patient has had a personal history of
cancer that is resolved.
4.1.4.7 Abnormal Findings – Abnormal findings such as laboratory, radiology, pathologic and others
are not coded and reported unless the doctor indicates their clinical significance. If the
findings are outside the normal range and the doctor has ordered other tests to evaluate the
condition or prescribed treatment, it is appropriate to code them if the doctor lists them as a
discharge diagnosis.
4.1.4.8 Uncertain Diagnosis – If the diagnosis documented at the time of discharge is qualified as
“probable”, “suspected”, “likely”, “questionable”, “possible” or “still to be ruled out”, or
other uncertain qualifier, code the condition as if it existed, as above in Principal Diagnosis
(Inpatient only).

4.1.5 Section Five: Outpatient and Ambulatory Patient Coding

4.1.5.1 The terms encounter and visit are often used interchangeably in describing outpatient or
ambulatory patient service contacts. These can range from Emergency Room visits to
Specialty Clinic visits to Ancillary Services encounters.
4.1.5.2 Diagnoses are not often established at the time of the initial encounter/visit. It might take
two or more visits before the diagnosis is confirmed.
4.1.5.3 Outpatient Surgery: When a patient presents for outpatient surgery, code the reason for the
surgery as the principal diagnosis (reason for encounter) even if the procedure is not
performed for any reason. You can use an additional code to describe why the procedure
was not performed, if appropriate.

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4.1.5.4 Observation: When a patient is admitted for observation for a medical condition, assign a
code for the medical condition as the principal diagnosis.
4.1.5.5 Complication: When a patient presents for outpatient surgery and develops a complication
requiring admission for observation, code the reason for the surgery as the principal
diagnosis, followed by codes for the complication as secondary diagnoses.
4.1.5.6 Symptoms and Signs: Codes that describe symptoms and signs, as opposed to diagnoses, are
acceptable for reporting purposes when a diagnosis has not been established or confirmed
by the care giver.
4.1.5.7 Other Encounter: There are also codes to deal with encounters for circumstances other than
injury or illness. These can be found in the Z-code section and are explained further in
section B, Chapter 21 below. (Z Codes).
4.1.5.8 Sequencing: A definition similar to principal diagnosis is used for ambulatory visits; that is the
condition, problem or other reason for the encounter/visit shown in the medical record
documentation to be chiefly responsible for the services provided. List additional codes that
describe any co-existing conditions.
4.1.5.9 Uncertain Diagnoses: Do not code diagnoses documented as “probable”, “suspected”,
“questionable”, “rule out”, or “working diagnosis” or other similar terms indicating
uncertainty in Outpatient Setting. Rather, code the condition(s) to the highest degree of
certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other
reason for the visit. NOTE: This differs from the coding rule for inpatient admissions.
4.1.5.10 Chronic Diseases: Chronic diseases treated on an ongoing basis may be coded and reported
as many times as the patient receives treatment and care for the condition(s).
4.1.5.11 Coexisting Conditions: Code all documented conditions that coexist at the time of the
encounter/visit and require or affect patient care treatment or management. Do not code
conditions that were previously treated and no longer exist. However, history codes (Z80-
Z87) may be used as secondary codes if the historical condition or family history has an
impact on current care or influences treatment.
4.1.5.12 Diagnostic Services Only: For patients receiving diagnostic services only during an
encounter/visit, sequence first the diagnosis, condition, problem or other reason for the
encounter/visit, as shown in the medical record to be chiefly responsible for the outpatient
diagnostic services provided during the encounter/visit. Codes for other diagnoses (e.g.
chronic conditions) may be sequenced as additional diagnoses.
▪ For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms or
associated diagnoses, assign Z01.89 and/or a code from subcategory. If routine testing is performed
during the same encounter as a test to evaluate a sign, symptom or diagnosis, it is appropriate to
assign both the Z code and the code describing the reason for the non-routine test.

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 ▪ For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the
final report is available at the time of coding, code any confirmed or definitive diagnosis(es)
documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.
▪ Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal
findings on test results
4.1.5.13 Therapeutic Services Only: For patients receiving therapeutic services only during an
encounter/visit, sequence first the diagnosis, condition, problem or other reason for the
encounter/visit, as shown in the medical record to be chiefly responsible for the outpatient
therapeutic services provided during the encounter/visit. Codes for other diagnoses (e.g.
chronic conditions) may be sequenced as additional diagnoses. The only exception to this
rule is that when the primary reason for the admission/encounter is chemotherapy, radiation
therapy or rehabilitation, then the appropriate V-code for the service is listed first and the
diagnosis or problem for which the service is being performed is listed second.
4.1.5.14 Preoperative Evaluations Only: For patients receiving preoperative evaluations only,
sequence first a code from category Z01.81, Other Specified Examinations, to describe the
pre-op consultations. Assign a code for the condition to describe the reason for the surgery
as an additional diagnosis. Code also any findings related to the pre-op evaluation.
4.1.5.15 Ambulatory Surgery: Code the diagnosis for which the surgery was performed as the
principal diagnosis. If the postoperative diagnosis is known to be different from the
preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative
diagnosis for coding, since it is the most definitive.
4.1.5.16 Routine Prenatal Visits: For routine outpatient prenatal visits when no complications are
present, codes Z34, Encounter for supervision of normal pregnancy, should be used as the
principal diagnosis. These codes should not be used in conjunction with Chapter 15 codes.
4.1.5.17 Encounters for general Medical examinations with abnormal findings
▪ The subcategories for encounters for general medical examinations, Z00.0- and encounter for
routine child health examination, Z00.12-, provide codes for with and without abnormal findings.
Should a general medical examination result in an abnormal finding, the code for general medical
examination with abnormal finding should be assigned as the first-listed diagnosis.
▪ An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a
change in severity of a chronic condition (such as uncontrolled hypertension, or an acute
exacerbation of chronic obstructive pulmonary disease) during a routine physical examination. A
secondary code for the abnormal finding should also be coded.

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 Coding Diagnostic
Guidelines

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 1. Chapter One: Official Coding Guidelines for FY 2018
The ICD-10-CM Official Guidelines for Coding and Reporting for FY 2018
The guidelines may be downloaded from the following site:
▪ https://www.cdc.gov/nchs/icd/icd10cm.htm
The direct links to the guideline files may be found as follows:
▪ https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf (posted 10th August 2017)
▪ https://www.cdc.gov/nchs/data/icd/Errata_fy18_ICD-10-CM_guidelines.pdf (posted 17th August
2017)
▪ https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

COVID-19 CODING
Due to the pandemic nature of the Coronavirus Disease (COVID-19) the current coding guidelines are listed below
to assist healthcare providers with the understanding the newly added ICD codes which will be available in the
available for coding of these cases.45

1.2.1 ICD-CM Codes

1.2.2 Code only confirmed cases (U07.1)

1.2.2.1 Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as
documented by the provider, documentation of a positive COVID-19 test result, or a
presumptive positive COVID-19 test result. For a confirmed diagnosis, assign code U07.1,
COVID-19.

1.2.3 Sequencing of codes

1.2.3.1 When COVID-19 meets the definition of principal diagnosis, code U07.1, COVID-19, should be
sequenced first, followed by the appropriate codes for associated manifestations, except in
the case of obstetrics patients. During pregnancy, childbirth or the puerperium, a patient
admitted (or presenting for a health care encounter) because of COVID-19 should receive a
principal diagnosis code of O98.5-, Other viral diseases complicating pregnancy, childbirth
and the puerperium, followed by code U07.1, COVID-19, and the appropriate codes for
associated manifestation(s). Codes from Chapter 15 always take sequencing priority.

4
Addendum 10: To HAAD Claims and Adjudication Rules: COVID Coding guidelines
5
https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

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 1.2.3.2 For asymptomatic individuals who test positive for COVID-19
1.2.3.3 For asymptomatic individuals who test positive for COVID-19, assign code U07.1, COVID-19.
Although the individual is asymptomatic, the individual has tested positive and is considered
to have the COVID-19 infection

1.2.4 Screening for COVID-19

1.2.4.1 For asymptomatic individuals who are being screened for COVID-19 and have no known
exposure to the virus, and the test results are either unknown or negative, assign code
Z11.59, Encounter for screening for other viral diseases.
1.2.4.2 For individuals who are being screened due to a possible or actual exposure to COVID-19, but
this is ruled out after evaluation, assign code Z03.818, Encounter for observation for
suspected exposure to other biological agents ruled out. For cases where there is an actual
exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and
the exposed individual either tests negative or the test results are unknown, assign code
Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. If the
exposed individual tests positive for the COVID-19 virus, follow guiding rules for Code only
confirmed cases (above).

1.2.5 Exposure to COVID-19

1.2.5.1 For cases where there is a concern about a possible exposure to COVID-19, but is ruled out
after evaluation, assign Z03.818 (Encounter for observation for suspected exposure to other
biological agents ruled out).
1.2.5.2 For cases where there is an actual exposure to someone who is confirmed to have COVID-19,
it would be appropriate to assign the code Z20.828 (Contact with and (suspected) exposure
to other viral communicable diseases)
1.2.5.3 If confirmed and respiratory in nature, principal diagnosis of any respiratory condition to be
assigned and additional diagnosis code for B97.29 (Other coronavirus as the cause of diseases
classified elsewhere).
1.2.5.4 For patients presenting with any signs/symptoms (such as fever, etc.) and where a definitive
diagnosis has not been established, assign the appropriate code(s) for each of the presenting
s/sx such as but not limited to:
- Cough
- Shortness of breath
- Fever, unspecified
1.2.5.5 Z11.59 Encounter for screening for other viral diseases – testing for asymptomatic patients
based on the instruction received.

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1.2.5.6 If confirmed and no source cited, principal diagnosis code to assign as B34.2 (coronavirus
infection, unspecified).
1.2.5.7 If the provider documents “suspected”, “possible” or “probable” COVID-19, Assign a code(s)
explaining the reason for encounter (such as fever, or Z20.828).

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 Coding Procedural
Guidelines

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1. Chapter One: Introduction
Current Procedural Terminology (CPT©) 4th Edition 2018
1.1.1 Section One: Introduction

1.1.1.1 Current Procedural Terminology, (CPT®) Fourth Edition, is a set of codes, descriptions, and
guidelines intended to describe procedures and services performed by physicians and other
health care providers. Each procedure or service is identified with a five-digit code. This is the
code set required for all procedure coding within the Emirate of Abu Dhabi. Only CPT five-
digit or T -Codes will be used for any procedure coding and all CPT Guidelines will take
precedence over all other procedural Guidelines or Rules.
1.1.1.2 Inclusion of a descriptor and its associated five-digit code number in the CPT codebook is
based on whether the procedure is consistent with contemporary medical practice and is
performed by many practitioners in clinical practice in multiple locations. Inclusion in the CPT
code set does not represent endorsement by the American Medical Association (AMA) of any
particular diagnostic or therapeutic procedure, service. Inclusion or exclusion of a procedure
or service does not imply any health insurance coverage or reimbursement policy.
1.1.1.3 Within the Emirate of Abu Dhabi there is a notification date followed by an adjustment
interval allowing physicians and other providers, payers, and vendors to incorporate CPT
changes into their systems prior to the effective date. See Section A, Chapter 3.2 for
effective dates for code sets and grouper versions.
1.1.1.4 The main body of the Category section is listed in six sections. Each section is divided in
subsections with anatomic, procedural, condition or descriptor subheadings. The procedures
and services with identifying codes are presented in numeric order with one exception: the
entire Evaluation and Management section [99201-99499] which appears at the beginning of
the listed procedures.
1.1.1.5 It is important to recognize that the listing of a service or procedure and its code number in a
specific section of this book does not restrict its use to a specific specialty group. Any
procedure or service in any section of the 2018 CPT book may be used to designate the
services rendered by any qualified physician or other qualified health care professional as
long as it meets the following criteria:
I. The code does not specify the specialty e.g. a geneticist
II. The code is within the Scope of Work of the healthcare professional
III. The documentation fully supports the selection of the most appropriate code.
1.1.1.6 Consensus from all payers regarding reimbursement policies in the use of codes which will be
discussed as required between parties.

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1.1.1.7 Select the name of the procedure or service that accurately identifies the service performed.
Do not select a CPT code that merely approximates the service provided. If no such
procedure or service exists, then report the service using the appropriate unlisted procedure
or service code. (See Section C, Chapter Five)
1.1.1.8 When reporting codes for services provided, it is important to ensure the accuracy and
quality of coding through verification of the intent of the code by use of the related
guidelines, parenthetical instructions, and coding resources, including CPT Assistant and
other publications resulting from collaborative efforts of the American Medical Association
with the medical specialty societies (e.g., Clinical Examples in Radiology).

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2. Chapter Two: Terms and Guidelines
Procedure Coding Terms and Guidelines
2.1.1 Definitions

2.1.1.1 Add-on Codes - Some of the listed procedures are commonly carried out in addition to the
primary procedure performed. These additional or supplemental procedures are designated
as add-on codes with the " " symbol and they are listed in Appendix D of the CPT codebook.
The add-on code concept in CPT 2018 applies only to the Add-on procedures or services
performed by the same physician. Add-on codes are always performed in addition to the
primary service or procedure and must never be reported as a stand-alone code. All Add-on
codes in the CPT code set are exempt from the multiple procedure concept [see the modifier
51 definition in Appendix A of the 2018 CPT codebook. (See Chapter Six)
2.1.1.2 Chief Complaint - A concise statement describing the presenting symptom, problem,
condition, diagnosis or other factor that is the reason for the encounter, usually stated in the
patient's words.
2.1.1.3 Concurrent Care - Concurrent care is the provision of similar services, e.g., hospital visits, by
the same patient to more than one physician or other qualified health care professional on
the same day.
2.1.1.4 Consultation - A consultation is a type of evaluation and management service provided by a
physician at the request of another physician or appropriate source to either recommend
care for a specific condition or problem or to determine whether to accept responsibility for
ongoing management of the patient's entire care or for the care of a specific condition or
problem. A physician consultant may initiate diagnostic and/or therapeutic services at the
same or subsequent visit.
▪ The written or verbal request for consult may be made by a physician or other appropriate
source and documented in the patient's medical record by either the consulting or requesting
physician or appropriate source. The consultant's opinion and any services that were ordered
or performed must also be documented in the patient's medical record and communicated by
written report to the requesting physician or other appropriate source.
▪ A "consultation" initiated by a patient and/or family, and not requested by a physician or other
appropriate source (e.g., physician assistant, nurse practitioner, doctor of chiropractic, physical
therapist, occupational therapist, speech-language pathologist, psychologist, social worker,
lawyer, or insurance company), is not reported using the consultation codes but may be
reported using the office visit, home service, or domiciliary/rest home care codes as
appropriate
▪ If subsequent to the completion of a consultation the consultant assumes responsibility for
management of a portion or all of the patient's condition(s), the appropriate Evaluation and

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 Management services code for the site of service should be reported. In the hospital or nursing
facility setting, the consulting physician should use the appropriate inpatient consultation code
for the initial encounter and then subsequent hospital or nursing facility care codes. In the
office setting, the physician should use the appropriate office or other outpatient consultation
codes and then the established patient office or other outpatient services codes.
2.1.1.5 Consultation Inpatient- When an inpatient consultation is performed on a date that a patient
is admitted to a hospital or nursing facility, all evaluation and management services provided
by the consultant related to the admission are reported with the inpatient consultation
service code [99215-99255]. If a patient is admitted after an outpatient consultation [office,
emergency department,] and the patient is not seen on the unit on the date of admission,
only report the outpatient consultation code [99241-99245].
▪ If the patient is seen by the consultant on the unit on the date of admission, report all evaluation and
management services provided by the consultant related to the admission with either the inpatient
consultation codes [99251-99255] or with the initial inpatient admission service codes [99221-
99223]. Do not report both and outpatient consultation [99251-99255] and inpatient consultation
[99251-99255] for services related to the same inpatient stay.
▪ When transfer of care services are provided on a date subsequent to the outpatient consultation,
use the subsequent hospital care codes [99231-99233] or subsequent nursing facility care codes
[99307-99310].
▪ The above and below codes are used to report physician or other qualified health care professionals,
consultations provided to hospital inpatients, residents of nursing facilities or patients in a partial
hospital setting. Only one consultation should be reported by a consultant per admission.
Subsequent services during the same admission are reported using subsequent hospital care codes
[99231-99233] or subsequent nursing facility care codes [99307-99310], including services to
complete the initial consultation, monitor progress, revise recommendations or address a new
problem. Use subsequent hospital care codes [99231-99233] or subsequent nursing facility care
codes [99307-99310], to report transfer of care services. [ See Concurrent Care and Transfer of Care
definitions]
2.1.1.6 Counselling - Counselling is a discussion with a patient and/or family concerning one or more
of the following areas:
▪ Diagnostic results, impressions, and/or recommended diagnostic studies
▪ Prognosis
▪ Risks and benefits of management (treatment) options
▪ Instructions for management (treatment) and/or follow-up
▪ Importance of compliance with chosen management (treatment) options
▪ Risk factor reduction
▪ Patient and family education

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2.1.1.7 Destruction - defined as the physical eradication of all or a portion of a body part by the
direct use of energy, force, or a destructive agent. Common terms that may be documented
are ablation, destruction, fulguration, cryotherapy, and cautery. For Example: the ablation of
benign, premalignant or malignant tissues by any method, with or without curettage, under
local Anesthesia, not requiring closure. Any method that includes electrosurgery,
cryosurgery, laser and chemical treatment for the destruction of a body part or Lesion.
Lesions include condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts
(i.e., common, plantar, flat), milia, or other benign, pre-malignant (e.g., actinic keratoses), or
malignant lesions. Surgical destruction is a part of a surgical procedure and different
methods of destruction may or may not be listed separately unless the technique
substantially alters the standard management of the condition. Exceptions under special
circumstances are provided by separate code numbers
2.1.1.8 Excision - is defined as the removal of tissue or a portion of tissue or all, of an organ or other
structure and includes the closure specified as simple, intermediate or complex when
performed.
2.1.1.9 External fixation - External fixation utilizes multiple pins placed through one cortex or both
cortices of bone, above and below a fracture site. These pins are held by an external device,
called an external fixator device. This external fixator is used as an alternative to pins and
plaster to hold the bone fragments in proper position. Pins and plaster also continue to be
used in certain clinical situations. External fixation is based on the principle of "load
transference." Forces that are normally transmitted through the fracture site are bypassed
through the external fixator frame and pin/bone interface at an early stage of treatment. As
the fracture callus begins to consolidate, more of the load will be shared by the bone
fragments. Such load transferring characteristics vary and depend on the rigidity and
adjustability of the fixation device used. When the fracture is stable or healed, all forces are
borne by the bone. At this point, the external fixation is then no longer needed and can be
safely removed. Subsequent casting, bracing, or surgery may also follow external fixation.
2.1.1.10 Family History - A review of medical events in the patient's family that includes significant
information about:
▪ The health status or cause of death of parents, siblings, and children
▪ Specific diseases related to problems identified in the Chief Complaint or History of the
Present Illness, and/or System Review
▪ Diseases of family members that may be hereditary or place the patient at risk
2.1.1.11 Fracture Treatment:
▪ Closed Treatment: - specifically means that the fracture site is not surgically opened (exposed to the
external environment and directly visualized). This terminology is used to describe procedures that
treat fractures by three methods: 1) without manipulation; 2) with manipulation; or 3) with or
without traction.

