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Tag Archives: Documentation

Documentation requirements for bilateral procedures

Does anyone have a reference for documentation requirements for symmetric procedures? We’ve searched high and low and cannot find a good source. We’re trying to determine if the provider is documenting sufficiently. Any help would be appreciated!

Medical Billing and Coding Forum – ENT/Otolaryngology

What documentation do I need to bill 93010?


I’m trying to find documentation for what needs to be documented in the office visit when an EKG is done. Patient will see our provider and if he feels an EKG need to be done he will tell his MA. MA will hook the patient up and print the report. Report is than handed to provider provider to review. Patient at this time is still in the clinic. What is happening is provider is not mentioning in his document that EKG was done. So trying to find out if we can go back using the EKG reports and see what EKG’s where missed. But if they provider does not mention the reading or the results of the EKG can we code 93010. We are an RHC clinic so we can only charge 93010. We can not use 93000. Any help on this would be greatly appreciated. Also I have read that MDCR can only be charged once a year for the 93010 and has to be done a their MDCR Wellness Visit. Is this true also.

Thanks again,


Medical Billing and Coding Forum – Family Practice

Five Documentation Vulnerabilities to Address in 2016

Physician Documentation

Expanding CDI to Physician Practices: Five Documentation Vulnerabilities to Address in 2016

By Dari Bonner, RMC, CCP, CHCA, and Dr. Karen M. Fancher, MD, RMC, CPC, CANPC, CFPC . Originally published in AHIMA.

Inpatient clinical documentation improvement (CDI) has thrived since the implementation of MS-DRGs. More recently, it has grown in popularity commensurate with the implementation of ICD-10-CM/PCS. In some cases, organizations took a holistic approach to ICD-10, deliberately embedding CDI specialists within their owned or affiliated physician practices to ensure a smooth transition—thereby expanding CDI efforts into outpatient and ambulatory settings.

With the proliferation of accountable care organizations (ACOs) and the rise in healthcare mergers and acquisitions, many hospitals and health systems are looking for ways to continue the ICD-10 educational momentum and expand CDI efforts into outpatient, ambulatory, and physician practice settings. Beyond these hospital-led initiatives, many independent practices and private physicians are also quickly recognizing the importance of documentation quality—and how coded data translates to reportable outcomes. This article takes a deeper dive into implementing effective CDI programs within physician practices. 

Why the Timing is Right

In today’s healthcare environment, documentation is paramount, being used for medical coding and reimbursement. It’s also increasingly used to gauge the quality of care provided. When physicians accurately and thoroughly capture the true clinical picture of a patient’s condition or problem, not only do they justify medical necessity, they may also avoid third-party audit scrutiny and denials. This has a direct positive effect on cash flow and the overall successful operation of the business—for both hospitals and physicians.

Regulatory changes have also forced physicians to take a closer look at clinical documentation. ACOs and bundled payments, for example, incentivize efficient and effective care, requiring physicians to document as specifically and completely as possible. Public outcomes data has also forced physicians to question the efficacy of their coded data, which almost always leads back to a discussion about documentation. In addition, the Physician Quality Reporting System (PQRS) and “meaningful use” Electronic Health Record (EHR) Incentive Program are pushing the need for better physician documentation. 

In the years ahead, the Centers for Medicare and Medicaid Services’ (CMS’) new Merit-Based Incentive Payment System (MIPS) will become a significant regulatory driver behind physician practice CDI. This program, which consolidates the PQRS, value-based payment modifier (VBPM), and meaningful use incentive program, uses data collected during 2017 to determine potential payment adjustments in 2019. Payment adjustments are determined based on a MIPS composite score that is partially driven by the coding of hierarchical condition categories (HCC), making HCC capture vital in the practice setting. 

Negative payment adjustments will be distributed as follows, depending on whether a provider’s composite score falls below a particular performance threshold: four percent in 2018, five percent in 2019, seven percent in 2020, and nine percent in 2021 through 2023. Above-par performance could earn a physician a bonus as high as 12 percent in 2018 and 27 percent by 2021.

