GOHEALTHCARE PM&R SPECIALTY GUIDE™

PM&R CPT & HCPCS Coding Library

2026 PM&R coding intelligence for PT, OT, SLP, EMG/NCS, chemodenervation, drugs, DME/O&P, work rehabilitation, modifiers, units and payer reconciliation.

Developed by Pinky Maniri, Founder & Chief Executive Officer, GoHealthcare Practice Solutions

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CODING INTELLIGENCE

Central CPT/HCPCS code-family reference for PM&R service lines.

REFERENCE YEAR

2026 code-set and Medicare-policy framework; verify the exact date of service.

CONTROL PRINCIPLE

Diagnosis, procedure, HCPCS, units, modifiers, authorization and documentation must reconcile.

GoHealthcare Coding & Revenue Integrity Standard

CodeValidate current CPT/HCPCS family

DiagnosisUse highest supported ICD-10-CM specificity

EditsCheck NCCI, MUE, payer and authorization rules

Operational use: This page is an educational coding-intelligence resource. It does not reproduce proprietary CPT descriptors and is not a substitute for licensed CPT content, current CMS files, payer policy, MAC articles, state rules or professional coding judgment.

Page Contents

Navigate the coding, diagnosis, modifier, NCCI, MUE, documentation and payer-control sections.

Code Architecture

1. How to Use This Library
2. PM&R CPT/HCPCS Service Matrix
3. PT Evaluation & Treatment Families
4. OT Evaluation & Treatment Families
5. SLP Evaluation & Treatment Families
6. EMG & NCS Code Relationships
7. Botulinum Toxin Procedure & Drug Codes
8. Botulinum Toxin HCPCS Crosswalk
9. Hyaluronan HCPCS Families
10. DME, Orthotics, Prosthetics & Mobility HCPCS

Crosswalks & Claim Controls

11. Timed vs Untimed Therapy Services
12. PTA / OTA Coding
13. JW/JZ Drug-Wastage Control
14. Professional vs Facility Coding
15. NCCI PTP Edits
16. Medically Unlikely Edits
17. Authorization-to-Code Reconciliation
18. Coding Denial Failure Modes
19. Pre-Bill Coding Audit
20. Annual & Quarterly Update Calendar

Governance & References

21. CPT Licensing & Public-Site Use
22. Related GoHealthcare Resources
23. Authoritative Coding References

01

FOUNDATION

How to Use This Library

This library gives operational code-family navigation without reproducing proprietary AMA CPT descriptors. Always verify the current licensed CPT codebook and 2026 CMS therapy code list before claim submission.

02

CPT / HCPCS

PM&R CPT/HCPCS Service Matrix

Service line	Common code families	Modifier layer	Operational note
PT	97161–97164; 97110; 97112; 97116; 97140; 97530; 97535; 97542; 97750; 97760; 97761	GP; CQ when applicable; KX above threshold	PT evaluation, therapeutic procedures, mobility, orthotic/prosthetic training.
OT	97165–97168; 97110; 97112; 97140; 97530; 97535; 97542; 97750; 97760; 97761	GO; CO when applicable; KX above threshold	OT evaluation, ADL/functional, mobility and device-training families.
SLP	92507; 92508; 92521–92524; 92526; 92610; 96125; 97129; 97130	GN; KX above threshold	Communication, swallowing and cognitive evaluation/treatment families.
EMG	95860–95864; 95867–95870; 95885–95887	Same-day NCS rules apply	Standalone vs same-day NCS needle-EMG structure.
NCS	95907–95913	Same-day EMG reported on same claim in CMS MAC article example	NCS family based on study count/type methodology.
Spasticity / botulinum toxin	64612; 64616; 64617; 64642–64647; 95873/95874 when appropriate	JW/JZ for drug wastage rules when applicable	Chemodenervation plus product-specific HCPCS.
Work rehabilitation	97750; 97545; 97546; 97530	GP/GO if applicable to plan/payer	FCE components and work-conditioning/hardening families.
DME/O&P	Therapy 97542/97760/97761 plus item-specific HCPCS	RT/LT; KX/GA/GY/GZ only when policy supports	Separate professional therapy service from device/supplier claim.