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 ▪ Open treatment - : is used when the fractured bone is either: 1) surgically opened (exposed to the
external environment) and the fracture (bone ends) visualized and internal fixation may be used; or
2) the fractured bone is opened remote from the fracture site in order to insert an intramedullary
nail across the fracture site (the fracture site is not opened and visualized).
▪ Percutaneous skeletal fixation describes fracture treatment which is neither open nor closed. In this
procedure, the fracture fragments are not visualized, but fixation (e.g., pins) is placed across the
fracture site, usually under X-ray imaging.
▪ Manipulation - is used throughout the musculoskeletal fracture and dislocation subsections to
specifically mean the attempted reduction or restoration of a fracture or joint dislocation to its
normal anatomic alignment by the application of manually applied forces.
2.1.1.12 HCPCS - Healthcare Common Procedure Coding System – The CPT Codes is divided into two
subsystems, which are referred to as level I and level II. Level I HCPCS coding includes the
Current Procedural Terminology (CPT) codes, which are a numerical coding system
maintained by the American Medical Association. CPT codes numerically identify medical
services and procedures. HCPCS coding level II was established in the 1980s as way to assign
codes to services, supplies, non-physician services and procedures not included in the CPT
coding system, but still covered by and billable to insurance companies. Level II HCPCS coding
consists of a single letter followed by four numbers. Level II HCPCS procedure codes are
assigned in the Emirate of Abu Dhabi for additional reporting codes in addition to the list for
high cost items.
2.1.1.13 LOINC Codes - is a database and universal standard for identifying medical laboratory
observations. First developed in 1994, it was created and is maintained by the Regenstrief
Institute. A formal, distinct, and unique 6-part name is given to each term for a test or
observation identity. The database currently has over 71,000 observation terms that can be
accessed and understood universally. Each database record includes six fields for the unique
specification of each identified single test, observation, or measurement. The LOINC codes
are currently used in the Emirate of Abu Dhabi for routine reporting of Observations.
2.1.1.14 Modifiers –- A modifier provides the means to report or indicate that a service or procedure
that has been performed has been altered by some specific circumstance but not changed in
its definition or code. Modifiers also enable health care professionals to effectively respond
to payment policy requirements established by other entities. The judicious application of
modifiers obviates the necessity for separate procedure listings that may describe the
modifying circumstance. Select Modifier codes will be used in the Emirate of Abu Dhabi in
conjunction for reporting Ambulatory Claims. (See Section C, Chapter three for the approved
list of Modifiers)
2.1.1.15 Guidelines – There are specific guidelines which are presented at the beginning of each of the
six sections in the CPT 2018 Book. These guidelines define items that are necessary to
appropriately interpret and report the procedures and services contained in that section.

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2.1.1.16 History of Present Illness - A chronological description of the development of the patient's
present illness from the first sign and/or symptom to the present. This includes a description
of location, quality, severity, timing, context, modifying factors, and associated signs and
symptoms significantly related to the presenting problem(s).
2.1.1.17 New and Established Patient in E & M Coding - Solely for the purposes of distinguishing
between new and established patients, professional services are those face-to faces services
rendered by physicians and other qualified health care professionals who may report
evaluation and management services reported by a specific CPT code(s).
I. A new patient is one who has not received any professional services from the physician/
qualified health care professional or another physician / qualified health care professional of
the exact same specialty and subspecialty who belongs to the same group practice, within the
past three years.
II. An established patient is one who has received professional services from the physician /
qualified health care professional or another physician / qualified health care professional of
the exact same specialty and subspecialty who belongs to the same group practice, within the
past three years.
In the instance where a physician / qualified health care professional is on call for or covering
for another physician, the patient's encounter will be classified as it would have been by the
physician/ qualified health care professional who is not available. No distinction is made
between new and established patients in the emergency department. E/M services in the
emergency department category may be reported for any new or established patient who
presents for treatment in the emergency department.
2.1.1.18 Professional services - are those face-to-face services rendered by a physician or other
qualified health care professionals and reported by a specific CPT code(s).
2.1.1.19 Principal Procedure – Is defined as the procedure performed for definitive treatment, rather
than one performed for diagnostic or exploratory purposes or was necessary to take care of a
complication. If there are two or more therapeutic procedures, then it is the one most
related to the principal diagnosis. If all procedures are diagnostic, then it is the one most
related to the principal diagnosis. If there is more than one, then it is the most resource
intensive. The hierarchy is as follows:
I. Therapeutic
II. Related to Principal Diagnosis
III. Most resource intensive
IV. If there is more than one procedure to be reported in a hospital or ambulatory visit, then the
procedures need to be sequenced as principal or secondary for reporting purposes.

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2.1.1.20 Repair Closure - The repair or closure of wounds in CPT 2018 designates wound closure
utilizing sutures, staples or tissue adhesives and may be classified as Simple, Intermediate or
Complex. (See also Section C, Chapter 10)
2.1.1.21 Simple repair is used when the wound is superficial; e.g., involving primarily epidermis or
dermis, or subcutaneous tissues without significant involvement of deeper structures, and
requires simple one-layer closure. This includes local Anesthesia and chemical or
electrocauterization of wounds not closed.
2.1.1.22 Intermediate repair includes the repair of wounds that, in addition to the above, require
layered closure of one or more of the deeper layers of subcutaneous tissue and superficial
(non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer
closure of heavily contaminated wounds that have required extensive cleaning or removal of
particulate matter also constitutes intermediate repair.
2.1.1.23 Complex repair includes the repair of wounds requiring more than layered closure, viz., scar
revision, debridement, (e.g., traumatic lacerations or avulsions), extensive undermining,
stents or retention sutures. Necessary preparation includes creation of a limited defect for
repairs (e.g., excision of a scar requiring a complex repair) or the debridement of complicated
lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or
malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005) or
debridement of an open fracture or open dislocation.
2.1.1.24 Results/Testing/Reports - Results are the technical component of a service. Testing leads to
results; results lead to interpretation. Reports are the work product of the interpretation of
numerous test results.
2.1.1.25 Secondary Procedures – All other significant procedures are to be reported as secondary
procedures. A significant procedure is one that:
I. Is surgical in nature
II. Carries a procedural risk
III. Carries an anesthetic risk
IV. Requires specialized training.
2.1.1.26 Separate Procedure -. Some of the procedures or services listed in the CPT codebook that are
commonly carried out as an integral component of a total service or procedure have been
identified by the inclusion of the term ‘separate procedure’. The codes designated as
‘separate procedure’ should not be reported in addition to the code for the total procedure
or service of which it is considered an integral component.
▪ When a procedure or service that is designated as a ‘separate procedure’ is carried out
independently or considered to be unrelated or distinct from other procedures/ services provided
at that time, it may be reported by itself or in addition to other procedures/ services by adding

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 modifier 59 to the specific ‘separate procedure’ code to indicate that the procedure is not
considered to be a component of another procedure, but is a distinct independent procedure.
This may represent a different session or patient encounter, different procedure or surgery,
different site or organ system, separate incision/ excision, separate lesion, separate injury or are
of injury in extensive injuries.
▪ These instructions are not intended as a listing of all possible code combinations that should not
be reported, nor to indicate all possible code combinations that are appropriately reported.
▪ If there is more than one procedure to be reported in a hospital or ambulatory visit, then the
procedures need to be sequenced as principal or secondary for reporting purposes.
2.1.1.27 Shaving of Epidermal or Dermal Lesions (11300-11313) - Shaving is the sharp removal by
transverse incision or horizontal slicing to remove epidermal and dermal lesions without a
full-thickness dermal excision. This includes local Anesthesia, chemical or electrocauterization
of the wound. The wound does not require suture closure.
2.1.1.28 Supervision & Interpretation - Supervision and interpretation (S&I) codes are used to describe
the supervision by one or more physicians and the interpretation of the findings during
certain imaging procedures which may require surgical procedures to access the imaged
area. Many services include image guidance which is not separately reportable and is so
stated in the descriptor or guidelines. When imaging is not included in a surgical procedure or
procedure from the Medicine Section, image guidance codes or codes labelled ‘Radiological
supervision and interpretation” may be reported for the portion of the service that requires
imaging Both services require image documentation and radiological supervision,
interpretation and report services require a separate interpretation.
2.1.1.29 Technical Component - Certain procedures or services described in CPT involve a technical
component which is the ‘test’ component.
2.1.1.30 Traction:
I. Skeletal traction is the application of a force (distracting or traction force) to a limb segment
through a wire, pin, screw, or clamp that is attached (e.g., penetrates) to bone.
II. Skin traction is the application of a force (longitudinal) to a limb using felt or strapping applied
directly to skin only.
2.1.1.31 Transfer of care - is the process whereby a physician or other qualified health care
professional who is providing management for some or all of a patient's problems
relinquishes this responsibility to another physician or other qualified health care
professional who explicitly agrees to accept this responsibility and who, from the initial
encounter, is not providing consultative services. The physician or other qualified health care
professional, transferring care is then no longer providing care for these problems though he
or she may continue providing care for other conditions when appropriate. Consultation
codes should not be reported by the physician who has agreed to accept transfer of care

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 before an initial evaluation but are appropriate to report if the decision to accept transfer of
care cannot be made until after the initial consultation evaluation, regardless of site of
service.
2.1.1.32 Unbundling - To inappropriately bill more CPT/HCPCS codes than necessary, applied when
certain codes represent procedures that are basic steps to accomplish a primary procedure
already on the bill and, by definition, are included in the reimbursement of the primary
procedure. In Essence, to bill separately by giving separate prices to equipment, procedures,
or supporting services.
2.1.1.33 Unlisted Procedure/Service – These are services or procedures performed by physicians or
other qualified health care professionals that are not listed in the CPT codebook. (See Section
C, Chapter Five).

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3. Chapter Three: Modifiers

Modifiers
3.1.1 General Overview

3.1.1.1 Selected modifiers have been approved for use within in the Emirate of Abu Dhabi for
Ambulatory with the implementation of Enhanced Ambulatory Patient Groups (EAPG.)
3.1.1.2 There are two levels of Modifiers: Level I Modifier or Level II Modifier
3.1.1.3 The level I have two digits for example: “50”, while the Level II have alphabetic characters.
3.1.1.4 Modifiers give CPT service or procedure code(s) added information/ specificity, without
changing the definition of the code the following Level I Modifiers (commonly referred to as
CPT modifiers) may be added
3.1.1.5 A service or a procedure can be further described by using 2-digit modifiers. Since medical
procedures and services are often complex, additional information needs to be supplied
when coding. CPT/HCPC Modifiers provider additional information about the procedure.
Modifiers may describe where the procedure was performed on the body as well as
circumstance surrounding the service and other information that may be critical to a claim’s
status with the insurance payer. Modifiers are always two characters and may be numeric or
alphanumeric
3.1.1.6 In the case of more than one modifier, the “functional” modifier is coded first, and the
“informational” modifier second. The distinction between the two is simple: the modifiers
that most directly affect the reimbursement process are always listed first.
3.1.1.7 Example: patient sustained several finger fractures of left hand and presented for ORIFs. CPT
code performed on 26735-F2 and 26735-F3. By adding the modifiers F2 - Left hand, third
digit and F3 – Left hand, fourth digit it is clear exactly what fingers were repaired.
3.1.1.8 The following modifiers are recommended: 27, 50, 52, 59, 73, 91 as well as E1, E2, E3, E4, F1,
F2, F3, F4, F5, F6, F7, F8, F9, FA, T1, T2, T3, T4, T5,T6,T7,T8,T9 and TA. See table in 3.1.4

3.1.2 Inpatient Modifiers

3.1.2.1 Inpatient modifiers will be used for reporting purposes only and do not impact DRG
payments.

3.1.3 Ambulatory Modifiers

3.1.3.1 Only modifiers from the approved list of level I and Level II will be accepted for Coding
purposes.

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3.1.4 List of Ambulatory Modifiers

3.1.4.1 Below is the list of Ambulatory Modifiers

Modifier Level Description of Modifier

Multiple E/M: Multiple outpatient hospital evaluation and management (E/M)

encounters on the same date. This modifier can identify when a patient receives
27 Level I
multiple e/M services performed by the same or different physicians in multiple
outpatient settings (e.g. emergency department, clinic, etc.)

Bilateral Procedure – Bilateral Procedures that are performed at the same

50 Level I session, should be identified by adding modifier 50 to the appropriate 5-digit
code.

Distinct Procedural Service – Modifier 59 is used to identify procedures /

services, other than E/M services, that are not normally reported together, but
are appropriate under the circumstances. Documentation must support a
59 Level I different session, different procedure or surgery, different site or organ system,
separate incision / excision, separate lesion, or separate injury (or area of injury
in extensive injuries) not ordinarily encountered or performed on the same day
by the same individual.

Discontinued Out-Patient Hospital/Procedure Prior to the Administration of

Anesthesia – Due to extenuating the intended service that is prepared for but
73 Level I
cancelled can be reported by its usual procedure number and the addition of
modifier 73.

Discontinued Out-Patient Hospital/Procedure After Administration of

Anesthesia – Due to extenuating circumstances the procedure started but
74 Level I
terminated can be reported by its usual procedure number and the addition of
modifier 74.

Reference (Outside) Laboratory – Physicians use of this modifier when

90 Level I laboratory procedures are performed by a party other than the treating or
reporting physician.

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MODIFIER LEVEL DESCRIPTION OF MODIFIER
E1 Level II Upper left, eyelid
E2 Level II Lower left, eyelid
E3 Level II Upper right, eyelid
E4 Level II Lower right, eyelid
F1 Level II Left hand, second digit
F2 Level II Left hand, third digit
F3 Level II Left hand, fourth digit
F4 Level II Left hand, fifth digit
F5 Level II Right hand, thumb
F6 Level II Right hand, second digit
F7 Level II Right hand, third digit
F8 Level II Right hand, fourth digit
F9 Level II Right hand, fifth digit
FA Level II Left hand, thumb
T1 Level II Left foot, second digit
T2 Level II Left foot, third digit
T3 Level II Left foot, fourth digit
T4 Level II Left foot, fifth digit
T5 Level II Right foot, great toe
T6 Level II Right foot, second digit
T7 Level II Right foot, third digit
T8 Level II Right foot, fourth digit
T9 Level II Right foot, fifth digit
TA Level II Left foot, great toe
RT Level II Right side (used to identify procedures performed on the right side of the body)
LT Level II Left side (used to identify procedures performed on the left side of the body)

3.1.5 Level II Modifiers

3.1.5.1 2 digits (A-V)

3.1.5.2 Updated annually by CMS
3.1.5.3 Level II give a CPT services or procedure code(s) added information/ specificity, without
changing the definition of the code the following Level II Modifiers (commonly referred to as
HCPCS modifiers), however only selected level II modifiers are approved for use in Abu Dhabi.
3.1.5.4 A modifier provides the means by which the reporting physician can indicate that a service or
procedure that has been performed has been altered by some specific circumstance but not
changed in its definition or code. The judicious application of modifiers obviates the necessity
for separate procedure listings that may describe the modifying circumstance. Modifiers may
be used to indicate to the recipient of a report that:

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 I. A service or procedure had both a professional and technical component.
II. A service or procedure was performed by more than one physician and/or in more than one
location.
III. A service or procedure was increased or reduced.
IV. Only part of a service was performed.
V. An adjunctive service was performed.
VI. A bilateral procedure was performed.
VII. A service or procedure was provided more than once.
VIII. Unusual events occurred.