Because of this potential negative impact on finances due to lax clinical documentation, CDI programs in physician practices will certainly become the norm. The question today is: How can HIM professionals help support them?

Logistics of CDI in a Physician Practice

Unlike hospitals that have more operational and personnel resources for CDI, physician practices must often rely on a certified coding professional or office manager to perform the task. In addition to overseeing CDI efforts, these individuals may also be responsible for checking patients in and out, obtaining insurance authorizations, responding to audits, coding, billing, performing accounts receivable follow-up, contracting, and much more. 

Given the plethora of responsibilities, CDI must therefore be extremely targeted and thoughtful in the practice setting. Those charged with CDI must audit documentation frequently so they can pinpoint educational opportunities for each individual provider—physicians, nurses, medical assistants, and scribes.

Another challenge is that CDI in a physician practice is often retrospective. Practices typically receive a denial and then perform physician or staff education based on the reason for the denial. Unfortunately, by the time the education occurs most physicians don’t remember making the documentation error or omission, and don’t recall the specifics of the case. Retrospective CDI also permits subsequent errors to snowball, causing a cascade of denials before a correction is provided. 

To be truly effective, practices need a “front-to-back” approach—proactive education and concurrent CDI on the front end of the process. This may require a more dedicated CDI resource within the practice as well as close collaboration with the practice’s EHR vendor to remediate documentation vulnerabilities, tweak templates, and update documentation alerts and prompts. 

Physician Documentation Vulnerabilities

To identify documentation vulnerabilities, one needn’t look further than the “FY 2016 Office of Inspector General (OIG) Work Plan” in which the OIG identifies trends and patterns of compliance risk and fraud. Some of these include non-covered chiropractic and anesthesia services as well as unreasonable use of prolonged services, high use of outpatient physical therapy services, and non-compliant referrals/orders for certain Medicare services, supplies, and durable medical equipment. But there are many other areas ripe for CDI. Consider the following five areas.

1. Cloned notes and assessments

This occurs when nurses or other providers copy and paste information from a previous visit into the current visit without verifying the accuracy of that information. In many cases, details are completely inaccurate or omitted entirely. There’s also often a mismatch between the chief complaint/history of present illness and the assessment. For example, a patient complains of neck pain but the entire assessment addresses the patient’s lower back pain. This incongruence can certainly benefit from a CDI specialist’s analytical eye.

2. Medical necessity

Physicians sometimes don’t understand that medical necessity isn’t synonymous with medical decision making. The specific ICD-10 diagnosis codes that the physician chooses can either make or break a payer’s decision to deem services medically necessary for the patient. Many physicians don’t even realize that local coverage determinations (LCDs) exist, requiring certain diagnoses as a prerequisite for payment. As payers continue to update these LCDs in light of ICD-10, someone focused on CDI can monitor changes and ensure that documentation is updated accordingly. 

3. ICD-10 diagnosis specificity

Certain specialties, such as orthopedics, OB/GYN, internal medicine, and cardiology, saw many more code expansions in ICD-10-CM than others. These specialties could benefit from CDI that prompts greater specificity related to laterality, disease manifestation, anatomical location, and more. An individual trained in CDI can help explain ICD-10 terminology to physicians and create ICD-10 favorite lists and shortcuts to alleviate the burden of sifting through diagnosis codes listed in the EHR—ultimately increasing productivity.

Unspecified codes may prove to be particularly problematic in practices. That’s because CPT codes—not diagnosis codes—drive reimbursement in the practice setting, leaving little incentive for physicians to pay attention to diagnoses. In addition, the American Medical Association/CMS joint announcement made last July indicates that contractors conducting medical reviews (i.e., Medicare administrative contractors, recovery auditors, zone program integrity contractors, and the supplemental medical review contractor) during the 12-month period following ICD-10’s implementation on October 1, 2015 could not deny claims solely for the specificity of the ICD-10 code. This is as long as the code is in the correct family of codes (i.e., the correct ICD-10 three-character category) and there is no evidence of potential fraud. This flexibility applies to both automated and complex medical reviews. 