03

THERAPY

PT Evaluation & Treatment Families

PT Coding Intelligence: CPT, ICD-10-CM, HCPCS & Modifiers

This coding matrix is an operational crosswalk, not a substitute for the current CPT codebook, HCPCS release, ICD-10-CM code set, Medicare NCCI files, payer policy or MAC article. Code descriptors below are deliberately paraphrased rather than reproduced verbatim.

CPT / HCPCS Level I Code Families

Code	Operational use	Coding control
97161–97163	PT initial evaluation family; complexity level must match the documented evaluation.	Untimed; verify current Medicare/payer rules.
97164	PT re-evaluation family.	Untimed; use only when re-evaluation criteria are met.
97110	Therapeutic exercise service family.	Timed; document skilled intervention and minutes.
97112	Neuromuscular re-education service family.	Timed; distinguish from therapeutic exercise.
97116	Gait-training service family.	Timed; support gait-specific skilled need.
97140	Manual therapy service family.	Timed; NCCI relationships require current edit review.
97530	Therapeutic activities service family.	Timed; document functional task focus.
97535	Self-care/home-management training family.	Timed; support skilled ADL/home-management need.
97542	Wheelchair management/training family.	Timed; document seating/mobility objective.
97750	Physical performance testing/measurement family.	Timed; report only when distinct and supported.
97760	Orthotic management/training family.	Timed; distinguish from DME supplier functions.
97761	Prosthetic training family.	Timed; document skilled prosthetic training.

Representative ICD-10-CM Diagnosis Crosswalk

ICD-10-CM	Clinical context	Crosswalk control
M54.12	Cervical radiculopathy	Use only when clinically established; diagnosis alone does not establish therapy coverage.
M54.16	Lumbar radiculopathy	Tie neurologic/MSK findings to measurable functional limitation.
M25.511 / M25.512	Right / left shoulder pain	Symptom diagnosis may require more definitive clinical context when available.
M25.561 / M25.562	Right / left knee pain	Laterality must match treatment record.
M17.11 / M17.12	Unilateral primary knee OA, right / left	Use highest supported specificity.
Z96.651 / Z96.652	Presence of right / left artificial knee joint	Often secondary/status context rather than the sole reason for skilled therapy.

HCPCS Level II Crosswalk

HCPCS / Family	Operational use	Control
G0283	Medicare HCPCS for certain unattended electrical stimulation circumstances.	Verify payer, setting and coverage; not interchangeable with attended stimulation.
DME/O&P families	E-, K-, L-code families may apply when equipment/orthotic/prosthetic items are furnished.	Separate therapist service from supplier billing and verify enrollment/coverage.

Modifier Matrix

Modifier	Use	Control
GP	Identifies services furnished under a PT plan of care.	Required on applicable Medicare therapy claims.
CQ	PTA involvement modifier when Medicare de minimis rules apply.	CMS requires CQ with GP when applicable.
KX	Attestation above Medicare therapy threshold that continued services are medically necessary and documented.	CY 2026 threshold: $2,480 for PT and SLP combined.
59 / XE / XP / XS / XU	NCCI-associated distinct-service modifiers when a current edit permits and facts support a true distinct service.	Never append solely to bypass an edit.

CODING CONTROL — VALID CODE ≠ COVERED SERVICE

A syntactically valid CPT, HCPCS or ICD-10-CM code does not establish medical necessity, authorization, benefit eligibility or payment. Reconcile diagnosis, procedure, units, modifiers, site of service, provider, authorization and current payer/MAC policy before billing.

Primary coding sources: CMS 2026 Therapy Code List · CMS NCCI · CMS MUE.

04

THERAPY

OT Evaluation & Treatment Families

OT Coding Intelligence: CPT, ICD-10-CM, HCPCS & Modifiers

This coding matrix is an operational crosswalk, not a substitute for the current CPT codebook, HCPCS release, ICD-10-CM code set, Medicare NCCI files, payer policy or MAC article. Code descriptors below are deliberately paraphrased rather than reproduced verbatim.