Guidelines on Correct and Incorrect usage of Modifiers

3.2.1 Modifier -27

3.2.1.1 Appropriate usage includes:

▪ Report modifier -27 for multiple outpatient hospital evaluation and management (E/M) encounters
on the same date.
▪ Report this modifier when a patient receives multiple E/M services performed by the same or
different physicians in multiple outpatient hospital settings (e.g., emergency department, clinic, etc.)
▪ Report this modifier if a patient was seen in two different hospital-based clinics on the same date of
service.
▪ Only append modifier -27 to E/M service codes within the range of 92002-92014, 99201-99499, and
with healthcare common procedure coding system codes G0378 and G0379 observation?
▪ Report this modifier to the second subsequent E/M code when more than one E/M service is
provided that same day in the same or different hospital outpatient setting
▪ When reporting modifier -27, report with condition code G0 when multiple medical visits occur on
the same day in the same revenue centers.
3.2.1.2 Inappropriate usage includes:
▪ Physician practices may not use this modifier. Report this modifier on the UB-04 Part A claim form or
electronic equivalent. This modifier is not valid when submitted on a CMS-1500 form or the
electronic equivalent.

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 3.2.2 Modifier -50

3.2.2.1 Appropriate usage includes:

▪ Report codes with a BILAT SURG by appending modifier 50 and submit 1 unit of service on one line.
▪ Report codes with a BILAT SURG by appending modifier 50 using 1 unit of service on one line or
when performing the procedure on bilateral body parts.
▪ Use modifier 50 to report bilateral procedures performed during the same operative session by the
same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or in the same
operative area (e.g., nose, eyes, breasts).
▪ Do not bill modifiers LT and RT on the same service line when using modifier 50 to indicate a
bilaterally performed procedure. Modifier LT or RT should be used to identify which of the paired
organs was operated on. Billing procedures as two lines of service using the LT and RT modifiers is
not the same as identifying the procedure with modifier 50. Modifier 50 is the coding practice of
choice when reporting bilateral procedures.
3.2.2.2 Incorrect usage

Inappropriate usage includes:

▪ Do not use modifier 50 when performing the procedure on different areas of the same side of the
body.
▪ Do not use modifier 50 when the BILAT SURG indicator is 0, 2 or 9.
▪ Do not use modifier 50 when removing a lesion on the right arm and a lesion on the left arm. Use the
RT and LT modifiers.
▪ Do not use modifier 50 with a procedure code that is described as bilateral, or unilateral or bilateral,
in its CPT description.
▪ Do not report a bilateral procedure on two lines of service by appending modifier 50 to the second
line of service. Do not submit modifier 50 on procedures for midline organs such as the bladder,
uterus, esophagus and nasal septum

3.2.3 Modifier -59

3.2.3.1 Appropriate use includes:

▪ Modifier 59 is used appropriately for different anatomic sites during the same encounter only when
procedures which are not ordinarily performed or encountered on the same day are performed on
different organs, or different anatomic regions, or in limited situations on different, non-contiguous
lesions in different anatomic regions of the same organ.

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 ▪ One of the common uses of modifier 59 is for surgical procedures, non-surgical therapeutic
procedures, or diagnostic procedures that are performed at different anatomic sites, are not
ordinarily performed or encountered on the same day, and that cannot be described by one of the
more specific anatomic NCCI-associated modifiers – i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1-T9.
▪ Modifier 59 is used appropriately when the procedures are performed in different encounters on the
same day.
▪ Another common use of modifier 59 is for surgical procedures, non-surgical therapeutic procedures,
or diagnostic procedures that are performed during different patient encounters on the same day
and that cannot be described by one of the more specific NCCI-associated.
▪ Modifier 59 is used appropriately for two services described by timed codes provided during the
same encounter only when they are performed sequentially.
▪ Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure
only when the diagnostic procedure is the basis for performing the therapeutic procedure.
▪ Modifier 59 is used appropriately for a diagnostic procedure which occurs subsequent to a
completed therapeutic procedure only when the diagnostic procedure is not a common, expected,
or necessary follow-up to the therapeutic procedure. When a diagnostic procedure follows the
surgical procedure or non-surgical therapeutic procedure, that diagnostic procedure may be
considered to be a separate and distinct procedure as long as (a) it occurs after the completion of
the therapeutic procedure and is not interspersed with or otherwise commingled with services that
are only required for the therapeutic intervention, and (b) it does not constitute a service that would
have otherwise been required during the therapeutic intervention. If the post procedure diagnostic
procedure is an inherent component or otherwise included (or not separately payable) post-
procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be
reported separately.
▪ Use of modifier 59 does not require a different diagnosis for each HCPCS/CPT coded procedure.
Conversely, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT
codes remain bundled unless the procedures are performed at different anatomic sites or separate
patient encounters or meet one of the other three scenarios described above.
3.2.3.2 Inappropriate usage includes:
▪ Modifier 59 should only be used to identify clearly independent services that represent significant
departures from the usual situations described by the NCCI edit. The treatment of contiguous
structures in the same organ or anatomic region does not constitute treatment of different anatomic
sites.
▪ Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two
codes is different. The common misuses of modifier 59 is related to the portion of the definition of
modifier 59 allowing its use to describe a “different procedure or surgery.” The code descriptors of
the two codes of a code pair edit usually represent different procedures, even though they may be

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 overlapping. The edit indicates that the two procedures in general should not be reported together
if performed at the same anatomic site and same patient encounter as those procedures would not
be considered to be “separate and distinct.” The provider should not use modifier 59 for such an
edit based on the two codes being “different procedures.”

3.2.4 Modifier -73

3.2.4.1 Appropriate usage includes:

▪ When a physician cancels a surgical or diagnostic procedure subsequent to the patient's surgical
preparation (including sedation when provided and being taken to the room where the procedure is
to be performed, but prior to the administration of anesthesia (local, regional block or general). This
as a result of extenuating circumstances or those that threatens the wellbeing of the patient.
▪ When none of the planned procedures are completed, then the first planned procedure is reported
with the modifier -73. The others are not reported.
▪ This modifier should be used to cover the expenses involved for the use of the facility
3.2.4.2 Inappropriate usage includes:
▪ The elective cancellation of a service prior to the administration of anesthesia and/or surgical
preparation of the patient should not be reported.

3.2.5 Modifier E1-E4 (Eyelid Modifiers)

3.2.5.1 Appropriate usage includes:

▪ Eyelid modifiers: -E1 for upper left, -E2 for lower left, -E3 for upper right, and -E4 for lower right.
Three common ophthalmological procedures require the eyelid modifiers: epilation (67820-67835),
punctal plug procedures (68760-68761), and chalazion excisions (67800-67805). In addition, 67810*
(Biopsy of eyelid), 67840* (Excision of lesion of eyelid [except chalazion] without closure or with
simple direct closure) and 67850* (Destruction of lesion of lid margin [up to 1 cm]) may be
performed on different lids.
▪ Use the E modifiers when a procedure can be performed on any one of the four eyelids. If the
definition of a procedure code specifies that it is only performed on the lower eyelids (e.g., 15820
[Blepharoplasty, lower eyelid]), use modifier -50 (Bilateral procedure) to indicate that both lower
eyelids were operated on.
3.2.5.2 Inappropriate usage includes:
▪ Do not use if CPT/HCPCS code indicates multiple occurrences.
▪ Do not use if the code indicates the procedure applies to different body parts.

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3.2.6 Modifiers F1-FA (Right- and Left-Hand Digits)

3.2.6.1 Appropriate usage includes:

▪ Append the appropriate modifier to the right- or left-hand digit.
3.2.6.2 Inappropriate usage includes:
▪ Do not use if CPT/HCPCS code indicates multiple occurrences.
▪ Do not use if the code indicates the procedure applies to different body parts.
▪ Do not use RT or LT for these modifiers.

3.2.7 Modifiers T1-TA (Right-and-Left-Foot Digits)

3.2.7.1 Appropriate usage includes:

▪ Append the appropriate modifier to the right or left foot digit.
▪ Coders should use these modifiers only when a podiatrist is operating specifically on toes.
3.2.7.2 Inappropriate usage includes:
▪ Do not use if CPT/HCPCS code indicates multiple occurrences.
▪ Do not use if the code indicates the procedure applies to different body parts.
▪ Do not use RT or LT for these modifiers.

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 4. Chapter Four: Unlisted Procedure

Unlisted Procedure or Service codes

It is recognized that there may be services or procedures performed by physicians that are not found in the 2018
CPT codebook. Therefore, a number of specific code numbers have been designated for reporting unlisted
procedures. Each of these unlisted procedural code numbers relates to a specific section of the book and is
presented in the guidelines of that section. In the Emirate of Abu Dhabi, to report the unlisted procedure or
service the following should be implemented:

▪ List the specific “unlisted” procedure code from the relevant chapter in the 2018 CPT codebook. (i.e.,
do not use the service code for undefined services)
▪ Charge the pre-agreed price for this code. If no specific charge has been pre-agreed, then use the
charge of the most closely related procedure, and describe this procedure in an Observation
(Type=Text, Code=ClosestUnlistedProcedure,Value=Text description of procedure);
▪ Disagreements on price can be resolved through the remittance/resubmission process.
▪ For the avoidance of doubt, the process of claiming for unlisted procedures does not alter the
benefits coverage for members.

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5. Chapter Five: Add- On Codes
Add – On Codes
I. Add-on codes in the CPT 2018 codebook can be readily identified by specific descriptor nomenclature that
includes phrases such as "each additional" or "(List separately in addition to primary procedure)." These
additional or supplemental procedures are designated as add-on codes with the " " symbol and they are
listed in Appendix D of the 2018 CPT codebook.
II. The add-on code concept in CPT 2018 applies only to add-on procedures or services performed by the
same physician. Add-on codes describe additional intra-service work associated with the primary
procedure, e.g., additional digit(s), lesion(s), neurorrhaphy(s), vertebral segment(s), tendon(s), joint(s).
III. Add-on codes are always performed in addition to the primary service or procedure and must never be
reported as a stand-alone code.
IV. All Add-on codes in the CPT code set are exempt from the multiple procedure concept (see the modifier
51 definition in Appendix A of the 2018 CPT codebook)

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6. Chapter Six: Time
Time
6.1.1 Time in Procedure Codes

6.1.1.1 The CPT code set contains many codes with a time basis for code selection. The following
standards shall apply to time measurement, unless there are code or code- range-specific
instructions in guidelines, parenthetical instructions, or code descriptors to the contrary.
6.1.1.2 Time is the face-to-face time with the patient. Phrases such as "interpretation and report" in
the code descriptor are not intended to indicate in all cases that report writing is part of the
reported time.
6.1.1.3 A unit of time is attained when the mid-point is passed. For example, an hour is attained
when 31 minutes have elapsed (more than midway between zero and sixty minutes). A
second hour is attained when a total of 91 minutes has elapsed. When codes are ranked in
sequential typical times and the actual time is between two typical times, the code with the
typical time closest to the actual time is used. (See also Chapter Eight the Evaluation and
Management (E/M) Services Guidelines). When another service is performed concurrently
with a time-based service, the time associated with the concurrent service should not be
included in the time used for reporting the time-based service.
6.1.1.4 Some services measured in units other than days extend across calendar dates. When this
occurs, a continuous service does not reset and create a first hour. However, any disruption
in the service does create a new initial service. For example, if intravenous hydration
(96360, 96361) is given from 11 PM to 2 AM 96360 would be reported once and 96361 twice.
For facility reporting on a single date of service or for continuous services that last beyond
midnight (i.e. over a range of dates) report the total units of time provided continuously.

6.1.2 Time in Evaluation & Management Coding

6.1.2.1 The inclusion of time in the definitions of levels of E/M services is done to assist physicians in
selecting the most appropriate level of E/M services. It should be recognized that the specific
times expressed in the visit code descriptors are averages, and therefore represent a range of
times which may be higher or lower depending on actual clinical circumstances.
6.1.2.2 Intra-service times are defined as face-to-face time for office and other outpatient visits and
as unit/floor time for hospital and other inpatient visits. This distinction is necessary because
most of the work of typical office visits takes place during the face-to-face time with the
patient, while most of the work of typical hospital visits takes place during the time spent on
the patient's floor or unit. When prolonged time occurs in either the office or the inpatient
areas, the appropriate add-on code should be reported.

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6.1.2.3 Face-to-face time (office and other outpatient visits and office consultations): For coding
purposes, face-to-face time for these services is defined as only that time that the physician
spends face-to-face with the patient and/or family. This includes the time in which the
physician performs such tasks as obtaining a history, performing an examination, and
counseling the patient.
▪ Physicians also spend time doing work before or after the face-to-face time with the patient,
performing such tasks as reviewing records and tests, arranging for further services, and
communicating further with other professionals and the patient through written reports and
telephone contact.
▪ This non-face-to-face time for office services - also called pre- and post-encounter time - is not
included in the time component described in the E/M codes. However, the pre-and post-non-face-
to-face work associated with an encounter was included in calculating the total work of typical
services in physician surveys.
▪ Thus, the face-to-face time associated with the services described by any E/M code is a valid proxy
for the total work done before, during, and after the visit.
6.1.2.4 Unit/floor time (hospital observation services, inpatient hospital care, and initial inpatient
hospital consultations, nursing facility): For reporting purposes, intra-service time for these
services is defined as unit/floor time, which includes the time that the physician is present on
the patient's hospital unit and at the bedside rendering services for that patient. This includes
the time in which the physician establishes and/or reviews the patient's chart, examines the
patient, writes notes, and communicates with other professionals and the patient's family.
▪ In the hospital, pre- and post-time includes time spent off the patient's floor performing such tasks
as reviewing pathology and radiology findings in another part of the hospital.
▪ This pre- and post-visit time is not included in the time component described in these codes.
However, the pre- and post-work performed during the time spent off the floor or unit was
included in calculating the total work of typical services in physician surveys. Thus, the unit/floor
time associated with the services described by any code is a valid proxy for the total work done
before, during, and after the visit.
▪ When counseling and/or coordination of care dominates (more than 50%) the physician/patient
and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit
time in the hospital or nursing facility), then time shall be considered the key or controlling factor
to qualify for a particular level of E/M services. This includes time spent with parties who have
assumed responsibility for the care of the patient or decision making whether or not they are
family members (e.g., foster parents, person acting in loco parentis, legal guardian). The extent of
counseling and/or coordination of care must be documented in the medical record.

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6.1.3 Time as a Factor in the Emergency Department Setting

6.1.3.1 Time is not a descriptive component for the emergency department levels of E/M services
because emergency department services are typically provided on a variable intensity basis,
often involving multiple encounters with several patients over an extended period of time.
Therefore, it is often difficult for physicians to provide accurate estimates of the time spent
face-to-face with the patient.

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7. Chapter Eight: E/M
Evaluation & Management
7.1.1 Introduction

7.1.1.1 In addition to the information presented in the Chapter One Introduction, several other items
unique to this section are defined or identified here.
7.1.1.2 The table below represents the E/M Codes currently used within the Emirate of Abu Dhabi:

Codes Range
Service Category
From To

Office and Other Outpatient Services 99201 99215

Hospital Observation Services 99217 99226

Hospital Inpatient Services 99221 99239

Consultations 99241 99255

Emergency Department Services 99281 99288

Critical Care Services 99291 99292

Nursing Facility Services 99304 99318

Domiciliary, Rest Home (e.g.; Boarding Home), or Custodial Care Services 99324 99337

Domiciliary, Rest Home (e.g.; ALF), or Home Care Plan Oversight Services 99339 99340

Home Services 99341 99350

Prolonged Services 99354 99416

Case Management Services 99366 99368

Care Plan Oversight Services 99374 99380

Preventive Medicine Services 99381 99429

Non-Face to Face Services 99441 99499

Special Evaluation and Management Services 99450 99456

Newborn Care Services 99460 99486

Delivery/Birthing Room Attendance & Resuscitation Services 99464 99465

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 Inpatient Neonatal Intensive Care services and Pediatric & Neonatal Critical Care Services 99466 99486

Cognitive Assessment and Care Plan Services 99483

Care Management Services 99487 99489,99490

Psychiatric Collaborative Care Management Services 99492 99494

Transitional Care Management Services 99495 99496

Advanced Care Planning 99497 99498

General Behavior Health Integration Care Management 99484

Other Evaluation and Management Services 99499

7.1.2 Classification of Evaluation and Management (E/M) Services

7.1.2.1 The E/M section is divided into broad categories such as office visits, hospital visits, and
consultations. Most of the categories are further divided into two or more subcategories of
E/M services. For example, there are two subcategories of office visits (new patient and
established patient) (please see Chapter Two Commonly Used Terms), and there are two
subcategories of hospital visits (initial and subsequent). The subcategories of E/M services are
further classified into levels of E/M services that are identified by specific codes. This
classification is important because the nature of work varies by type of service, place of
service, and the patient's status.
7.1.2.2 In the CPT 4th Edition 2018 code book, the basic format of the levels of E/M services is the
same for most categories. First, a unique code number is listed. Second, the place and/or
type of service is specified, e.g., office consultation. Third, the content of the service is
defined, e.g., comprehensive history and comprehensive examination. (See "Levels of E/M
Services" below for details on the content of E/M services.) Fourth, the nature of the
presenting problem(s) usually associated with a given level is described. Fifth, the time
typically required to provide the service is specified. (See Chapter Seven Time)
7.1.2.3 In the Emirate of Abu Dhabi, E & M codes are used for coding and billing in the Outpatient
and Inpatient Setting. Valid E & M Codes to be used with the Emirate of Abu Dhabi within the
scope of work and meeting the documentation criteria (See Levels of E & M Codes below), will
be published by the DoH Mandatory Pricelist, and may be used to designate the services
rendered by any qualified licensed physician or other qualified licensed healthcare
professional (See Chapter One Introduction) as follows:

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 ▪ Registered School Nurse ▪ Podiatrists
▪ Registered Nurses ▪ Chiropractic Practitioner
▪ Registered Midwife ▪ Osteopathy Practitioner
▪ Optometrist
7.1.2.4 However, it is important to liaise with the Payor(s) as to whether these codes will be
reimbursed.