Many physicians don’t understand that this flexibility pertains only to Medicare and only to retrospective audits. Some have misinterpreted the announcement to mean that they have complete flexibility with all payers for ICD-10 reporting on the front end. Someone well-versed in CDI can ensure compliant coding that won’t subsequently jeopardize reimbursement once the Medicare flexibility has expired.

4. E/M levels

Due to fear of denials and audits, physicians frequently down-code their evaluation and management (E/M) levels (i.e., code a lower-level, lesser paying E/M code). In some cases, a higher level might be justified if the individual trained in CDI can identify opportunities where documentation is lacking—and then query for clarification. In other cases, a CDI specialist can identify patterns of over-coding that could trigger an audit or raise a payer’s red flag. An example is when a physician provides a follow-up office visit or subsequent hospital visit and then bills using a higher level E/M code as though a comprehensive new patient office visit or an initial hospital visit had been provided.

5. Bundling and modifier usage

CDI specialists can help physicians identify when it’s appropriate to use a modifier and when a particular procedure or service is inherent in a more extensive procedure or service performed at the same time. 

How to Get Started with Physician CDI

In this age of documentation scrutiny, physician practices can’t afford to wait for an OIG or CMS audit to reveal noncompliance. Doing so could put a practice out of business. It’s also in the practice’s best interest to improve documentation if it’s part of an ACO, shared-savings initiative, or larger health system. Consider these three strategies:

• Hire a certified coding professional. Several associations, including AHIMA, can point a practice to certified coding professionals. By ensuring that documentation meets regulatory requirements, a certified coding professional is an invaluable asset for any physician practice. A certified coding professional can also use his or her auditing skills to provide CDI feedback. Allow coding professionals to spend time in the clinical areas of the practice so they become more familiar with clinical diagnoses and procedures and can assist with documentation improvement.
• Focus on collaboration. Collaboration among key staff members in the provider practice will help providers document better and more efficiently. Also, quality CDI programs can help a practice streamline processes and procedures that currently create extra work for office staff and providers alike. 
• Seek assistance from hospital-based CDI specialists and HIM directors. These individuals can share valuable resources (i.e., policies, documentation tools/tips) that can help practices launch their CDI efforts.

    Documentation quality begins in the outpatient setting. Physicians who document well in their practices help establish a baseline for patient severity and justify medical necessity for inpatient services. Quality documentation enhances outcomes and ensures accurate revenue. Now is the time to evaluate needs, build partnerships, and begin the important task of improving physician practice documentation. 

    CDI Training

    Healthcare is rapidly changing. Stay in the game by taking a proactive approach to clinical documentation.

    Online Clinical Documentation Improvement Course: Click Here



    The Medical Management Institute – MMI – Medical Coding News & MMI Updates

    Coding for Initial Encounter; Subsequent Encounter; Sequela: ICD-10 documentation Challenges

