Chapter 35 — Further Reading

The orientation for this chapter's sources. Specialty coding has an unusual literature: the authoritative material is thin, free, and federal; the useful material is thick, professional, and partisan; and almost none of it is a textbook. The list below is organized the way §35.10's method uses it — the code set's own instructions first, the edit policy second, the coverage policy third, and the professional societies fourth, with a clear note about what each one is and is not the authority for. A specialty reference published before the year its CPT section was restructured is not merely dated; it is actively wrong, and this is the one field where that happens on a schedule.

Tier 1 — Canonical: the code sets, the edit policy, and the coverage rules

• The current year's CPT® code book — the section guidelines and the parenthetical notes (American Medical Association). The single highest-yield reading in this chapter's method: three to eight pages per section, containing the family rules that every specialty question eventually resolves to. Read the Surgery guidelines, the Medicine guidelines, and — before you touch an anesthesia claim — the Anesthesia guidelines, which define anesthesia time, the reporting of physical status, and the qualifying-circumstances add-ons. CPT changes every January 1.
• The NCCI Policy Manual for Medicare Services (CMS, free, revised annually with quarterly edit files). One chapter per CPT section, in prose, with rationale. Chapter 21 §21.5 told you to read it before overriding an edit; §35.10 tells you to read your specialty's chapter before coding at all. The edit files themselves change quarterly.
• The ICD-10-CM Official Guidelines for Coding and Reporting, current year, free from CMS and NCHS — with the chapter-specific guidelines for the specialty you are entering. Chapter 15 of the Guidelines (pregnancy, childbirth, and the puerperium) is required reading before an obstetric claim; the injury and external-cause guidance is required before an orthopedic one.
• Medicare Claims Processing Manual, CMS Publication 100-04. The operational text behind several of this chapter's sections: Chapter 12 covers physician and non-physician practitioner billing, including the anesthesia payment rules — base units, time reporting, the provider-arrangement modifiers, and the medical-direction requirements — and Chapter 4 covers hospital outpatient billing, including facility visit reporting.
• The annual OPPS/ASC final rule (Federal Register; CMS OPPS rulemaking pages), and in particular the CY2014 final rule, which replaced the five hospital outpatient clinic visit E/M levels with G0463 and left the emergency department's five levels in place. The rulemaking history across the 2000s — the alternatives considered and the principles published for hospitals' internal facility leveling guidelines — is Case Study 2's primary source and the reason §35.6 looks the way it does.
• National coverage determinations and the Medicare Coverage Database (CMS). The instrument Chapter 22 §22.3 taught and Case Study 1 turns on: nationwide, binding, free, and searchable. Pull the NCDs and your Medicare Administrative Contractor's LCDs and billing-and-coding articles for your specialty's top ten services before your first week ends.
• The False Claims Act, 31 U.S.C. §§ 3729–3733, and the Department of Justice's own announcements of resolved health care matters. Where this book declines to print an enforcement figure, the Department's releases are the place to get one — with the caution that a settlement resolves allegations without a determination of liability, and the announcement says so.
• Medicare's telehealth policy pages and the list of services payable when furnished via telehealth (CMS). This is the section of the list you check rather than remember, and the date on the page is part of the answer. Add your state's telehealth and licensure requirements, which are a legal question outside this book.
• 42 CFR Part 2 — the federal confidentiality regulation for substance use disorder treatment records from federally assisted programs, which operates in addition to HIPAA with different consent requirements. If your work touches those records, read the regulation itself; reasoning by analogy from HIPAA produces wrong answers here.
• The Mental Health Parity and Addiction Equity Act — the statutory background to §35.8's observation that behavioral health patients absorb more administrative burden than most.

Tier 2 — Attributed: the professional literature, and what it is good for

• The specialty societies' coding resources. The American College of Cardiology, the American Academy of Orthopaedic Surgeons, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Society of Anesthesiologists each publish coding guidance, frequently-asked-question files, and in several cases full specialty coding manuals. They are the fastest correct answer to a specialty question and they are written by people who do the work. ⚠️ They are also advocacy for their members' interests: where a society's reading conflicts with a payer's published policy, the payer's policy governs the claim, and the society's position is what you cite in an appeal rather than what you rely on when you submit.
• AAPC and AHIMA specialty resources and credential materials. AAPC maintains a family of specialty credentials taken after a core credential; the study material for each is a usable inventory of what the specialty's conventions actually are. Chapter 39 §39.3 covers the credential landscape and which one signals what.
• MedPAC's annual Report to the Congress: Medicare Payment Policy — the recurring plain-language analysis of outpatient and physician payment, including hospital outpatient visit reporting and the effects of site-of-service payment differences. Read for the analysis, not for a number to quote.
• OIG reports and Work Plan items touching this chapter's specialties — emergency department facility visit level reporting, cardiac device and procedure coverage, anesthesia time and medical direction, and evaluation and management with preventive services. The recurring subjects are the point; the figures belong to the reports. Search the OIG site for current items rather than trusting any summary's vintage.
• The professional coding press and payer provider bulletins. Every plan publishes its own updates — and a plan's provider bulletin is where a telehealth policy change, an anesthesia rounding rule, or an obstetric package interpretation will appear before it appears anywhere else. Subscribe to the bulletins of the plans that carry your practice's volume. This is Chapter 6 §6.7's annual-update discipline made specific.

Tier 3 — Illustrative and constructed: this book's own apparatus

• Figure 35.1 — the constructed catheterization report; Figure 35.2 — the two constructed orthopedic office-note plans; Figure 35.3 — the constructed ED facility acuity criteria sheet and the chart scored against it, including its point values and level bands. All constructed; no hospital's real criteria are reproduced anywhere in this book, and no two hospitals' would match.
• The anesthesia arithmetic of §35.7 — 8 base units, a P2 patient, a 98-minute case against a 106-minute room time, at Chapter 18 §18.11's constructed conversion factor of \$22.00, producing \$308.00 or \$330.00. Constructed teaching figures throughout; base units, increments, rounding rules, and conversion factors are payer-specific and published.
• The vaccine-administration arithmetic of §35.5 — 1,200 doses, a constructed \$26.40 allowed amount, a 9% capture gap, \$2,851.20. Constructed; verify your own contracts.
• The obstetric episode log and the specialty grid of §35.10 — schematic artifacts, offered as designs to copy rather than as forms to fill in.
• The ED anchor, Accounts 22-7788 and 10-7789 — the facility and professional claims from the Chapter 1 emergency department bill, both carrying 99284, reused here at their frozen figures.
• The Encounter counterfactual — Account 10-4471's patient referred to an orthopedic practice. A lens only: the canonical March 14 file is unchanged, and this chapter deliberately prices nothing.