7.1.3 New Patient (See definition in Chapter 1)

7.1.3.1 A new patient is one who has not received any professional services from the physician/
qualified health care professional or another physician / qualified health care professional of
the exact same specialty and subspecialty who belongs to the same group practice, within
the past three years.

7.1.4 Established Patient (See definition in Chapter 1)

7.1.4.1 An Established patient is one who has received professional services from the physician /
qualified health care professional or another physician / qualified health care professional of
the exact same specialty and subspecialty who belongs to the same group practice, within
the past three years.
7.1.4.2 The decision tree below is provided to aid in determining whether to report the E/M service
provided as new or an established patient encounter.

7.1.5 Chief Complaint (See Definition Chapter 1)

7.1.5.1 A concise statement describing the presenting symptom, problem, condition, diagnosis or
other factor that is the reason for the encounter, usually stated in the patient's words.

7.1.6 Counseling (See Definition Chapter 1)

7.1.6.1 Counselling is a discussion with a patient and/or family concerning one or more of the
following areas:
▪ Diagnostic results, impressions, and/or recommended diagnostic studies
▪ Prognosis
▪ Risks and benefits of management (treatment) options
▪ Instructions for management (treatment) and/or follow-up
▪ Importance of compliance with chosen management (treatment) options
▪ Risk factor reduction
▪ Patient and family education
7.1.7 Family History

A review of medical events in the patient's family that includes significant information about:
▪ The health status or cause of death of parents, siblings, and children
▪ Specific diseases related to problems identified in the Chief Complaint or History of the Present
Illness, and/or System Review
▪ Diseases of family members that may be hereditary or place the patient at risk

7.1.8 History of Present Illness (See Definition Chapter 1)

7.1.8.1 A chronological description of the development of the patient's present illness from the first
sign and/or symptom to the present. This includes a description of location, quality, severity,
timing, context, modifying factors and associated signs and symptoms significantly related to
the presenting problem(s).

7.1.9 Levels of E/M Services

7.1.9.1 Within each category or subcategory of E/M service, there are three to five levels of E/M
services available for reporting purposes. Levels of E/M services are not interchangeable
among the different categories or subcategories of service. For example, the first level of E/M
serves in the subcategory of office visit, new patient, does not have the same definition as
the first level of E/M services in the subcategory of office visit, established patient.
7.1.9.2 The levels of E/M services include examinations, evaluations, and treatments, conferences
with or concerning patients, preventive pediatric and adult health supervision, and similar
medical services, such as the determination of the need and/or location for appropriate care.
7.1.9.3 Medical screening includes the history, examination, and medical decision-making required
to determine the need and/or location for appropriate care and treatment of the patient
(e.g., office and other outpatient setting, emergency department, nursing facility, etc.). The
levels of E/M services encompass the wide variations in skill, effort, time, responsibility and
medical knowledge required for the prevention or diagnosis and treatment of illness or injury
and the promotion of optimal health. Each level of E/M services may be used by all physicians
and or other qualified health care professionals, providing the appropriate documentation is
evident and the level of work is within the scope of his/her license,
7.1.9.4 The descriptors for the levels of E/M services recognize seven components, six of which are
used in defining the levels of E/M services. These components are:
▪ History ▪ Coordination of care
▪ Examination ▪ Nature of presenting problem
▪ Medical decision making ▪ Time
▪ Counseling

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 7.1.9.5 The first three of these components (history, examination and medical decision making) are
considered the key components in selecting a level of E/M services, within the Emirate of Abu
Dhabi.
7.1.9.6 The next three components (counselling, coordination of care and the nature of the
presenting problem) are considered contributory factors in the majority of encounters.
Although the first two of these contributory factors are important E/M services, it is not
required that these services be provided at every patient encounter. Coordination of care
with other physicians, other health care professionals or agencies without a patient
encounter on that day is reported using the case management codes. The final component is
time. These components are currently not used within the Emirate of Abu Dhabi to
determine E&M levels.
7.1.9.7 The actual performance and/or interpretation of diagnostic test/ studies ordered during a
patient encounter are not included in the levels of E/M services. Physician performance of
diagnostic tests/studies for which specific CPT codes are available may be reported
separately, in addition to the appropriate E.M code. The physician’s interpretation of the
results of diagnostic tests/ studies (i.e.: professional component) with preparation of
separate distinctly identifiable signed written report may also be reported separately, using
the appropriate CPT code with modifier 26 assigned.

7.1.10 Nature of Presenting Problem

A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other
reason for encounter, with or without a diagnosis being established at the time of the encounter. The E/M
codes recognize five types of presenting problems that are defined as follows:
7.1.10.1 Minimal: A problem that may not require the presence of the physician, or other qualified
health care professional, but service is provided under the physician's or other qualified
health care professionals, supervision.
7.1.10.2 Self-limited or minor: A problem that runs a definite and prescribed course, is transient in
nature, and is not likely to permanently alter health status OR has a good prognosis with
management/compliance.
7.1.10.3 Low severity: A problem where the risk of morbidity without treatment is low; there is little
to no risk of mortality without treatment; full recovery without functional impairment is
expected.
7.1.10.4 Moderate severity: A problem where the risk of morbidity without treatment is moderate;
there is moderate risk of mortality without treatment; uncertain prognosis OR increased
probability of prolonged functional impairment.
7.1.10.5 High severity: A problem where the risk of morbidity without treatment is high to extreme;
there is a moderate to high risk of mortality without treatment OR high probability of severe,
prolonged functional impairment.
7.1.11 Past History

7.1.11.1 A review of the patient's past experiences with illnesses, injuries, and treatments that
includes significant information about:
▪ Prior operations ▪ Allergies (e.g., drug, food)
▪ Prior hospitalizations ▪ Prior major illnesses and injuries
▪ Age appropriate immunization status ▪ Age appropriate feeding/dietary
status
▪ Current medications

7.1.12 Social History

7.1.12.1 An age appropriate review of past and current activities that includes significant information
about:
▪ Marital status and/or living ▪ Use of drugs, alcohol, and tobacco
arrangements
▪ Level of education
▪ Current employment
▪ Sexual history
▪ Occupational history
▪ Other relevant social factors
▪ Military History

7.1.13 System Review

7.1.13.1 An inventory of body systems obtained through a series of questions seeking to identify signs
and/or symptoms which the patient may be experiencing or has experienced. For the
purposes of the CPT codebook the following elements of a system review have been
identified:
▪ Constitutional symptoms (fever, weight loss, ▪ Musculoskeletal
etc.)
▪ Integumentary (skin and/or breast)
▪ Eyes
▪ Neurological
▪ Ears, Nose, Mouth, Throat
▪ Psychiatric
▪ Cardiovascular
▪ Endocrine
▪ Respiratory
▪ Hematologic/Lymphatic
▪ Gastrointestinal
▪ Allergic/Immunologic
▪ Genitourinary

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 7.1.13.2 The review of systems helps define the problem, clarify the differential diagnosis, identify
needed testing, or serves as baseline data on other systems that might be affected by any
possible management options.

7.1.14 Time – (See Chapter Seven Time)

Instructions for Selecting a Level of E/M Service

7.2.1 Review the reporting Instruction for the selected Category or Subcategory

7.2.1.1 Most of the categories and many of the subcategories of service have special guidelines or
instructions unique to that category or subcategory. When these are indicated, e.g.,
“inpatient Hospital Care” special instructions will be presented preceding the levels of E/M
service.

7.2.2 Review the Level of E/M Service Descriptors and Examples in the Selected Category or
Subcategory

7.2.2.1 The descriptors for the levels of E/M services recognize seven components, six of which are
used in defining the levels of E/M services. The components are:
▪ History ▪ Coordination of Care
▪ Examination ▪ Nature of Presenting Problem
▪ Medical Decision Making ▪ Time
▪ Counseling
7.2.2.2 The first of these components (History, examination and medical decision making) should be
considered key in selecting the level of E/M services. An Exception to this rule is in the care of
visits that consist predominantly of counselling or coordination of care.
7.2.2.3 The nature of presenting problem and time are provided in some levels to assist physician in
determining the appropriate level of E/M service.

7.2.3 Determine the Extent of History Obtained

7.2.3.1 The extent of the history is dependent upon clinical judgment and on the nature of the
presenting problem(s). The levels of E/M services recognize four types of history that are
defined as follows:
I. Problem focused: chief complaint; brief history of present illness or problem.
II. Expanded problem focused: chief complaint; brief history of present illness; problem pertinent
system review.

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 III. Detailed: chief complaint; extended history of present illness; problem pertinent system review
extended to include a review of a limited number of additional systems; pertinent past, family,
and/or social history directly related to the patient's problems.
IV. Comprehensive: chief complaint; extended history of present illness; review of systems which is
directly related to the problem(s) identified in the history of the present illness plus a review of all
additional body systems; complete past, family and social history.
7.2.3.2 The comprehensive history obtained as part of the preventive medicine evaluation and
management service is not problem-oriented and does not involve a chief complaint or
present illness. It does, however, include a comprehensive system review and comprehensive
or interval past, family and social history as well as a comprehensive assessment/history of
pertinent risk factors.

7.2.4 Determine the Extent of Examination Performed

7.2.4.1 The extent of the examination performed is dependent on clinical judgment and on the
nature of the presenting problem(s). The levels of E/M services recognize four types of
examination that are defined as follows:
I. Problem focused: a limited examination of the affected body area or organ system.
II. Expanded problem focused: a limited examination of the affected body area or organ system and
other symptomatic or related organ system(s).
III. Detailed: an extended examination of the affected body area(s) and other symptomatic or related
organ system(s).
IV. Comprehensive: a general multi-system examination or a complete examination of a single organ
system. Note: The comprehensive examination performed as part of the preventive medicine
evaluation and management service is multi-system, but its extent is based on age and risk factors
identified.
7.2.4.2 For the purposes of these CPT definitions, the following body areas are recognized:
▪ Head, including the face ▪ Genitalia, groin, buttocks
▪ Neck ▪ Back
▪ Chest, including breasts and axilla ▪ Each extremity
▪ Abdomen
7.2.4.3 For the purposes of these CPT definitions, the following organ systems are recognized:
▪ Eyes ▪ Respiratory
▪ Ears, Nose, Mouth and Throat ▪ Gastrointestinal
▪ Cardiovascular ▪ Genitourinary

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 ▪ Musculoskeletal ▪ Psychiatric
▪ Skin ▪ Hematologic/Lymphatic/Immunologic
▪ Neurologic

7.2.5 Determine the Complexity of Medical Decision Making

7.2.5.1 Medical decision making refers to the complexity of establishing a diagnosis and/or selecting
a management option as measured by:
▪ the number of possible diagnoses and/or the number of management options that must be
considered
▪ the amount and/or complexity of medical records, diagnostic tests, and/or other information that
must be obtained, reviewed and analyzed
▪ the risk of significant complications, morbidity and/or mortality, as well as co morbidities, associated
with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible
management option
7.2.5.2 Four types of medical decision making are recognized: straightforward; low complexity;
moderate complexity; and high complexity. To qualify for a given type of decision making,
two of the three elements in the table below must be met or exceeded.
7.2.5.3 Co morbidities/underlying diseases, in and of themselves, are not considered in selecting a
level of E/M services unless their presence significantly increases the complexity of the
medical decision making.

Complexity of Medical Decision Making

Number of
Diagnoses or Amount and/or Complexity Risk of Complications and/or Type of Decision
Management of Data to be Reviewed Morbidity or Mortality Making
Options

minimal minimal or none minimal straightforward

limited limited low low complexity

multiple moderate moderate moderate complexity

extensive extensive high high complexity

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 7.2.6 Select the Appropriate Level of E/M Services Based on the Following

7.2.6.1 For the following categories/subcategories, all of the key components, e.g., history,
examination, and medical decision making, must meet or exceed the stated requirements to
qualify for a particular level of E/M service: office, new patient; hospital observation services;
initial hospital care; office consultations; initial inpatient consultations; emergency
department services; initial nursing facility care; domiciliary care, new patient; and home,
new patient.
7.2.6.2 For the following categories/subcategories, two of the three key components (e.g., history,
examination, and medical decision making) must meet or exceed the stated requirements to
qualify for a particular level of E/M services: office, established patient; subsequent hospital
care;
7.2.6.3 subsequent nursing facility care; domiciliary care, established patient; and home, established
patient.
7.2.6.4 When counselling and/or coordination of care dominates (more than 50%) the
physician/patient and/or family encounter (See Chapter Seven Time)
7.2.6.5 DoH recommends the 1995 Guidelines for Evaluation and Management codes may be utilized
for assigning Evaluation and Management codes. However, if a facility has utilized the 1997
Guidelines it may state this at the onset of the Jawda audit, the auditor will then audit strictly
using the 1997 guidelines and state this fact in his report as well as showing this in the record
of the audit. The facility must state one guideline or another. A usage of a combination of
these two guidelines is not acceptable. (See the Jawda Certification for Healthcare Providers
2018- Part 1)
7.2.6.6 For Telemedicine/tele-consulting, the DOH Service Codes levels will be based on the criteria
of listed with the 2014 DOH Standard for Tele-consultation, with Telemedicine CPT codes not
utilized in the use for consultations.6

7.2.7 Consultation E & M Codes (99241 – 99255)

7.2.7.1 A consultation is a type of evaluation and management service provided at the request of
another physician or appropriate source to either recommend care for a specific condition or
problem or to determine whether to accept responsibility for ongoing management of the
patient’s entire care or for the care of a specific condition or problem. Do not confuse with a
“referral” which is a transfer of a patient’s care to another physician.

6
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7.2.7.2 A physician consultant may initiate diagnostic and/or therapeutic services at the same or
subsequent visit.
7.2.7.3 A ‘consultation’ initiated by a patient and /or family and not requested by a physician or
other appropriate source (e.g.: physician assistant, nurse, practitioner, doctor of chiropractic,
physical therapist, occupational therapist, speech-language pathologist, psychologist, social
worker, lawyer or insurance company) is not reported using the consultation codes but may
be reported using the office visit, home service or domiciliary/ rest home care codes as
appropriate.
7.2.7.4 The written or verbal request for a consult may be made by a physician or other appropriate
source and documented in the patient's medical record, by either the consulting or
requesting physician or appropriate source. The consultant's opinion and any services that
were ordered or performed must also be documented in the patient's medical record and
communicated by written report to the requesting physician or other appropriate source
7.2.7.5 Any specifically identifiable procedures (i.e. Identified with a specific CPT code) performed on
or subsequent to the date of the initial consultation should be reported.
7.2.7.6 If subsequent to the completion of a consultation the consultant assumes responsibility for
management of a portion or all of the patient’s condition(s), the appropriate Evaluation and
Management services code for the site of service should be reported. In the hospital or
nursing facility setting, the consultant should use the appropriate inpatient consultation code
for the initial encounter and the subsequent hospital or nursing facility care codes. In the
office setting, the consultant should use the appropriate office or outpatient consultation
codes and the established patient office or other outpatient services codes.

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 8. Chapter Eight: Telemedicine
Telemedicine and Telephone Services [NEVER TO BE CODED TOGETHER]
8.1.1 Telephone Services (99441-99443)

Telephone services are non-face-to-face evaluation and management (E/M) services provided by a physician
or other qualified health care professional who may report evaluation and management services, to a
patient using the telephone. These codes are used to report episodes of care by the physician initiated by an
established patient or guardian of an established patient.

If the telephone service ends with a decision to see the patient within 24 hours or next available urgent visit
appointment, the code is not reported; rather the encounter is considered part of the preservice work of
the subsequent E/M service, procedure, and visit. Likewise, if the telephone call refers to an E/M service
performed and reported by the physician within the previous seven days (either physician requested or
unsolicited patient follow-up) or within the postoperative period of the previously completed procedure,
then the service(s) are considered part of that previous E/M service or procedure. (Do not report 99441-
99443 if reporting 99441-99444 performed in the previous seven days.)

8.1.2 Telemedicine
8.1.2.1 Telemedicine refers to healthcare services provided via a range of technology enabled
communication media other than face-to-face interactions, such as telephone, internet,
video and others.
8.1.2.2 Coding will follow the DOH7 Standard for Tele-counselling in the Emirate of Abu Dhabi with
the assignment of the relevant DOH service codes
8.1.2.3 The four service codes 01-01 to 01-04 for Tele-medicine consultations have 4-key
components which requires the appropriate ICD-10-CM and CPT assignment.

▪ Triage (patient prioritization and categorization according to medical and management needs, such
as illness/injury, severity/complexity, prognosis and resource availability and referral to specialized
care as indicated by case)
▪ Diagnosis
▪ Video sighting of body symptoms (Optional)
▪ And may require (In a different facility)
▪ Invasive or noninvasive clinical interventions and or medical management and/or pathology and/or
point of care testing (POCT) and/or radiology investigation.