    Coding for Initial Encounter; Subsequent Encounter; Sequela:  ICD-10 documentation Challenges 
    Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP
    Originally Published: May 15, 2016
    A bit of Background
    ICD-10cm has been fully implemented, however the struggle is still very “real” to both inpatient and outpatient coders that spend the majority of the work day performing diagnosis coding.  The issue at hand is trying to gain perspective regarding whether the encounter should be considered “initial”  “subsequent” or “sequela” when coding from ICD10cm chapters 19 and 20.   These chapters contain the codes for injuries, poisonings, and other external causes. 
    Unfortunately, physician and mid-level care providers also struggle with the clinical  documentation required for accurate coding within this code set.  One area in particular, is documentation to support, or to define the “initial”, “subsequent” or “sequela” for care provided.    Upon review of medical care provided, physician providers are very good at documenting when the issue is “initial”  or “subsequent”, however the “sequela” or late effect documentation remains an issue of concern.  
    In ICD-10cm, the diagnosis is meant to describe the complete reason(s) why a patient is seeking care during a specific encounter with a provider or facility.  This may be a simplistic observation, however, with the onset of the new ICD-10cm codes and its implementation on October 1, 2015; the usage of the term(s) initial, subsequent and sequela have not only taken on a specific meaning in relation to the code set but requires coders  to append the seventh character for injuries, poisoning and other consequences regarding the diagnosis and patient care for injuries, burns and fracture care.  
    As we have learned, the seventh character indicates coders to use the letters: A – Initial encounter; D – Subsequent encounter and S – Sequela.    A, D, and S usually represent the diagnosis from the patient’s perspective, however, in the ICD-10cm guidelines note that if the visit/encounter  is a patient’s initial encounter for active treatment of the injury, it’s to be considered and coded as an initial encounter. The patient may be seen by a new or different provider over the course of treatment for an injury.   Again, the assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.
    Understanding Critical Verbiage
    As a coder, it is imperative that we understand the differences and are able to discern if the care being provided is considered “active treatment” care, or if the care provided is considered a subsequent treatment care phase.  The usage of the 7th character “A” requires definitive clinical documentation and clarity of the care being performed.  In addition, clarity regarding the term “active care” needs to be well documented within the medical record and is paramount to successfully coding “active treatment” correctly. 
    Examples of active treatment are:
    ·         surgical treatment
    ·         Emergency department encounter
    ·         Evaluation and continuing management treatment by the same or a different physician
    The 7th character “D” subsequent encounter,  is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.
    Examples of subsequent care are:
    ·         Cast change or removal
    ·         An x-ray to check healing status of fracture
    ·         Removal of external or internal fixation device
    ·         Medication adjustment,
    ·         Other aftercare and/or  follow up visits following treatment of the injury or condition
    The 7th Character of “S” is to be used to denote a sequela , late effect, complication or condition that arises due to the direct result of an injury or complication of care.  Sequela is defined by the ICD-10 guidelines as “…the residual effect (condition produced) after the acute phase of an illness or injury has terminated.” There is no time limit on when a sequela code can be used. The residual complication or “sequela” may be apparent soon after subsequent care has been completed,  or it may occur months or even years later.
    Examples of Sequela include
    ·         scar formation resulting from a burn
    ·         deviated septum due to a nasal fracture
    ·         chronic pain from previous back injury
    When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code.  The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.
    Procedure Documentation Scenario:
    Scenario for “A” Initial Encounter

    An adult patient is evaluated in the emergency department (ED ) for a traumatic rupture of the right ear drum. The ED provider informs the patient that the ENT physician is unavailable at this time, and provides the patient with painkillers.  The patient is then instructed by the ED to present to the ENT office directly upon discharge from the Emergency department care.  Coding for the care in the ED would be reported with ICD10cm code S09.21A  Traumatic rupture of right ear drum.
    The patient then presents to the ENT office, and the provider  rechecks the patient and applies a paper patch to the eardrum in the ENT office.  At this time, the patient is receiving  active treatment for this injury.
    In summation; this is the first encounter at which the patient receives definitive care (the ED was able to apply comfort care only and referred on to the ENT). Per ICD-10 guidelines, you would again report S09.21A for an initial encounter at the ENT office. 
    Scenario for “D”  Subsequent Encounter
    An adult patient is evaluated in the emergency department (ED ) for a traumatic rupture of the right ear drum. The ED provider informs the patient that the ENT physician is unavailable at this time.  The ED provider applies a paper patch to the eardrum while the patient is still in the ED per request of the ENT physician, and provides the patient with painkillers upon discharge from the ED.  .  The patient is then instructed by the ED to present to the ENT office directly upon discharge from the Emergency department care.  Coding for the care in the ED would be reported with ICD10cm code S09.21A  Traumatic rupture of right ear drum, initial encounter. 
    The patient was instructed upon discharge from the ED to follow up with the ENT in one week to ensure healing of the eardrum.  One week later the ENT provider rechecks the ear-drum injury in the office.  As per ICD-10cm guidelines, this care would be considered  a subsequent encounter, and would be reported as S09.21D traumatic rupture of right ear drum subsequent encounter.  
     The rationale for the subsequent encounter code,  is the ENT provider cared for the same condition, but was not performing “active care”  but “follow up” care for the injury.  
    Scenario for “S”  Sequela
    Scenario 1:
    A patient is admitted to a longterm acute care facility for chronic respiratory failure and ventilator dependency after an acute admission for treatment of an accidental drug overdose.
     – Assign code J96.10, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, as the principal diagnosis