CPT / HCPCS Level I Code Families

Code	Operational use	Coding control
97165–97167	OT initial evaluation family; complexity must match documentation.	Untimed.
97168	OT re-evaluation family.	Untimed.
97110	Therapeutic exercise service family.	Timed; use when appropriate to OT plan.
97112	Neuromuscular re-education service family.	Timed.
97140	Manual therapy service family.	Timed; verify NCCI relationships.
97530	Therapeutic activities service family.	Timed; connect activity to occupational function.
97535	Self-care/home-management training family.	Timed; core OT relevance.
97542	Wheelchair management/training family.	Timed; document mobility/positioning objective.
97750	Physical performance testing/measurement family.	Timed; distinct testing rationale required.
97760	Orthotic management/training family.	Timed; separate from supplier billing.
97761	Prosthetic training family.	Timed.

Representative ICD-10-CM Diagnosis Crosswalk

ICD-10-CM	Clinical context	Crosswalk control
G56.01 / G56.02 / G56.03	Carpal tunnel syndrome, right / left / bilateral	Laterality and clinical findings should match the OT episode.
M25.511 / M25.512	Shoulder pain, right / left	Use only when supported by the evaluation.
M25.531 / M25.532	Wrist pain, right / left	Laterality should reconcile with treatment.
I69.320	Aphasia following cerebral infarction	May coexist with OT cognitive/functional deficits but SLP may address communication.
I69.314	Frontal/executive function deficit following cerebral infarction	Connect cognitive deficit to occupational performance.
R27.8	Other lack of coordination	Use only when clinically appropriate and not as a substitute for a known diagnosis.

HCPCS Level II Crosswalk

HCPCS / Family	Operational use	Control
DME/O&P families	E-, K-, L-code families may apply to mobility, orthotics, splints and adaptive equipment depending on item and supplier role.	Verify supplier enrollment, coverage, authorization and documentation.

Modifier Matrix

Modifier	Use	Control
GO	Identifies services furnished under an OT plan of care.	Required on applicable Medicare therapy claims.
CO	OTA involvement modifier when Medicare de minimis rules apply.	CMS requires CO with GO when applicable.
KX	Medicare therapy-threshold attestation when criteria are satisfied.	CY 2026 OT threshold: $2,480.
59 / X modifiers	Distinct-service modifiers only when a current NCCI edit allows and documentation supports the distinction.	Not a generic unbundling tool.

CODING CONTROL — VALID CODE ≠ COVERED SERVICE

A syntactically valid CPT, HCPCS or ICD-10-CM code does not establish medical necessity, authorization, benefit eligibility or payment. Reconcile diagnosis, procedure, units, modifiers, site of service, provider, authorization and current payer/MAC policy before billing.

Primary coding sources: CMS 2026 Therapy Code List · CMS NCCI · CMS MUE.

05

THERAPY

SLP Evaluation & Treatment Families

SLP Coding Intelligence: CPT, ICD-10-CM & Modifiers

This coding matrix is an operational crosswalk, not a substitute for the current CPT codebook, HCPCS release, ICD-10-CM code set, Medicare NCCI files, payer policy or MAC article. Code descriptors below are deliberately paraphrased rather than reproduced verbatim.

CPT / HCPCS Level I Code Families

Code	Operational use	Coding control
92507	Individual speech/language/communication treatment family.	Verify current descriptor and payer coverage.
92508	Group speech/language treatment family.	Group documentation and payer rules apply.
92521–92524	Speech/language/voice/fluency evaluation families.	Select the code matching the evaluation performed.
92526	Swallowing/oral-function treatment family.	Document dysphagia-related skilled need.
92610	Clinical swallowing evaluation family.	Untimed; distinguish from instrumental studies.
96125	Standardized cognitive performance testing family.	Timed; document standardized testing and interpretation.
97129	Initial cognitive-function intervention unit.	Timed; follow add-on/primary-code rules.
97130	Additional cognitive-function intervention unit(s).	Add-on relationship must be respected.