7
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9. Chapter Nine: Anesthesia
Anesthesia
9.1.1 Services and Definitions

9.1.1.1 The reporting of anesthesia services is appropriate by or under the responsible supervision of
a physician. These services may include but are not limited to general, regional,
supplementation of local Anesthesia, or other supportive services in order to afford the
patient the anesthesia care deemed optimal by the anesthesiologist during any procedure.
Unless specified in the procedure code, they are assigned in addition to the procedure code.
9.1.1.2 These services include the usual preoperative and postoperative visits, the anesthesia care
during the procedure, the administration of fluids and/or blood and the usual monitoring
services (e.g., ECG, temperature, blood pressure, oximetry, capnography, and mass
spectrometry). Unusual forms of monitoring (e.g., intra-arterial, central venous, and Swan-
Ganz) are not included.
9.1.1.3 Moderate Sedation - For the procedures, when a second physician other than the health care
professional performing the diagnostic or therapeutic services provides moderate (conscious)
sedation in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center,
skilled nursing facility), the second physician reports the associated moderate sedation
procedure/service (99155,99156,99157) when these services are performed by the second
physician in the non-facility setting (e.g., physician office, freestanding imaging center), codes
(99155,99156,99157) would not be reported. Moderate sedation does not include minimal
sedation (anxiolysis), deep sedation, or monitored anesthesia care (00100-01999). Take note
of the extensive editions on pages 676-678 in the 2018 CPT codebook for Moderate Sedation.
9.1.1.4 Separate or Multiple Procedures - When multiple surgical procedures are performed during a
single anesthetic administration, the anesthesia code representing the most complex
procedure is reported. The time reported is the combined total for all procedures.
9.1.1.5 Time for Reporting - Anesthesia time begins when the anesthesiologist begins to prepare the
patient for the induction of anesthesia in the operating room or in an equivalent area and
ends when the anesthesiologist is no longer in personal attendance, that is, when the patient
may be safely placed under postoperative supervision.
9.1.1.6 Aborted Procedure - Modifier 73/74 will be added to the relevant anesthesia code in the case
of an aborted or discontinued anesthesia procedures
9.1.1.7 For further information See Chapter Ten, CPT Surgical Package, in addition to the DOH Claims
and Adjudication Rules.

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 10. Chapter Ten: Surgery
Surgery
Physicians' services rendered in the office, home, or hospital, consultations, and other medical services are listed in
the section entitled Evaluation and Management Services (99201-99499, Chapter Eight E & M Codes)

10.1.1 CPT Surgical Package

The services provided by the physician to any patient by their very nature are variable. The CPT codes that
represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of
services. In defining the specific services "included" in a given CPT surgical code, the following services related to
the surgery when furnished by the physician or other qualified health care professional who performs the surgery
are included in addition to the operation per se:

▪ Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before
and/or day of surgery (including history and physical)
▪ Local infiltration, metacarpal/metatarsal/digital block or topical Anesthesia;
▪ Immediate postoperative care, including dictating operative notes, talking with the family and other
physicians or other qualified health care professionals;
▪ Writing orders;
▪ Evaluating the patient in the post-Anesthesia recovery area;
▪ Typical postoperative follow-up care.

10.1.2 Follow-up Care for Diagnostic Procedures

10.1.2.1 Follow-up care for diagnostic procedures (e.g., endoscopy, arthroscopy, injection procedures
for radiography) includes only that care related to recovery from the diagnostic procedure
itself. Care of the condition for which the diagnostic procedure was performed or of other
concomitant conditions is not included and may be listed separately.

10.1.3 Follow-up Care for Therapeutic Surgical Procedures

10.1.3.1 Follow-up care for therapeutic surgical procedures includes only that care which is usually a
part of the surgical service. Complications, exacerbations, recurrence, or the presence of
other diseases or injuries requiring additional services should be separately reported.

10.1.4 Supplied Materials

10.1.4.1 Supplies and materials (e.g., sterile trays/drugs), over and above those usually included with
the procedure(s) carried out are reported separately. List drugs, trays, supplies, and materials
provided. Identify the specific supply code.

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 10.1.5 Reporting More than Once Procedure/ Service

10.1.5.1 When more than one procedure/ service is performed on the same date, same session or
during a post-operative period (subject to the “surgical package” concept), several CPT
modifiers may apply. (See Appendix A in 2018 CPT Codebook for definition.)

10.1.6 Separate Procedure

10.1.6.1 Some of the procedures or services listed in the CPT codebook that are commonly carried out
as an integral component of a total service or procedure have been identified by the inclusion
of the term ‘separate procedure’. The codes designated as ‘separate procedure’ should not
be reported in addition to the code for the total procedure or service of which it is
considered an integral component.
10.1.6.2 When a procedure or service that is designated as a ‘separate procedure’ is carried out
independently or considered to be unrelated or distinct from other procedures/ services
provided at that time, it may be reported by itself or in addition to other procedures/ services
by adding modifier 59 to the specific ‘separate procedure’ code to indicate that the
procedure is not considered to be a component of another procedure, but is a distinct
independent procedure. This may represent a different session or patient encounter,
different procedure or surgery, different site or organ system, separate incision/ excision,
separate lesion, separate injury or are of injury in extensive injuries.

10.1.7 Subsection Information

10.1.7.1 Many of the Subheadings and Subsections in the CPT book have special needs or instructions
unique to that section. The coder should always refer to these guidelines when assigning
codes and these guidelines, as stated in the CPT book, are the rules for coding all CPT code(s)
in the Emirate of Abu Dhabi. Where these are indicated (e.g., "Maternity Care and Delivery"),
special "Notes" will be presented preceding those procedural terminology listings, referring
to that subsection specifically. If there is an "Unlisted Procedure" code number (see below)
for the individual subsection, it will also be shown.

10.1.8 Unlisted Procedures Code(s) (Surgery Section)

10.1.8.1 A service or procedure may be provided that is not listed in the CPT2018 Edition. When
reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate
the service. The "Unlisted Procedures" and accompanying codes for Surgery are as follows:
The following applies to Unlisted Procedures in the Emirate of Abu Dhabi:
10.1.8.2 Report the specific “unlisted” procedure code from the chapter in CPT that it belongs to and
is relevant for the documentation (i.e., don't use the service code for undefined services)

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 10.1.8.3 Charge the pre-agreed price for this code. If no specific charge has been pre-agreed, then
use the charge of the most closely related procedure, and describe this procedure in an
Observation (Type=Text,Code=ClosestUnlistedProcedure,Value=Text description of
procedure);
10.1.8.4 Disagreements on price can be resolved through the remittance/resubmission process
10.1.8.5 For the avoidance of doubt, the process of claiming for unlisted procedures does not alter the
benefits coverage for members

10.1.9 Musculoskeletal System

The codes for treatment of fractures and joint injuries (dislocations are categorized by the type of manipulation
(reduction) and stabilization (fixation or immobilization). These codes can only apply to either open (compound) or
closed fractures or joint injuries.

The type of fracture (e.g.: open, compound, closed) does not have any coding correlation with the type of
treatment. (Closed, open or percutaneous)

10.1.9.1 Closed Treatment: specifically means that the fracture site is not surgically opened (exposed
to the external environment and directly visualized). This terminology is used to describe
procedures that treat fractures by three methods: 1) without manipulation; 2) with
manipulation; or 3) with or without traction.
10.1.9.2 Open Treatment: is used when the fractured bone is either: 1) surgically opened (exposed to
the external environment) and the fracture (bone ends) visualized and internal fixation may
be used; or 2) the fractured bone is opened remote from the fracture site in order to insert
an intramedullary nail across the fracture site (the fracture site is not opened and visualized)
10.1.9.3 Percutaneous skeletal fixation describes fracture treatment which is neither open nor closed.
In this procedure, the fracture fragments are not visualized, but fixation (e.g., pins) is placed
across the fracture site, usually under X-ray imaging.
10.1.9.4 Skeletal traction is the application of a force (distracting or traction force) to a limb segment
through a wire, pin, screw, or clamp that is attached (e.g., penetrates) to bone.
10.1.9.5 Skin traction is the application of a force (longitudinal) to a limb using felt or strapping
applied directly to skin only.
10.1.9.6 External fixation is the usage of skeletal pins plus an attaching mechanism/device used for
temporary or definitive treatment of acute or chronic bony deformity. Codes for external
fixation are to be used only when external fixation is not already listed as part of the basic
procedure.

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10.1.10 Application of Casts, Strapping and Fixation [29000 -29799]

I. Cast and strapping procedure appear at the end of the Musculoskeletal System section of the CPT
2018 Codebook section
II. The services listed in the introduction of the Musculoskeletal System section of the CPT 2018
Codebook namely (Open /Closed treatment and percutaneous skeletal fixation) includes the
application and removal of the first cast or traction device only. Subsequent replacement of the cast
and or traction device may require additional listing.
III. The listed procedures apply when the cast application or strapping is a replacement procedure used
during or after the period of follow-up care, or when the cast application or strapping is an initial
service performed without a restorative treatment or procedure(s) to stabilize or protect a fracture,
injury or dislocation and/or to afford comfort to a patient. Restorative treatment or procedure(s)
rendered by another physician following the application of the initial cast/splint/strap may be reported
with a treatment of fracture and/or dislocation code.
IV. An individual who applies the initial cast, strap or splint and also assumes all of the subsequent
fracture, dislocation, or injury care cannot use the application of casts and strapping codes as an initial
service, since the first cast/splint or strap application is included in the treatment of fracture and/or
dislocation codes. A temporary cast/splint/strap is not considered to be part of the preoperative care.
Additional evaluation and management services are reportable only if significant identifiable further
services are provided at the time of the cast application or strapping. If the cast application or
strapping is provided as an initial service (e.g., casting of a sprained ankle or knee) in which no other
procedure or treatment (e.g., surgical repair, reduction of a fracture, or joint dislocation) is performed
or is expected to be performed by an individual rendering the initial care only, use the casting,
strapping, and/or supply code (99070) in addition to an evaluation and management code as
appropriate. Listed procedures include removal of cast or strapping.

10.1.11 Excision of subcutaneous soft tissue tumors

10.1.11.1 Excision of subcutaneous soft tissue tumors (including simple or intermediate repair) involves
the simple or marginal resection of tumors confined to subcutaneous tissue below the skin
but above the deep fascia. These tumors are usually benign and are resected without
removing a significant amount of surrounding normal tissue. Code selection is based on the
location and size of the tumor. Code selection is determined by measuring the greatest
diameter of the tumor plus that margin required for complete excision of the tumor. The
margins refer to the narrowest margin required to adequately excise the tumor, based on the
physician's judgment.
10.1.11.2 The measurement of the tumor plus margin is made at the time of the excision. Appreciable
vessel exploration and/or neuroplasty should be reported separately. Extensive undermining
or other techniques to close a defect created by skin excision may require a complex repair
which should be reported separately.

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 10.1.11.3 Dissection or elevation of tissue planes to permit resection of the tumor is included in the
excision. For excision of benign lesion for cutaneous origin (e.g. Sebaceous cyst) see 11400-
11446.

10.1.12 Excision of fascial or sub-fascial soft tissue tumors

10.1.12.1 Excision of fascial or sub-fascial soft tissue tumors (including simple or intermediate repair)
involves the resection of tumors confined to the tissue within or below the deep fascia, but
not involving the bone. These tumors are usually benign, are often intramuscular, and are
resected without removing a significant amount of surrounding normal tissue. Code selection
is based on size and location of the tumor. Code selection is determined by measuring the
greatest diameter of the tumor plus that margin required for complete excision of the tumor.
The margins refer to the narrowest margin required to adequately excise the tumor, based
on the physician's judgment.
10.1.12.2 The measurement of the tumor plus margin is made at the time of the excision. Appreciable
vessel exploration and/or neuroplasty should be reported separately. Extensive undermining
or other techniques to close a defect created by skin excision may require a complex repair
which should be reported separately. Dissection or elevation of tissue planes to permit
resection of the tumor is included in the excision. Digital (i.e. fingers and Toes) subfascial
tumors are defined as those tumors involving the tendons sheaths or joints of the digit.
Tumors which simply abut but don not breach the tendon, tendon sheath or joint capsule are
considered soft tissue tumors.

10.1.13 Radical resection of soft tissue tumors

10.1.13.1 Radical resection of soft tissue tumors (including simple or intermediate repair) involves the
resection of the tumor with wide margins of normal tissue. Appreciable vessel exploration
and/or neuroplasty repair or reconstruction (e.g., adjacent tissue transfer[s], flap[s]) should
be reported separately. Extensive undermining or other techniques to close a defect created
by skin excision may require a complex repair which should be reported separately.
10.1.13.2 Dissection or elevation of tissue planes to permit resection of the tumor is included in the
excision. Although these tumors may be confined to a specific layer (e.g., subcutaneous,
subfascial), radical resection may involve removal of tissue from one or more layers. Radical
resection of soft tissue tumors is most commonly used for malignant tumors or very
aggressive benign tumors. Code selection is based on size and location of the tumor. Code
selection is determined by measuring the greatest diameter of the tumor plus that margin
required for complete excision of the tumor.

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 10.1.13.3 The margins refer to the narrowest margin required to adequately excise the tumor, based
on the physician's judgment. The measurement of the tumor plus margin is made at the time
of the excision. For radical resection of tumors of cutaneous origin, (e.g., melanoma) see
11600-11646.

10.1.14 Radical resection of bone tumors

10.1.14.1 Radical resection of bone tumors (including simple or intermediate repair) involves the
resection of the tumor with wide margins of normal tissue. Appreciable vessel exploration
and/or neuroplasty and complex bone repair or reconstruction (e.g., adjacent tissue
transfer[s], flap[s]) should be reported separately. Extensive undermining or other techniques
to close a defect created by skin excision may require a complex repair which should be
reported separately.
10.1.14.2 Dissection or elevation of tissue planes to permit resection of the tumor is included in the
excision. It may require removal of the entire bone if tumor growth is extensive (e.g.,
clavicle). Radical resection of bone tumors is usually performed for malignant tumors or very
aggressive benign tumors. If surrounding soft tissue is removed during these procedures, the
radical resection of soft tissue tumor codes should not be reported separately. Code selection
is based solely on the location of the tumor, not on the size of the tumor or whether the
tumor is benign or malignant, primary or metastatic.

10.1.15 Integumentary System

10.1.15.1 Repair (Closure)

Use the codes in the Integumentary Section to designate wound closure utilizing sutures, staples,
or tissue adhesives (e.g., 2-cyanoacrylate), either singly or in combination with each other, or in
combination with adhesive strips. Wound closure utilizing adhesive strips as the sole repair
material should be coded using the appropriate E/M code. The repair of wounds may be classified
as Simple, intermediate or Complex. (See Chapter Two Procedure Coding Terms and Guidelines)
10.1.15.2 Definitions of classifications:
I. Simple repair is used when the wound is superficial; e.g., involving primarily epidermis or dermis, or
subcutaneous tissues without significant involvement of deeper structures, and requires simple
one-layer closure. This includes local anesthesia and chemical or electrocauterization of wounds
not closed.
II. Intermediate repair includes the repair of wounds that, in addition to the above, require layered
closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle)
fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily
contaminated wounds that have required extensive cleaning or removal of particulate matter also
constitutes intermediate repair.

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 III. Complex repair includes the repair of wounds requiring more than layered closure, viz., scar
revision, debridement, (e.g., traumatic lacerations or avulsions), extensive undermining, stents or
retention sutures. Necessary preparation includes creation of a limited defect for repairs (e.g.,
excision of a scar requiring a complex repair) or the debridement of complicated lacerations or
avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-
11646) lesions, excisional preparation of a wound bed (15002-15005) or debridement of an open
fracture or open dislocation.

10.1.16 Instructions for listing services at time of wound repair

10.1.16.1 The repaired wound(s) should be measured and recorded in centimeters, whether curved,
angular, or stellate.
10.1.16.2 When multiple wounds are repaired, add together the lengths of those in the same
classification (see above) and from all anatomic sites that are grouped together into the same
code descriptor. For example, add together the lengths of intermediate repairs to the trunk
and extremities. Do not add lengths of repairs from different groupings of anatomic sites
(e.g., face and extremities). Also, do not add together lengths of different classifications (e.g.,
intermediate and complex repairs).
10.1.16.3 When more than one classification of wounds is repaired, list the more complicated as the
primary procedure and the less complicated as the secondary procedure, using modifier 59.
▪ Decontamination and/or debridement: Debridement is considered a separate procedure only when
gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or
contaminated tissue are removed, or when debridement is carried out separately without immediate
primary closure.
10.1.16.4 (For extensive debridement of soft tissue and/or bone, not associated with open fracture(s)
and/or dislocation(s) resulting from penetrating and/or blunt trauma, see 11042-11047.)
10.1.16.5 (For extensive debridement of subcutaneous tissue, muscle fascia, muscle, and/or bone
associated with open fracture(s) and/or dislocation(s), see 11010-11012.)
▪ Involvement of nerves, blood vessels and tendons: Report under appropriate system (Nervous,
Cardiovascular, Musculoskeletal) for repair of these structures. The repair of these associated
wounds is included in the primary procedure unless it qualifies as a complex repair, in which case
modifier 59 applies.
10.1.16.6 Simple ligation of vessels in an open wound is considered as part of any wound closure.
Simple "exploration" of nerves, blood vessels or tendons exposed in an open wound is also
considered part of the essential treatment of the wound and is not a separate procedure
unless appreciable dissection is required. If the wound requires enlargement, extension of
dissection (to determine penetration), debridement, removal of foreign body(s), ligation or
coagulation of minor subcutaneous and/or muscular blood vessel(s) of the subcutaneous

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 tissue, muscle fascia, and/or muscle, not requiring thoracotomy or laparotomy, use codes
20100-20103, as appropriate.