     – Assign secondary codes – T50.901S, Poisoning by unspecified drugs, medicaments and biological substances, accidental (unintentional), sequela

    – Z99.11, Dependence on respiratory [ventilator] status
    Scenario 2:
    A patient presents for release of skin contracture due to third degree burns of the right hand that occurred due to a house fire five years ago.
    Assign code(s)
             L90.5, Scar conditions and fibrosis of skin, as the principal diagnosis.
             T23.301S, Burn of third degree of right hand, unspecified site, sequela
             X00.0XXS, Exposure to flames in uncontrolled fire in building or structure, sequela
    A 29 year old female patient has presented to the Internal Medicine specialty clinic to establish care.  She is a complete paraplegic due to a tramatic L3 vertebral fracture 8 years ago due to a motor vehicle accident.  In her intake, she does not have any other current problems.  
    Assign code(s)
             G82.21 paraplegia complete
             S32.029S Fracture traumatic vertebra, lumbar, second.
    Clinical documentation:   a look to the future….
    Good clinical documentation for accurate coding of the 7th placeholder in ICD-10cm is necessary not only for the claims process, but to ensure transparency and clarity for the medical record.  Fracture and burn documentation have additional requirements for coders to clearly code care that is rendered.  The Clinical documentation needs to include:
    **Documentation for a current encounter:
    – Diagnoses current and relevant
             Clearly denotes;  “active”  treatment; “subsequent” treatment or “sequela” .
    **Clinical Documentation for Fractures need to include:
    • Cause:
    – Traumatic
    – Stress
    – Pathologic
    • Location:
    – Which bone?
    – Which part of the bone?
    – Laterality (right, left, or bilateral)
    • Type:
    – Non-displaced
    – Displaced
    – Open (Gustilo classification where applicable)
    – Closed (Greenstick, spiral, etc.)
    – Salter-Harris (specify type)
    • Encounter:
    – Initial
    – Subsequent
    ° For routine healing
    ° For delayed healing
    ° For non-union
    ° For malunion
    – Sequela (such as bone shortening)
    • Include the external cause of the fracture, such as fall while skiing, motor
    vehicle accident, tackle in sports, etc.
    • Document any associated diagnoses/conditions
    **Clinical documentation for burns need to include:
    • Type:
    – Corrosion
    – Thermal
    • Site:
    – Specify body part
    – Include laterality
    • Degree:
    – First
    – Second
    – Third
    • Document total body surface area (TBSA) burned (percentage)

    • Specify the percentage of third degree burns

    • Include the external cause of the burn, such as house fire, stove, acid, etc.

    • Document any associated diagnoses/conditions
    Final thoughts – wrap it up neatly
    As a coder, when coding these difficult treatment scenarios, always read the ICD-10cm guidelines thoroughly and pay close attention to any includes or excludes statements, present on admission, primary, secondary and all pertinent diagnoses. 
    If the medical record documentation is not clear to you, or you are uncertain regarding “initial, subsequent, or sequela” query the provider or ask for clarification regarding the scope and definition of care that has been provided to the patient.

    Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:   