Representative ICD-10-CM Diagnosis Crosswalk

ICD-10-CM	Clinical context	Crosswalk control
I69.320	Aphasia following cerebral infarction	CMS SLP communication article includes post-stroke communication diagnoses.
I69.322	Dysarthria following cerebral infarction	Document speech impairment and functional impact.
R47.01	Aphasia	Use when clinically appropriate and consistent with etiology/documentation.
R13.12	Oropharyngeal dysphagia	Swallowing evaluation/treatment must be supported by the record.
R41.841	Cognitive communication deficit	Connect cognition to communication/function and skilled SLP need.
R49.0	Dysphonia	Voice-related diagnosis must align to performed service.

HCPCS Level II Crosswalk

HCPCS / Family	Operational use	Control
AAC/DME families	Speech-generating and augmentative communication devices may use HCPCS Level II codes depending on item and payer.	Verify device-specific HCPCS, supplier requirements and authorization.

Modifier Matrix

Modifier	Use	Control
GN	Identifies services furnished under an SLP plan of care.	Required on applicable Medicare therapy claims.
KX	Medicare therapy-threshold attestation when criteria are satisfied.	PT and SLP share the CY 2026 $2,480 threshold.
59 / X modifiers	Use only for a true distinct service when current NCCI rules permit.	Documentation must establish the distinction.

CODING CONTROL — VALID CODE ≠ COVERED SERVICE

A syntactically valid CPT, HCPCS or ICD-10-CM code does not establish medical necessity, authorization, benefit eligibility or payment. Reconcile diagnosis, procedure, units, modifiers, site of service, provider, authorization and current payer/MAC policy before billing.

Primary coding sources: CMS 2026 Therapy Code List · CMS NCCI · CMS MUE.

06

ELECTRODIAGNOSTIC

EMG & NCS Code Relationships

EMG Coding Intelligence: CPT, ICD-10-CM & Same-Day NCS Rules

This coding matrix is an operational crosswalk, not a substitute for the current CPT codebook, HCPCS release, ICD-10-CM code set, Medicare NCCI files, payer policy or MAC article. Code descriptors below are deliberately paraphrased rather than reproduced verbatim.

CPT / HCPCS Level I Code Families

Code	Operational use	Coding control
95860–95864	Needle EMG families used when NCS 95907–95913 are not performed the same day, as applicable.	CMS coding articles distinguish standalone needle EMG from same-day NCS/EMG.
95867–95870	Additional specialized needle EMG families without same-day NCS, when clinically appropriate.	Verify current code definition and applicability.
95885	Limited extremity needle EMG add-on family when NCS is performed same day.	Use only with appropriate NCS primary service.
95886	Complete extremity needle EMG add-on family when NCS is performed same day.	Use only with appropriate NCS primary service.
95887	Non-extremity needle EMG add-on family when NCS is performed same day.	Follow add-on rules.

Representative ICD-10-CM Diagnosis Crosswalk

ICD-10-CM	Clinical context	Crosswalk control
M54.12	Radiculopathy, cervical region	Included in CMS MAC EDX coding article example.
M54.16	Radiculopathy, lumbar region	Included in CMS MAC EDX coding article example.
G54.0	Brachial plexus disorders	Representative EDX indication when clinically supported.
G54.1	Lumbosacral plexus disorders	Representative EDX indication.
G56.01 / .02 / .03	Carpal tunnel syndrome, right / left / bilateral	CMS article specifically addresses NCS-alone scenarios for CTS under certain circumstances.
G57.51 / .52 / .53	Tarsal tunnel syndrome, right / left / bilateral	CMS article specifically addresses NCS-alone scenarios for TTS under certain circumstances.

HCPCS Level II Crosswalk

HCPCS / Family	Operational use	Control
95999	Unlisted neurologic diagnostic procedure may be used for certain non-covered/unlisted EDX technologies in a MAC article.	Do not use as a substitute for standard NCS/EMG coding; follow payer instructions.