10.1.17 Spine (Vertebral Column)

10.1.17.1 Within the spine section (Cervical, thoracic and lumbar spine), bone grafting procedures are
reported separately and in addition to arthrodesis. For bone grafts in other Musculoskeletal
sections, see specific code(s) descriptor(s) and/or accompanying guidelines.
10.1.17.2 Within the spine section (Cervical, thoracic and lumbar spine), instrumentation is reported
separately and in addition to arthrodesis. To report instrumentation procedures performed
with definitive vertebral procedure(s), see 22840-22855,22859 Instrumentation procedure
codes 22840-22848, 22853,22854,22859 are reported in addition to the definitive
procedure(s). Modifier 62 may not be appended to the definitive or add-on spinal
instrumentation procedure codes(s) 22840-22848, 22850, 22852, 22853,22854,22859
10.1.17.3 When arthrodesis is performed in addition to another procedure, the arthrodesis should be
reported in addition to the original procedure with modifier 51 (Multiple Procedures).
Examples are after osteotomy, fracture care, vertebral corpectomy and laminectomy. Bone
grafts and instrumentation are never performed without arthrodesis.

10.1.18 Endoscopy/Arthroscopy

10.1.18.1 Selective vascular catheterizations should be coded to include introduction and all lesser
order selective catheterizations used in the approach (e.g., the description for a selective
right middle cerebral artery catheterization includes the introduction and placement
catheterization of the right common and internal carotid arteries). Additional second and/or
third order arterial catheterizations within the same family of arteries supplied by a single
first order artery should be expressed by 36218 or 36248. Additional first order or higher
catheterizations in vascular families supplied by a first order vessel different from a
previously selected and coded family should be separately coded using the conventions
described above.

10.1.19 Cardiovascular System

10.1.19.1 Surgical endoscopy/arthroscopy always includes a diagnostic endoscopy/arthroscopy.

10.1.19.2 When an arthroscopy is performed in conjunction with arthrotomy, add modifier 51.

10.1.20 Arteries and Veins

10.1.20.1 Primary vascular procedure listings include establishing both inflow and outflow by whatever
procedures necessary. Also included is that portion of the operative arteriogram performed
by the surgeon, as indicated. Sympathectomy, when done, is included in the listed aortic
procedures.

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10.1.21 Chemotherapy

10.1.21.1 For provision of chemotherapeutic agents, report both the specific service codes or modes of
administration. Use DoH Drug codes NOT CPT product codes.

10.1.22 Maternity Care and Delivery

10.1.22.1 The services normally provided in uncomplicated maternity cases include antepartum care,
delivery, and postpartum care; however, at this time in the Emirate of Abu Dhabi these
‘package’ codes are not utilized do to Billing Rules with the Payor.
10.1.22.2 Delivery services include admission to the hospital, the admission history and physical
examination, management of uncomplicated labor, vaginal delivery (with or without
episiotomy, with or without forceps), or caesarean delivery. When reporting delivery only
services (59409, 59514, 59612, 59620), report inpatient post -delivery management and
discharge services using Evaluation and Management Services codes. Delivery and
10.1.22.3 postpartum services (59410, 59515, 59614, and 59622) include delivery services and all
inpatient and outpatient postpartum services. Medical problems complicating labor and
delivery management may require additional resources and should be identified by utilizing
the codes in the Medicine and Evaluation and Management Services section in addition to
codes for maternity care.
10.1.22.4 The code(s) for Antepartum care includes the initial and subsequent history, physical
examinations, recording of weight, blood pressures, fetal heart tones, routine chemical
urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation,
and weekly visits until delivery. Any other visits or services within this time period should be
coded separately.
10.1.22.5 The code(s) for Postpartum care only services (59430) include office or other outpatient visits
following vaginal or caesarean section delivery. Postpartum care includes hospital and office
visits following vaginal or caesarean section delivery.

10.1.23 Operating Microscope (+69990 Code)

10.1.23.1 The surgical microscope is employed when the surgical services are performed using the
techniques of microsurgery. Code 69990 should be reported in addition to the code for the
primary procedure performed. Do not use 69990 for visualization with magnifying loupes or
corrected vision. Do not report 69990 in addition to procedures where use of the operating
microscope is an inclusive component (15756-15758, 15842, 19364, 19368, 20955-20962,
20969-20973, 22551, 22552, 22856-22861, 26551-26554, 26556, 31526, 31531, 31536,
31541, 31545, 31546, 31561, 31571, 43116, 43180, 43496, 46601, 46607, 49906, 61548,
63075-63078, 64727, 64820-64823,64912,64913, 65091-68850, 0184T,0308T.

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 11. Chapter Eleven: Radiology
Radiology Guidelines (Including Nuclear Medicine and Diagnostic Ultrasound)
11.1.1 Subject Listings

All codes in this Section apply when radiological services are performed by or under the responsible supervision of
a physician.

11.1.2 Unlisted Procedure(s) Radiology Section

11.1.2.1 A service or procedure may be provided that is not listed in this edition of the CPT codebook.
When reporting such a service, the appropriate "Unlisted Procedure" code may be used to
indicate the service, identifying it by "Special Report" as discussed below. The "Unlisted
Procedures" and accompanying codes for Radiology (Including Nuclear Medicine and
Diagnostic Ultrasound) are as follows: Unlisted codes must be compared with the 2018
manual.

Unlisted
Unlisted Code Description
Code

76496 Unlisted fluoroscopic procedure (e.g., diagnostic, interventional)

76497 Unlisted computed tomography procedure (e.g. Diagnostic, interventional)

76498 Unlisted magnetic resonance procedure (e.g. Diagnostic, interventional)

76499 Unlisted diagnostic radiographic procedure

76999 Unlisted ultrasound procedure (e.g. diagnostic, interventional)

77299 Unlisted procedure, therapeutic radiology clinical treatment planning

Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special
77399
services

77499 Unlisted procedure, therapeutic radiology treatment management

77799 Unlisted procedure, clinical brachytherapy

78099 Unlisted endocrine procedure, diagnostic nuclear medicine

78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine

78299 Unlisted gastrointestinal procedure, diagnostic nuclear medicine

78399 Unlisted musculoskeletal procedure, diagnostic nuclear medicine

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 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine

78599 Unlisted respiratory procedure, diagnostic nuclear medicine

78699 Unlisted nervous system procedure, diagnostic nuclear medicine

78799 Unlisted genitourinary procedure, diagnostic nuclear medicine

78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine

79999 Radiopharmaceutical therapy, unlisted procedure

11.1.3 Separate Procedures

11.1.3.1 Some of the procedures or services listed in the CPT codebook that are commonly carried out
as an integral component of a total service or procedure have been identified by the inclusion
of the term "separate procedure." The codes designated as "separate procedure" should not
be reported in addition to the code for the total procedure or service of which it is
considered an integral component.

11.1.4 Subsection Information

11.1.4.1 Several of the subheadings or subsections have Guidelines &/or special needs or instructions
unique to that section. Where these are indicated (e.g., "Radiation Oncology") special "Notes"
will be presented preceding those procedural and coding coders are directed to adhere to
these Guidelines.

11.1.5 Supervision and Interpretation

11.1.5.1 Imaging may be required during the performance of certain procedures or certain imaging
procedures may require surgical procedures to access the imaged area. Many services
include image guidance which is not separately reportable and is so stated in the descriptor
or guidelines. When imaging is not included in a surgical procedure or procedure from the
Medicine section, image guidance codes or codes labelled "radiological supervision and
interpretation" may be reported for the portion of the service that requires imaging.
11.1.5.2 Both services require image documentation and radiological supervision, interpretation, and
report services require a separate interpretation.(The Radiological Supervision and
Interpretation codes are not applicable to the Radiation Oncology subsection.)

11.1.6 Administration of Contrast Material(s)

11.1.6.1 The phrase "with contrast" used in the codes for procedures performed using contrast for
imaging enhancement represents contrast material administered intravascularly, intra-
particularly or intrathecally.

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 11.1.6.2 For intra-articular injection, use the appropriate joint injection code. If radiographic
arthrography is performed, also use the arthrography supervision and interpretation code for
the appropriate joint (which includes fluoroscopy). If computed tomography (CT) or magnetic
resonance (MR) arthrography are performed without radiographic arthrography, use the
appropriate joint injection code, the appropriate CT or MR code (“with contrast” or “without
followed by contrast”), and the appropriate imaging guidance code for needle placement for
contrast injection.
11.1.6.3 For spine examinations using computed tomography, magnetic resonance imaging, magnetic
resonance angiography, “with contrast” includes intrathecal or intravascular injection. For
intrathecal injection, use also 61055 or 62284.
11.1.6.4 Injection of intravascular contrast material is part of the “with contrast” CT, computed
tomographic angiography (CTA), magnetic resonance imaging (MRI), and magnetic resonance
angiography (MRA) procedures.
11.1.6.5 Oral and/or rectal contrast administration alone does not qualify as a study “with contrast.”

11.1.7 Written Report(s)

11.1.7.1 A written report signed by the interpreting physician should be considered an integral part of
a radiologic procedure or interpretation

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12. Chapter Twelve: Pathology & Laboratory
Pathology & Laboratory
12.1.1 Services in Pathology and Laboratory

12.1.1.1 Services in Pathology and Laboratory are provided by a physician or by technologists under
responsible supervision of a physician.

12.1.2 Separate or Multiple Procedures

12.1.2.1 It is appropriate to designate multiple procedures that are rendered on the same date by
separate entries.

12.1.3 Subsection Information

12.1.3.1 Several of the subheadings or subsections have Guidelines and/or special needs or
instructions unique to that section. Where these are indicated, (e.g., "Organ or Disease
Oriented Panels "), special "Notes" will be presented preceding those procedural terminology
listings referring to that subsection specifically and coders must adhere to these. If there is
an "Unlisted Procedure" code number (see the following section) for the individual
subsection, it will be shown.

12.1.4 Organ or Disease-Oriented Panels (80047-80076)

12.1.4.1 These panels were developed for coding purposes only and should not be interpreted as
clinical parameters. The tests listed with each panel identify the defined components of that
panel.
12.1.4.2 These panel components are not intended to limit the performance of other tests. If one
performs tests in addition to those specifically indicated for a particular panel, those tests
should be reported separately in addition to the panel code.
12.1.4.3 Do not report two or more panel codes that include any of the same constituent tests
performed from the same patient collection. If a group of tests overlaps two or more panels,
report the panel that incorporates the greater number of tests to fulfil the code definition
and report the remaining tests using individual test codes (e.g., do not report 80047 in
conjunction with 80053).

12.1.5 Unlisted Service or Procedure (Pathology & Laboratory)

12.1.5.1 A service or procedure may be provided that is not listed in this edition of the CPT codebook.
When reporting such a service, the appropriate "Unlisted Procedure" code may be used to
indicate the service, the "Unlisted Procedures" and accompanying codes for Pathology and
Laboratory are as follows:

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 Unlisted Code Unlisted Code Description

81099 Unlisted urinalysis procedure

81479 Unlisted Molecular Pathology Procedure

81599 Unlisted multianalyte assay with algorithmic analysis

84999 Unlisted chemistry procedure

85999 Unlisted hematology and coagulation procedure

86486 Unlisted antigen, each

86849 Unlisted immunology procedure

86999 Unlisted transfusion medicine procedure

87999 Unlisted microbiology procedure

88099 Unlisted necropsy (autopsy) procedure

88199 Unlisted cytopathology procedure

88299 Unlisted cytogenetic study

88399 Unlisted surgical pathology procedure

88749 Unlisted in vivo (e.g., transcutaneous) laboratory service

89240 Unlisted miscellaneous pathology test

89398 Unlisted reproductive medicine laboratory procedure

12.1.6 Surgical Pathology (88300-88398)

12.1.6.1 Services 88300 through 88309 include accession, examination, and reporting. They do not
include the services designated in codes 88311 through 88365 and 88399, which are coded in
addition when provided
12.1.6.2 The unit of service for codes 88300 through 88309 is the specimen. A specimen is defined as
tissue or tissues that is (are) submitted for individual and separate attention, requiring
individual examination and pathologic diagnosis. Two or more such specimens from the same
patient (e.g., separately identified endoscopic biopsies, skin lesions) are each appropriately
assigned an individual code reflective of its proper level of service.

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12.1.6.3 Service code 88300 is used for any specimen that in the opinion of the examining pathologist
can be accurately diagnosed without microscopic examination. Service code 88302 is used
when gross and microscopic examination is performed on a specimen to confirm
identification and the absence of disease. Service codes 88304 through 88309 describe all
other specimens requiring gross and microscopic examination and represent additional
ascending levels of physician work. Levels 88302 through 88309 are specifically defined by
the assigned specimens.
12.1.6.4 Any unlisted specimen should be assigned to the code which most closely reflects the
physician work involved when compared to other specimens assigned to that code.

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 13. Chapter Thirteen: Medicine
Medicine
13.1.1 Multiple Procedures

It is appropriate to designate multiple procedures that are rendered on the same date by separate entries.

13.1.2 Subsection Information

13.1.2.1 Several of the subheadings or subsections have special instructions &/or guidelines unique to
that section. These special instructions &/or guidelines will be presented preceding those
procedural terminology listings, referring to that subsection specifically and coders must
adhere to these. Whereas all codes within the CPT code book are appropriate to assign, it is
advisable to refer to the Payer as to whether or not the specific code will be reimbursed.
This is especially true in the Medicine Section.

13.1.3 Vaccines, Toxoids (90476-90749)

13.1.3.1 These vaccine and toxoid codes are not assigned in the Emirate of Abu Dhabi. For correct
coding and billing, one must assign the required Mandatory Tariff version of the Pharmacy
Drug Codes (DoH Drug codes) as defined by DoH Pharma and regulated by DoH. The
Pharmacy Drug Code(s) must be reported in addition to the administration code(s) 90460 and
90461 with the following criteria:
13.1.3.2 Report codes 90460 and 90461 only when the physician or qualified health care professional
provides face-to-face counselling of the patient and family during the administration of a
vaccine. For immunization administration of any vaccine that is not accompanied by face-to-
face physician or qualified health care professional counselling to the patient/family or for
administration of vaccines to patients over 18 years of age, report codes 90471-90474.
13.1.3.3 For the emirate of Abu Dhabi, vaccinations administration is reported by occurrence or
number of injections given and not by the count of vaccine / toxoid components
13.1.3.4 If a significant separately identifiable Evaluation and Management service (e.g., office or
other outpatient services, preventive medicine services) is performed, the appropriate E/M
service code should be reported in addition to the vaccine and toxoid administration codes.

13.1.4 Immune Globulins, Serum or Recombinant Products (90281-90399)

13.1.4.1 Codes 90281-90399 identify the serum globulins, extracted from human blood; or
recombinant immune globulin products created in a laboratory through genetic modification
of human and/or animal proteins. These CPT codes are not assigned in the Emirate of Abu
Dhabi. For correct coding and billing, the required Mandatory Tariff version of the Pharmacy
Drug Codes (DoH Drug codes) as defined by DoH Pharma and regulation by DoH.

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 13.1.5 Unlisted Service or Procedure

A service or procedure may be provided that is not listed in the edition of 2018 CPT codebook. When reporting
such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service. The "Unlisted
Procedures" and accompanying codes for Medicine are as follows:

Unlisted Code Unlisted Code Description

90399 Unlisted immune globulin
90749 Unlisted vaccine/toxoid

90899 Unlisted psychiatric service or procedure

90999 Unlisted dialysis procedure, inpatient or outpatient

91299 Unlisted diagnostic gastroenterology procedure

92499 Unlisted ophthalmological service or procedure

92700 Unlisted otorhinolaryngological service or procedure

93799 Unlisted cardiovascular service or procedure

93998 Unlisted noninvasive vascular diagnostic study

94799 Unlisted pulmonary service or procedure

95199 Unlisted allergy/clinical immunologic service or procedure

95999 Unlisted neurological or neuromuscular diagnostic procedure

96379 Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion

96549 Unlisted chemotherapy procedure

96999 Unlisted special dermatological service or procedure

97039 Unlisted modality (specify type and time if constant attendance)

97139 Unlisted therapeutic procedure (specify)

97799 Unlisted physical medicine/rehabilitation service or procedure

99199 Unlisted special service, procedure or report

99600 Unlisted home visit service or procedure

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14. Chapter Fourteen: Category II Codes
Category II (A0021-V5364)
14.1.1 Category II (HCPCS) and High Cost Device List for Abu Dhabi

14.1.1.1 Category II Codes are supplemental tracking codes that can be used for performance
measurement. These codes are intended to facilitate data collection about the quality of care
rendered by coding certain services and test results that support nationally established
performance measures and that have an evidence base as contributing to quality patient
care.
14.1.1.2 The use of these codes is optional. The codes are not required for correct coding and may not
be used as a substitute for Category I codes.
14.1.1.3 These codes describe clinical components that may be typically included in evaluation and
management services or clinical services and, therefore, do not have a relative value
associated with them. Category II codes may also describe results from clinical laboratory or
radiology tests and other procedures, identified processes intended to address patient safety
practices, or services reflecting compliance
14.1.1.4 Category II codes, often referred to as “HCPCS Codes” make use of alphabetical characters
with each alphabetical letter referring toc category, such as ‘D” for Dental. Not all the
categories are currently in use as the ‘J’ codes are not be used as the MOH/DOH drug list with
the Drug codes is an example.
14.1.1.5 Category II codes are reviewed by the Performance Measures Advisory Group (PMAG), an
advisory body to the CPT Editorial Panel and the CPT/HCPAC Advisory Committee. The PMAG
is comprised of performance measurement experts representing the Agency for Healthcare
Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for
Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and the Physician
Consortium for Performance Improvement® (PCPI). The PMAG may seek additional expertise
and/or input from other national health care organizations, as necessary, for the
development of tracking codes. These may include national medical specialty societies, other
national health care professional associations, accrediting bodies, and federal regulatory
agencies.
14.1.1.6 Effective the 15th September 2014 Abu Dhabi makes use of specific HCPCS codes to identify
high cost devices with the goal being to reimburse a limited number or new technology
devises or high cost devices that are that are not fully recognized in the DRG weights. This
table has been updated for 2020.
14.1.1.7 The revised devices that are eligible for the add- on payment, High Cost Listed HCPCS as per
the*** January 2020, may be found in the updated listing.