    Lori-Lynne’s Coding Coach Blog

    Sterilization forms and coding: documentation tips post ICD-10 implementation

    Sterilization forms and coding:  documentation tips post ICD-10 implementation
    Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP
    Originally published: March 25, 2016
    Coding and reimbursement for sterilization has more to it than simply applying the CPT code, diagnosis code, submitting the claim and “voila”  having the reimbursement dollars  magically appear in the revenue stream. 
    The Federal Government has regulations in place that need to be followed for those providers that perform sterilizations and accept reimbursement from federally funded payers.    These mandates are found within U.S. Code: Title 42 – The public health and welfare  and are contained in the laws within Title 42.  The sterilization consent form requirements can be officially found  within; Title 42; Chapter I, Subchapter D, Part 50, Subpart B,  Section 50.205.  This is commonly referred to as  “42 CFR 50.205 – Consent form requirements”
    If you are a provider who performs sterilization procedures on a frequent basis, you are probably well versed in the process of getting this form filled out correctly and getting reimbursement.  Many providers who only occasionally provide sterilization services are unaware of this mandated form, and either get the form filled out incorrectly, or don’t get the form filled out at all.  This creates issues for the entire practice, and impacts the revenue you rightly deserve for providing this care.   The requirement of this form is non-discriminatory, in the fact that it has to be filled out and utilized for those who perform sterilization procedures on men as well as those sterilization procedure performed on women.
    50.205 Consent form requirements
    “42 CFR 50.205” contains these parameters to be fulfilled
    (a)   Required consent form. The consent form appended to this subpart or another consent form approved by the Secretary must be used.   link to federal form HHS-687
    (b) Required signatures. The consent form must be signed and dated by:
    (1) The individual to be sterilized; and
    (2) The interpreter, if one is provided; and
    (3) The person who obtains the consent; and
    (4) The physician who will perform the sterilization procedure.
    (c) Required certifications.

    (1) The person obtaining the consent must certify by signing the consent form that:

    (i) Before the individual to be sterilized signed the consent form, he or she advised the individual to be sterilized that no Federal benefits may be withdrawn because of the decision not to be sterilized,

    (ii) He or she explained orally the requirements for informed consent as set forth on the consent form, and

    (iii) To the best of his or her knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.

    (2) The physician performing the sterilization must certify by signing the consent form, that:

    (i) Shortly before the performance of the sterilization, he or she advised the individual to be sterilized that no Federal benefits may be withdrawn because of the decision not to be sterilized,

    (ii) He or she explained orally the requirements for informed consent as set forth on the consent form, and

    (iii) To the best of his or her knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized. Except in the case of premature delivery or emergency abdominal surgery, the physician must further certify that at least 30 days have passed between the date of the individual’s signature on the consent form and the date upon which the sterilization was performed. If premature delivery occurs or emergency abdominal surgery is required within the 30-day period, the physician must certify that the sterilization was performed less than 30 days but not less than 72 hours after the date of the individual’s signature on the consent form because of premature delivery or emergency abdominal surgery, as applicable. In the case of premature delivery, the physician must also state the expected date of delivery. In the case of emergency abdominal surgery, the physician must describe the emergency.

    (3) If an interpreter is provided, the interpreter must certify that he or she translated the
    information and advice presented orally, read the consent form and explained its contents and to the best of the interpreter’s knowledge and belief, the individual to be sterilized understood what the interpreter told him or her.
    Critical verbiage and procedures
    As you can see from the above, there are a lot of “rules” to be followed.  However, the government has given us a standardized form to use and be implemented by the providers.  They have even given us an electronic type version that can be downloaded and filled in, or even filled in on-line.  This form can be found at   This government form is currently valid for use though 12/31/2018.  
    The critical verbiage that must be followed closely is the mandate that “at least 30 days have passed between the date of the individual’s signature, and the date for when the sterilization is performed”.   If this is not followed closely, the physician and the facility/hospital will not be paid. 
    This form is used across the United States, however, some State funded Medicaid programs may use their own form, but it has to contain the minimum information that has been outline in 42 CFR 50.205.  
    When implementing the procedure to get this form completed correctly, all staff, and especially the physician/provider,  should be aware of its content and ensure that it is filled out correctly.   This seems like more government buracracy  however, if you are a Medicare/Medicaid provider this is part of the process we must perform to ensure the patient fully understands the implications of sterilization, and that as a patient they consent to the procedure.
    ICD-10 diagnosing –  ICD-10 procedure – CPT procedure
    In the post ICD-10cm and ICD-10pcs world things have changed for the coding and reimbursement for sterilization codes. 
    In ICD-9cm we used code V25.2; Sterilization
    In ICD-10cm we now use code Z30.2; Encounter for Sterilization
    The codes are very similar, but in ICD-10cm they expanded the description to state that the usage of the code was for the encounter  for sterilization –  not just stating the word “sterilization” .    So for the diagnosing of sterilization procedures it remains straightforward for the diagnosis of the sterilization procedure.
    However, that is not the same for ICD10pcs.  In ICD10pcs, the procedure of “vasectomy” is found in the index, and you’re referred to the code tables that provide the codeset for   a procedure performed on the male reproductive organ system.    The same can be said for the term  “tubal ligation”   as when you go to look it up the ICD-10pcs system as a tubal ligation, it refers you to the term “occlusion”  where as you view the index, you find  “Occlusion; Fallopian Tube; Left, Right, Bilateral”  and refers you to the table sections that are appropriate.   (see attached pages)  
    CPT procedures have many different codes that can be used for “sterilization procedures”  so careful review of the operative reports to determine the correct code is a vital piece to ensuring your smooth reimbursement of sterilization procedures.
    If you look in the CPT manual index, you will find the term for the “vasectomy”procedure, and CPT refers you to the numeric code of 55250.  In the CPT codeset the code 55250 is found in the surgery/male genital system section under Vas Deferens; Excision; then the code 55250 is the only code that appears in this subset.  If your provider does the traditional vasectomy procedure this is the correct code to use.  However, there have been newer and less invasive techniques for “vasectomy”  so code 55250 may not be the correct choice.   It is this new technology that requires coders to carefully review the operative note(s) to ensure the correct CPT code goes with the correct diagnosis. 
    The same can be said for coding of sterilization for female patients.  In the CPT manual sterilization codes for female patients can range from a very simple to extremely complex invasive procedures.  CPT includes sterilization procedures that range from simple “incision” type procedure, and include codes for sterilization procedures that utilize  laparoscopic technique, hysteroscopic technique,  percutaneous incision, to abdominally open surgical procedures.  CPT even includes codes that factor in a sterilization performed at the time of delivery (with a cesarean section)  or even performed shortly after a vaginal delivery.
    Diagnosis beyond “encounter for sterilization”
    In cases where a sterilization is being performed, not all sterilization procedures are performed strictly for birth control.  Providers, clinical personnel, and coders all need to ensure that the coding and documentation for a sterilization procedure is clearly reflective of why the procedure is being performed.  Sterilization procedures may be required for a medically necessary or medically indicated diagnosis. 
    If a sterilization procedure is needed by the patient, this does not absolve us from not getting the proper paperwork filled out. (eg the federal sterilization form, appropriate consents, pre-authorizations, and referrals)   In the case of a female patient requiring an emergent type of sterilization procedure, the 42 CFR 50.205 federal form allows for this circumstance in which the form still needs to be filled out, but the caveat of “emergency abdominal surgery” is noted on the form, and in the patients’ medical record.
    When filling out the claim form for sterilization procedures that are not for contraceptive reasons, the medically necessary diagnosis would be appended first;  then any additional medically indicated symptoms or diagnoses, with the final code of  Z30.2; Encounter for Sterilization.  When sequenced, this paints the picture of a medically indicated procedure, and denotes that the patient is also rendered sterile.
    Prior to sending your claim, take the time to review the sterilization form and review it has been filled out correctly,  all signatures and dates are correct and within the mandated guidelines.  If the form is incomplete, or incorrect take the time to make all necessary corrections, and get all necessary signatures. 
    As you submit your claim, if it is an electronic claim, you may be required to submit a copy of the signed sterilization form, the operative report and also supporting medical records with your claim.  If you are still submitting your claim as hard copy, you will need to include these documents as hard copy.  
    Final thoughts – wrap it up neatly
    As a coder, you now have the unique opportunity to connect with your providers, clinical back office personnel, and your first line patient representatives to ensure that all the appropriate forms are filled out.  You can provide the education and the importance of the sterilization form,  and the importance of clear documentation to determine the reasons for the sterilization procedure. (eg, if done for “contraceptive or birth control” or “medically necessary/medically therapeutic” ).
    If the sterilization procedure is denied for payment by the insurance carrier, review the denial code carefully, and if needed, contact the carrier to fully determine the cause of the denial.   If warranted, appeal your denial. 

    For “male sterilization “ procedures performed in ICD-10 PCS

     … for female sterilization “tubal ligation” procedures in ICD-10 pcs

    Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:   

    Lori-Lynne’s Coding Coach Blog

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