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15. Chapter Fifteen: Category III Codes
Category III Codes (0019T-0259T)
15.1.1 Temporary Codes for New technology

15.1.1.1 This section contains a set of temporary codes for emerging technology, services, and
procedures. Category III codes will allow data collection for these services/procedures. If a
Category III code is available, this code must be reported instead of a Category I unlisted
code.
15.1.1.2 All CPT codes are relevant for assignation; however, it is advised that the coder communicate
with the Payer prior to assigning these codes for billing purposes. Services/procedures
described in this section make use of alphanumeric characters.
15.1.1.3 These codes have an alpha character as the 5th character in the string, preceded by four
digits. The digits are not intended to reflect the placement of the code in the Category I
section of CPT nomenclature.
15.1.1.4 Codes in this section may or may not eventually receive a Category I CPT code. In either case,
in general, a given Category III code will be archived five years from its date of publication or
revision in the CPT code book unless it is demonstrated that a temporary code is still needed.
Services/procedures described by Category III codes which have been archived after five
years, without conversion, may be reported using the Category I unlisted code. New codes in
this section are released semi-annually via the AMA/CPT internet site, to expedite
dissemination for reporting. The full set of temporary codes for emerging technology,
services, and procedures are published annually in the CPT codebook. Go to www.ama-
assn.org/go/cpt for the most current listing.

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 16. Chapter Sixteen: COVID CPT Codes
Due to the pandemic nature of the Coronavirus Disease (COVID-19) the current coding guidelines are listed below
to assist healthcare providers with the understanding that the newly added CPT codes will only be available in the
2021 CPT edition.89

All CPT codes are included in the DRG for payment.

16.1.1 Influenza POCT = 2 units

16.1.2 87804: Infectious agent antigen detection by immunoassay with direct optical observation; Influenza.

16.1.3 MDX: Novel Human Coronavirus RT-PCR = 1 unit

16.1.4 87798: Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified
probe technique, each organism

16.1.5 Respiratory Panel would be requested for cases with Pneumonia based on clinical judgement of the
physician

16.1.6 8763510: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique11

8
Addendum 10: To HAAD Claims and Adjudication Rules: COVID Coding guidelines
9
https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf
10
https://www.ama-assn.org/system/files/2020-05/cpt-reporting-covid-19-testing.pdf
11
https://www.ama-assn.org/system/files/2020-03/cpt-assistant-guide-coronavirus.pdf

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17. Chapter Seventeen: Observation Codes
Observation Codes
17.1.1 General Observation guidelines

17.1.1.1 This section describes observation codes and the two types of observation found namely
Ancillary and Medical
17.1.1.2 The HCPCS codes G0378 and G0379 are essential to observation coding and if it not used the
EAPG will not recognize the observation service which has been rendered.
17.1.1.3 The unit of service needs to be documented, in addition to the HCPCS codes for observation
time namely, 2 hours, 4 hours or 8 hours.
17.1.1.4 The primary diagnosis needs to be documented, to indicate the reason for observation and
must always be present.
17.1.1.5 Modifier 25 may be utilized in observation services when added to the MVI (medical visit
indicator) when a significant procedure is reported.
17.1.1.6 All observation is packaged in the presence of a significant procedure

EAPG types:

2 Significant Procedure 23 Dental Procedure

21 Physical Therapy & Rehab 24 Radiologic Procedure

22 Mental Health & Counseling 25 Diagnostic Significant Proc

17.1.2 Ancillary Observation

17.1.2.1 The Ancillary observation requirements are the following:

▪ No significant procedure present.

▪ MVI (Medical Visit Indicator) present

▪ Primary Diagnosis

▪ G0378 present, with the number of hours in the units’ field

17.1.2.2 The medical visit indicator is coded via the follow codes:

▪ Medical visit in EAPG is assigned based on the primary diagnosis code

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 ▪ Evaluation and management (E/M) codes:

- 99201 – 99205;

- 99211 – 99214,

- 99281 – 99285,

- G0378, G0379

17.1.2.3 Ancillary observation is based on MVI, the primary diagnosis code and G0378, which will
assign to EAPG 450 (Observation).

17.1.3 Medical Observation

17.1.3.1 The Medical observation requirements are the following:

▪ No significant procedure present.

▪ No medical visit indicator present

▪ Observation visit indicator (OVI) i.e. G0379

▪ Primary Diagnosis

▪ G0378 is present, with number of hours in units’ field

17.1.3.2 This situation is where observation is the primary reason for the visit. For example, a patient
may be sent directly from his/her physician with a script to the ED to be admitted for
observation care, so no ED E&M code would be present. Because observation is the primary
service, an OVI, such as G0379, must be present on the claim, in addition to the G0378
17.1.3.3 Medical observation EAPG assigned by OVI based is on primary diagnosis code assigns to:

▪ 500 ENCOUNTER/REFERRAL FOR OBSERVATION –OBSTETRICAL 3 (Medical)

▪ 501 ENCOUNTER/REFERRAL FOR OBSERVATION -OTHER DIAGNOSES 3 (Medical)

▪ 502 ENCOUNTER/REFERRAL FOR OBSERVATION -BEHAVIORAL HEALTH 3 (Medical)

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17.1.3.4 The list below indicates the Observation visit indicator (OVI) codes:

CODE CODE DESCRIPTION

99217 Observation Care discharge

99218 Initial Observation Care

99219 Initial Observation Care

99220 Initial Observation Care

99224 Subsequent Observation Care

99225 Subsequent Observation Care

99226 Subsequent Observation Care

99234 Observation/Hospital same date

99235 Observation/Hospital same date

99236 Observation/Hospital same date

G0379 Direct refer hospital observation

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Data Standards

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 1. Chapter Chapter 1
Clinical Coders are responsible for the data abstraction ensuring that the discharge disposition of the patient is
correct and that the coding is as per the service area the patient received care in. In the Emirate of Abu Dhabi
these codes may be found as per the Data Elements in the link below.
See the DOH Data Elements (alphabetical) https://doh.gov.ae/en/Shafafiya

Place-of-Service Codes / Encounter Codes for Claims

Listed below are place-of-service codes and descriptions which are utilized in the Emirate of Abu Dhabi. These
codes should be used on claims in the Encounter Type.
They specify the entity where service(s) were rendered along with the established Encounter Type.
Check with individual payers for reimbursement policies regarding these codes.

Place of Service Place of Service Place of Service Description

Code(s) Name
1 Outpatient No Bed + No Emergency room

2 Emergency Room No Bed + Emergency room

3 Inpatient Inpatient Bed + No Emergency room

4 Inpatient Inpatient Bed + Emergency room

5 Day case Day case Bed + No Emergency room

6 Day case Day case Bed + Emergency room

7 National Screening

8 New Visa Screening

9 Renewal Visa Screening

12 Home Location, other than a hospital or other facility, where the patient receives care in
a private residence.

13 Assisted Living Facility Congregate residential facility with self-contained living units providing assessment
of each resident’s needs and on-site support 24 hours a day, 7 days a week, with
the capacity to deliver or arrange for services including some health care and
other services.

15 Mobile Unit A facility/unit that moves from place-to-place equipped to provide preventive,
screening, diagnostic, and/or treatment services.

41 Ambulance - Land A land vehicle specifically designed, equipped and staffed for lifesaving and
transporting the sick or injured.

42 Ambulance – Air or Water An air or water vehicle specifically designed, equipped and staffed for lifesaving
and transporting the sick or injured.

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3.1.1. There are different ways to classify Encounters as inpatients and ambulatory (day cases, emergencies and
outpatients). They vary according to whether the Encounter went past midnight, lasted for more than 24
hours, involved a hospital bed and whether they involved an emergency room. To benchmark with
different countries, one needs to know, whether the patient was in the emergency room, and whether the
patient occupied a hospital bed.
3.1.2. An Inpatient bed is a licensed bed approved by the competent authority which is assigned to a patient who
is arriving to a health care facility for an emergent, urgent or elective/planned Encounter. Beds assigned
temporarily for "holding" purposes in a no bed situation may be designated and included in hospital
occupancy rate calculation (e.g. emergency room, recovery room). Only beds included in the licensed
inpatient bed complement will be used for purposes of hospital occupancy rate calculation. Beds may have
an associated accommodation value such as private (i.e. single bed/room) or shared (i.e. multiple
beds/room).
3.1.3. Beds included in the inpatient bed complement:
• Beds in general wards or units set up and staffed for inpatient services
• Beds in special care units set up and staffed for inpatient services such as intensive care, coronary care,
neonatal intensive care, pediatric intensive care, medical and surgical step-down, burn units
3.1.4. Beds excluded from the inpatient bed complement:
• Beds/cots for healthy newborns
• Beds in Day Care units, such as surgical, medical, pediatric day care, interventional radiology • Beds in
Dialysis units
• Beds in Labor Suites (e.g. day of birth beds, birthing chairs)
• Beds in Operating Theatre
• Temporary beds such as stretchers
• Chairs, Cots or Beds used to accommodate sitters, parents, guardians accompanying patients or sick
children and healthy baby accompanying a hospitalized breast-feeding mother
• Beds closed during renovation of patient care areas when approved by the competent authority
3.1.5. Day case bed is also known as observation beds and are beds used in Day Care units such as surgical,
medical, pediatric day-care interventional radiology. They are not included in the inpatient bed
complement.
3.1.6. Restrictions: Only Encounter values allowed are: 1 = No Bed + No emergency room 2 = No Bed +
Emergency room 3 = Inpatient Bed + No emergency room 4 = Inpatient Bed + Emergency room 5 = Day
case Bed + No emergency room 6 = Day case Bed + Emergency room 7 = Nationals Screening 8 = New Visa
Screening 9 = Renewal Visa Screening 12 = Home 13 = Assisted Living Facility 15 = Mobile Unit 41 =
Ambulance - Land 42 = Ambulance - Air or Water.
3.1.7. All encounters are further divided into Encounter Start and Encounter End with types for both.

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3.1.8. EncounterStart or commonly known as the Admission date, is the date and time at which the patient
comes under the care of a responsible clinician.
▪ For Elective patients this will typically be the date and time of the visit registration/admission on
arrival of the patient at the healthcare facility.
▪ For Emergency patients this will typically be the date and time of the registration and admission on
arrival of the patient at the healthcare facility.
▪ For Transfer patients between facilities (i.e. inter-hospital transfers), this will typically be the date
and time of the visit registration and admission on arrival of the patient at the receiving healthcare
facility.
▪ For Livebirth this will typically be the date and time of the registration and admission of the
newborn at the healthcare facility. The Encounter start will also be the date and time of birth.
▪ For Stillbirth this will typically be the date and time of the registration of the stillborn at the
healthcare facility. The Encounter start will also be the date and time of stillbirth.
▪ For Death on arrival this will typically be the date and time of the visit registration on arrival of the
patient at the healthcare facility for pronouncement. Restrictions: Needs to be after 1/1/1900 and
before the present.
3.1.9. EncounterStart Types are seen in the below table:

Encounter Start
Encounter Start Name Encounter Start Description
Code

1 Elective An Encounter is scheduled in advance

2 Emergency An Encounter not scheduled in advance

3 Transfer An admission from acute care

4 Live birth Livebirth Born within the facility

5 Stillbirth Stillbirth within the facility

6 Dead on Arrival

7 Continuing Encounter

I. Example 1 | An urgent referral from an outpatient clinic to the cardiology ward, i.e., not scheduled, would
be considered as EncounterStartType 2 = Emergency, and EncounterType would be 3 = Inpatient bed + No
emergency room

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 II. Example 2 | A patient is referred to a consultant, by her general practitioner, and an appointment is
scheduled for two weeks later. This outpatient appointment has EncounterStartType 1 = Elective.
3.1.10. EncounterEnd (also known as the Discharge disposition)
This is the time the patient ceases to be under the direct care of a responsible clinician and is document as
the discharge disposition or how the patient was discharged.
▪ For inpatients and day patients this would be the discharge date and time.
▪ For emergency patients this would be the time that the patient was released from the ER
1 = Discharged with approval 2 = Discharged against advice 3 = Discharged absent without leave 4 =
Discharge transfer to acute care 5 = Deceased 6 = Not discharged 7 = Discharge transfer to non-acute care
3.1.11. EncounterEnd Types are seen in the below table

Encounter End
Encounter End Name Encounter End Description
Code

1 Discharged with approval Discharged with Physician Approval

2 Discharged against advice Discharged against Physician Approval

3 Discharged absent without leave Patient left facility without Discharge from Physician

Discharged with Physician Approval to another acute

4 Discharge transfer to acute care
care facility

5 Deceased

6 Not discharged

Discharge transfer to non-acute Discharged with Physician Approval to a non- acute

7
care care facility / Long Term Care or Rehabilitation Facility

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 Current Dental
Terminology

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1. Chapter One
Canadian Dental Association (CDA) Current Dental Terminology (CDT)
1.1.1 All CDA coding rules, guidelines and descriptors will be followed explicitly and any questions and
issues will be addressed to in the coding section at DOH.

1.1.2 The following issues have been addressed:

I. Rules as published by CDA and in the full descriptor will be followed. All Unbundling coding rules as
specified in the Coding Manual and Claims Adjudication will be followed. Unbundling rules within the
Coding Manual will be updated to include the CDT codes
II. The process for coding '' Unlisted Codes" is clarified in the Claims Adjudication and Coding Manual which
includes CDT unspecified codes"
III. Reply from ADA on Temporary Crown and to be added to the Coding Manual: “There is no CDT Code if the
prosthesis is placed for temporization during crown fabrication. Such a “temporary” is considered an
integral component of the restorative crown procedure. However, there are two situations where there
are discreet codes.” The CDT code descriptors states they D2970 and D2799, are not applicable for
temporization.
IV. Reply from ADA on Temporary Pontic: “Neither CDT 2010-2011 nor CDT 2014 include an entry for
temporary Pontiac as such a prosthesis is considered an integral component of the applicable fixed
prosthodontic procedure. D6999 is the available code for special circumstances.

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 International Refined
Diagnosis Related Groups
[IRDRG]

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1. Chapter One
Purpose and Scope of IR DRG
Purpose
The DOH Standard establishes and mandates the diagnosis related groupings system, definitions and rules for
the management and monitoring of health insurance claims by healthcare providers and payers under the
health insurance scheme of Abu Dhabi12.

Scope
The Standard applies to all inpatient healthcare services – except for long-term care services, as defined by the
DOH Standard for the Provision of Long-Term Care, and non-emergency dental inpatient cases provided by all
DOH licensed healthcare providers and payers operating in the Emirate of Abu Dhabi. Inpatient healthcare
services are defined according to the Clinical Coding Steering Committee’s (CCSC) criteria. The diagnosis
related groupings (DRGs) payments are applicable to all inpatient encounters as defined by Abu Dhabi
Department of Health.

DRGs must be used for payment for the Basic Product from service date 1 August 2010, and 31 st December
2011 for all other products. The DOH Grouper (currently provided by 3M) prevails in case of conflict between
the parties13.

12
DOH Standard establishing the Diagnosis Related Groupings System Reference: HSF/DRG/1.0 as well as DOH Claims and Adjudication
Rules)
13DOH Standard establishing the Diagnosis Related Groupings System Reference: HSF/DRG/1.0 as well as DOH Claims and Adjudication
Rules- for Review

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2. Chapter Two
IR-DRG Standard Definitions
The following definitions apply in the interpretation and enforcement of the Standard,
The definitions manual is available from DOH.14

2.1.1 Definitions

The following definitions apply as per the IRDRG Standard, document reference HSF/DRG/ 1.0:

2.1.1.1 Base DRG – is defined as the first two-digit MDC plus the 3-digit DRG (excluding the 6th and
7th digit severity of illness and risk of mortality digits).
2.1.1.2 Relative Weight (RW) – is a unitless factor reflecting the degree of resources consumed by a
particular DRG in comparison within the group of all DRGs. The RW is set by DOH, and may be
reviewed by DOH, at its sole discretion, from time to time
2.1.1.3 Base Rate – is the established reimbursement rate that is used to multiply against the DRG
Relative Weight to determine the reimbursement amount on a per case basis
2.1.1.4 DRG – refers to the International Refined Diagnosis Related Groups (IR-DRGs), as developed
by 3M. The Definitions Manual is available from 3M.
2.1.1.5 DRG Average Length of Stay (ALOS) – the total patient days for the DRG divided by the total
number of discharges.
2.1.1.6 DRG High Trim Point (HT) - is a threshold LOS value based on the 98th percentile of the LOS of
all episodes at the DRG level defined during the norms calculation.
2.1.1.7 DRG Low Trim Point (LT) – is a threshold LOS value based on the 2nd percentile of the LOS of
all episodes at the DRG level defined during the norms calculation.
2.1.1.8 Observed Length of Stay -The actual inpatient LOS calculated by EncounterEnd date -
EncounterStart date, If EncounterEnd date and encounter start date are the same date, the
observed LOS defaults to 1.
2.1.1.9 DRG High Outlier Length of Stay (HTLOS)– length of stay above high trim point calculated as
[Observed LOS – HT].
2.1.1.10 DRG Low Outlier Length of Stay (LTLOS) –length of stay below the low trim point [if OLOS is <
LT, then LTLOS = OLOS]

14
DOH Standard establishing the Diagnosis Related Groupings System Reference: HSF/DRG/1.0 as well as DOH Claims and Adjudication Rules

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2.1.1.11 Inpatient Episode Payment – Three types of inpatient episodes are paid on a DRG RW
concept: IP Low Outlier, IP Inlier, and IP High Outlier. In addition, if applicable, there may be
Add-ons for high cost items or Adjustors.
2.1.1.12 Inpatient Inlier Payment – [Base Rate * DRG RW]
2.1.1.13 Inpatient Low Outlier Payment - payment is calculated as the per diem RW multiplied by the
observed LOS up to the low trim point length of stay [Observed LOS*(DRG RW/DRG ALOS)]
2.1.1.14 Inpatient Hight Outlier Payment - payment is calculated as the inlier DRG RW plus an
additional per diem RW for the number of days above the high trim point length of stay {DRG
RW + [(DRG RW/DRG ALOS) *(OLOS-HT) *Discount}
2.1.1.15 Discount – per diem payments for high outliers are paid at 80% for medical DRGs (DRG type
4) and 60% for procedural DRGs (DRG type 1).
2.1.1.16 Add-on payment – is payment for high-cost consumables and new technology based on
approved list of HCPCS codes that is updated periodically.
2.1.1.17 Readmissions are defined as those cases where:
▪ A patient is readmitted to a hospital with the same base DRG within 30 calendar days of being
discharged for the first time;
▪ A patient is readmitted to a hospital with the same principal diagnosis category within 30 calendar
days of being discharged for the first time and where the first DRG was medical, while the second
DRG was surgical;
▪ A patient is readmitted to a hospital for a potentially preventable complication of medical care
acquired during the stay with a provider within 30 calendar days of being discharged for the first
time. Unavoidable side effects from cancer-related chemotherapy and radiotherapy are not counted
as readmission (or case splitting) and are exempt from this definition.
▪ A potentially preventable complication is a condition that was not present at admission to the
hospital for the first time and that could reasonably have been prevented through the application of
evidence-based guidelines.

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 Enhanced Ambulatory
Patient Groups [EAPG]

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 1. Chapter One
Purpose and Scope of EAPG
1.1.1 Purpose

The DOH Standard establishes and mandates the diagnosis related groupings system, definitions and rules for
the management and monitoring of health insurance claims by healthcare providers and payers under the
health insurance scheme of Abu Dhabi.15

Scope
The Standard applies to all ambulatory health care services except for dental services, and transportation,
home health care, provided by all DOH licensed healthcare providers and payers operating in the Emirate of
Abu Dhabi. Ambulatory healthcare services are defined according to the Claims and Adjudication rules. The
enhanced ambulatory payment group (EAPG) payments are applicable to all ambulatory encounters as defined
by Abu Dhabi Department of Health.

EAPGs must be used for ambulatory claims from service date XX XXX 2020 for all products. The DOH Grouper
(currently provided by 3M) prevails in case of conflict between the parties.

15
DOH Standard establishing the Enhanced Ambulatory Patient Groups Reference: HSF/DRG/X.X as well as DOH Claims and Adjudication Rules

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2. Chapter Two
EAPG Standard Definitions
The following definitions apply in the interpretation and enforcement of the Standard,
The definitions manual is available from DOH16

2.1.1 Definitions

The following definitions apply as per specified in the EAPG Standard HSF/ DRG/ X.X:

2.1.1.1 Add-on payment – is payment for high-cost consumables and new technology based on an
approved list of HCPCS codes that is updated periodically.
2.1.1.2 Ambulatory Episode Payment – is the cumulative EAPG relative weight multiplied by the base
rate plus, if applicable, an add-on payment for high cost drugs and devices as well as
adjustor(s).
2.1.1.3 Payment = [EAPG RW*Base Rate] + Add-on High Cost + Adjustor(s)
2.1.1.4 Base Rate – is the established reimbursement rate that is used to multiply against the
cumulative EAPG Relative Weight to determine the reimbursement amount of a per case
basis.
2.1.1.5 EAPG – refers to the Enhanced Ambulatory Payment Groups (EAPGs) as developed by 3M, a
patient classification system designed to explain the amount and type of resources used in an
ambulatory visit. Patients in each EAPG have similar clinical characteristics and similar
resource use and cost. The Definitions Manual is available from 3M.
2.1.1.6 Relative Weight (RW) – is a unitless factor reflecting the degree of resources consumed by a
particular EAPG in comparison within the group of all DRGs. The RW is set by DOH, and may
be reviewed by DOH, at its sole discretion, from time to time.
2.1.1.7 Medical Visit Indicator (MVI) – A medical visit is identified by the presence of a medical visit
indicator is a CPT / HCPCS code in the following ranges:

- 99201 – 99205;
- 99211 – 99214,
- 99281 – 99285,

16
EAPG Standard on https://doh.gov.ae/en/Shafafiya/standards

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2.1.1.8 Observation Visit Indicator (OVI) – Are the codes used to assign observation visit status based
on the patient’s principal diagnosis. when either directly evaluated and/or referred for
observation. The list below is the range of OVI codes:

- 99217 – 99220;

- 99224 – 99226;

- 99234 – 99236;

- G0379

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 Coding References,
Policies, Processes, Audit &
Arbitration

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1. Chapter One
Coding References
1.1.1 ICD-10-CM Official Guidelines for Coding and Reporting

The Centers for Medicare and Medicaid Services (CMS), the National Center for Health Statistics (NCHS), U. S.
Federal Government’s Department of Health and Human Services (DHHS); approved by the four organizations
that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the
American Health Information Management Association (AHIMA), CMS, and NCHS.

1.1.2 List of Approved Coding References

1.1.2.1 Anatomy and Physiology in Health and Illness, publisher of choice

1.1.2.2 AHA Coding Clinic® American Hospital Association updated to the applicable code set.
1.1.2.3 AHA Coding Clinic® for HCPCS, updated to the applicable code set
1.1.2.4 Atlas of Anatomy publisher of choice. For Example: Grant’s or Elsevier’s Anatomy Plates
1.1.2.5 Canadian Dental Codes (USCLS)
1.1.2.6 Current Procedural Terminology, 4th Edition, 2018 Code set American Medical Association
1.1.2.7 Dorland’s Medical Dictionary
1.1.2.8 Encoding Software - 3M™ CodefinderTM
1.1.2.9 Health Information Management Concepts, Principles and Practice, current edition, AHIMA
1.1.2.10 ICD-10-CM Coding Handbook, With and Without Answers,
1.1.2.11 The ICD-10-CM Code Book, Publisher of choice
1.1.2.12 The Merck Manual of Diagnosis and Therapy, edited by M. H. Beers, MD and R. Berkow, MD,
Merck Research Laboratories

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2. Chapter Two
Coding Policies
2.1.1 Reviewing Medical Documentation:
Coders must review the medical record documentation for the entire visit they are coding before finalizing
the coding process. The purpose of this is to provide the most accurate and specific coding possible, by
reviewing all the pertinent notes, exams and tests before completing the coding assignment. Special care
should be given in reviewing the listed documents:
2.1.1.1 Discharge Summary
2.1.1.2 Operative Report
2.1.1.3 Progress notes
2.1.1.4 Lab reports, i.e. microbiology
2.1.1.5 Consultation reports
2.1.1.6 Radiology reports
2.1.1.7 Special procedure reports such as endoscopy
2.1.1.8 Histopathology reports
2.1.1.9 Emergency visit notes
2.1.1.10 Day care visit notes

2.1.2 Consulting with Attending Physicians

If in doubt, consult with the attending physicians. There will be times when the Coder is unable to assign
the correct code because of unclear or conflicting documentation in the medical record. In those
instances, it is best practice to consult with the attending physician for that visit to get clarification before
assigning the final codes.

2.1.3 Coding to Specificity

Code specificity as documented in laboratory and radiology reports. It is recommended best practice for
the Coder to refer to the laboratory and/or radiology reports to obtain the specificity necessary for
accurate coding. If, for example, the physician documents a UTI (urinary tract infection) but does not
identify the organism, you can code the organism from the microbiology report, such as E. Coli. The same
applies to radiology reports; if the physician documents a fracture of the femur but does not identify the
site, you can refer to the radiology report to find the specific site, such as the shaft of the femur.

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 This does not mean, however, that the Coder should code everything directly from the reports, if the
physician has not documented the condition in the medical record, then he/she must be consulted before
coding it. For example, if the blood culture lists staph aureus as an organism found on the test, you cannot
assume that the patient has sepsis, the physician must be consulted first. The same applies to the
radiology report; if the chest X-ray shows a slight pleural effusion but the doctor has not documented this
in his notes, you cannot code it without consulting him/her first.

2.1.4 Coding for Specific Excised Neoplasm from Pathology reports

If the patient has a neoplasm that was excised or biopsied and sent to Pathology, code the specific
diagnosis from the pathology report. The pathology report is the best reference for the Coder when
coding any type of neoplasm such as cancer, tumor or other abnormal growth. The pathology report will
give the final, definitive diagnosis of the specific type of neoplasm and the specific site of the neoplasm for
accurate coding.

2.1.5 Review pathology report for specificity

Review the pathology report for specificity of diagnosis. Whenever a specimen is sent to the Pathology
Department for analysis, it is best practice for the Coder to review the pathology report before coding.
The pathology report will provide the specificity needed for more accurate coding of the diagnosis. For
example, if the physician documents that the patient had appendicitis, the pathology report may more
accurately document acute, gangrenous appendicitis, which is a different diagnosis code.

2.1.6 Code all significant procedures

Code all significant procedures. If in doubt, Coders should always code those procedures that were
performed in the Operating Room; were performed under any type of anesthesia, including local
anesthesia; where any tissue was removed and sent to Pathology; and any excisional or sharp
debridement of a wound.

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3. Chapter Three
Coding Processes
3.1.1 Inpatient Coding

3.1.1.1 Retrieve discharged record from hospital ward`

3.1.1.2 Assemble record in pre-defined order, attaching all loose sheets as appropriate
3.1.1.3 Analyze record for deficiencies, i.e. missing documentation, dictated discharge summaries,
dictated operative reports, missing signatures.
3.1.1.4 Send record to Coding Section
3.1.1.5 Match record to discharge list
3.1.1.6 Check record for discharge summary if available and/or required and review it for diagnoses
and procedures performed during visit
3.1.1.7 Review Face Sheet and discharge note for diagnosis and procedures
3.1.1.8 Review admission record for additional information regarding diagnoses, procedures and
external causes, while taking notes on key points.
3.1.1.9 Documents to be reviewed include:
▪ History and Physical Exam ▪ Progress Notes
▪ Operative Report ▪ Radiology Reports
▪ Procedure Reports such as Endoscopy ▪ Lab Reports
and Cardiac Catheterization
▪ Other Clinical Services Reports
▪ Consultation Reports
▪ Emergency Record, if applicable
▪ Medical Reports
▪ Anesthesia Record
3.1.1.10 Determine sequencing of principal diagnosis and principal procedure
3.1.1.11 Code text using 3M encoder or coding books
3.1.1.12 Verify sequencing
3.1.1.13 Enter codes in coding database
3.1.1.14 Abstract record with remaining information such as date of surgery and type of anesthesia

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3.1.2 Emergency Coding

3.1.2.1 Receive or retrieve emergency documentation for encounter

3.1.2.2 Review all emergency documentation including labs, radiology reports, consultations, if
applicable – taking notes of diagnoses and procedures
3.1.2.3 Determine sequencing of principal diagnosis and principal procedure
3.1.2.4 Code text using 3M encoder or coding books
3.1.2.5 Verify sequencing
3.1.2.6 Enter codes in coding database
3.1.2.7 Abstract record with remaining information such as date of procedure and Emergency
Physician’s Name

3.1.3 Ambulatory Coding

3.1.3.1 Receive or retrieve medical record from clinic

3.1.3.2 Review Clinic Note for diagnoses and procedures, if applicable or reason for visit if diagnosis
is not determined at that time
3.1.3.3 Review all pertinent investigations from clinic visit to further refine diagnoses, such as lab
reports and radiology reports
3.1.3.4 Take notes of applicable diagnoses and procedures, ensuring that only procedures done
during the visit are coded as a part of the clinic visit
3.1.3.5 Determine sequencing of principal diagnosis and principal procedure – Note that the
principal diagnosis may be a symptom or suspected condition not yet determined at the time
of visit.
3.1.3.6 Code text using 3M encoder or coding books
3.1.3.7 Verify sequencing
3.1.3.8 Enter codes in coding database
3.1.3.9 Abstract record with remaining information such as name of clinic physician

3.1.4 Locating Codes in ICD-10-CM

3.1.4.1 The first step in coding is to locate the main term in the Alphabetic Index. Some conditions
are indexed under more than one main term.
3.1.4.2 If a main term cannot be located, the coder should consider a synonym, eponym, or other
alternative term.

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 3.1.4.3 Once the main term is located, a search should be made of sub terms, notes, or cross-
references. Sub terms provide more specific information of many types and must be checked
carefully, following all the rules of alphabetization.
3.1.4.4 The main term code entry should not be assigned until all sub term possibilities have been
exhausted.
3.1.4.5 During this process, it may be necessary to refer again to the medical record to determine
whether any additional information is available to permit assignment of a more specific code.
3.1.4.6 If a sub term cannot be located, the nonessential modifiers following the main term should
be reviewed to see whether the sub term may be included there. If not, alternative terms
should be considered.
3.1.4.7 The first coding principle is that both the Alphabetic Indexes and the Tabular Lists must be
used to locate and assign appropriate codes. The condition or procedure to be coded must
first be in the index, and the code provided there must then be verified in the Tabular List.
3.1.4.8 The coder must follow all instructional notes to determine that more specific sub terms or
important instructional notes are not overlooked.
3.1.4.9 Experienced coders sometimes rely on their memory for commonly used codes, but
consistent reference to the Alphabetic Index and the Tabular Lists is imperative, no matter
how experienced the coder is.

3.1.5 Locating Codes in the CPT Codebook

3.1.5.1 Select the name of the procedure or service that accurately identifies the service performed.
Do not select a CPT code that merely approximates the service provided.
3.1.5.2 If no such specific code exists, then report the service using the appropriate unlisted
procedure or service code. In surgery, it may be an operation; in medicine, a diagnostic or
therapeutic procedure; in radiology, a radiograph.
3.1.5.3 Other additional procedures performed, or pertinent special services are also listed. When
necessary, any modifying or extenuating circumstances are added. Any service or procedure
should be adequately documented in the medical record.
3.1.5.4 Instructions, typically included as parenthetical notes, with selected codes indicate that a
code should not be reported with another code or codes. These instructions are intended to
prevent errors of significant probability and are not all inclusive. For example, the code with
such instructions may be a component of another code and therefore it would be incorrect
to report both codes even when the component service is performed.
3.1.5.5 These instructions are not intended as a listing of all possible code combinations that should
not be reported, nor to indicate all possible code combinations that are appropriately
reported.

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3.1.5.6 When reporting codes for services provided, it is important to assure the accuracy and quality
of coding through verification of the intent of the code by use of the related guidelines,
parenthetical instructions, and coding resources, including CPT Assistant and other
publications resulting from collaborative efforts of the American Medical Association with the
medical specialty societies (i.e., Clinical Examples in Radiology).

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 4. Chapter Four
Coding Audit
4.1.1 Objective:

This coding audit will endeavor to build trust between payers and providers by:
I. Creating a shared understanding of the facility’s coding quality.
II. Giving the payers confidence that a facility is coding accurately.
III. Giving the facility the right, if certified, to bill for Evaluation and Management (E&M) codes and potentially
achieve higher levels of reimbursement and/or lower payer scrutiny.
IV. Providing the facility with an action plan of recommendations to improve the quality of coding.
The coding audit will give:
I. A coding accuracy score for the facility, which will range from 0-100.
II. A coding completeness score for the facility, which will range from 0-100.

4.1.2 Clinical Coding Certification (CCC) for Health Care Providers

The Health Authority Abu Dhabi has signed a service level agreement with TASNEEF through its subsidiary
TASNEEF-RINA Business Assurance (TRBA) (www.tasneefba.ae) that TRBA is responsible on behalf of DOH to
ensure the quality of clinical coding of all healthcare providers in Abu Dhabi. Therefore, TRBA is authorized to issue
“Clinical Coding Certifications” (CCC) as defined in “DOH Periodical No.45 – Health Insurance” as of 11 July 2011 to
all Abu Dhabi Healthcare providers. See JAWDA Certification for Healthcare Providers on the following link:
https://doh.gov.ae/en/Shafafiya/standards
Reference Websites for Coding Audit
4.1.2.1 The DoH methodology can be reached from the Tasneef website from the following link:
http://www.tasneefba.ae/jdc-methodology.
4.1.2.2 List of Coding Certified Facilities: https://doh.gov.ae/en/Shafafiya/dictionary

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