Modifier Matrix

Modifier	Use	Control
No universal therapy modifier	EMG is not PT/OT/SLP therapy.	Verify MPFS and payer modifier requirements.
59 / X modifiers	Only if a current NCCI relationship permits and facts support a distinct service.	Do not append routinely.
26 / TC	Do not assume professional/technical component applicability.	Verify each code's MPFS indicator before use.

CODING CONTROL — VALID CODE ≠ COVERED SERVICE

A syntactically valid CPT, HCPCS or ICD-10-CM code does not establish medical necessity, authorization, benefit eligibility or payment. Reconcile diagnosis, procedure, units, modifiers, site of service, provider, authorization and current payer/MAC policy before billing.

Primary coding sources: CMS 2026 Therapy Code List · CMS NCCI · CMS MUE.

NCS Coding Intelligence: CPT, ICD-10-CM & Same-Day EMG Rules

This coding matrix is an operational crosswalk, not a substitute for the current CPT codebook, HCPCS release, ICD-10-CM code set, Medicare NCCI files, payer policy or MAC article. Code descriptors below are deliberately paraphrased rather than reproduced verbatim.

CPT / HCPCS Level I Code Families

Code	Operational use	Coding control
95907–95913	NCS code family stratified by number/types of studies.	CMS coding articles require proper count methodology; do not count every waveform/stimulation as a separate study.
95885–95887	Needle EMG add-on families used when appropriate NCS is performed the same day.	Same-day NCS and needle EMG should be reported on the same claim per CMS MAC article example.

Representative ICD-10-CM Diagnosis Crosswalk

ICD-10-CM	Clinical context	Crosswalk control
G56.01 / G56.02 / G56.03	Carpal tunnel syndrome, right / left / bilateral	CMS article identifies these in NCS-without-needle-EMG circumstances.
G56.21 / G56.22 / G56.23	Ulnar nerve lesion, right / left / bilateral	Representative upper-extremity mononeuropathy.
G57.51 / G57.52 / G57.53	Tarsal tunnel syndrome, right / left / bilateral	CMS article identifies these in NCS-without-needle-EMG circumstances.
M54.12	Cervical radiculopathy	Common EDX differential/indication when clinically supported.
M54.16	Lumbar radiculopathy	Common EDX differential/indication when clinically supported.
Z79.01 / Z79.02	Long-term antithrombotic/antiplatelet use contexts referenced by a CMS MAC article for certain NCS-without-EMG scenarios.	Secondary-code requirements are policy specific; verify jurisdiction.

HCPCS Level II Crosswalk

HCPCS / Family	Operational use	Control
95999	Unlisted neurologic diagnostic procedure for certain unlisted/non-covered technologies per payer instructions.	Not a substitute for 95907–95913.

Modifier Matrix

Modifier	Use	Control
No therapy modifier	NCS is electrodiagnostic medicine, not outpatient therapy.	Verify payer claim instructions.
59 / X modifiers	Only where current NCCI policy permits and service is truly distinct.	Document why.

CODING CONTROL — VALID CODE ≠ COVERED SERVICE

A syntactically valid CPT, HCPCS or ICD-10-CM code does not establish medical necessity, authorization, benefit eligibility or payment. Reconcile diagnosis, procedure, units, modifiers, site of service, provider, authorization and current payer/MAC policy before billing.

Primary coding sources: CMS 2026 Therapy Code List · CMS NCCI · CMS MUE.

07

CHEMODENERVATION

Botulinum Toxin Procedure & Drug Codes

Spasticity / Botulinum Toxin Coding Intelligence

This coding matrix is an operational crosswalk, not a substitute for the current CPT codebook, HCPCS release, ICD-10-CM code set, Medicare NCCI files, payer policy or MAC article. Code descriptors below are deliberately paraphrased rather than reproduced verbatim.

CPT / HCPCS Level I Code Families

Code	Operational use	Coding control
64642–64647	Extremity/trunk chemodenervation code families based on region and muscle-count structure.	Select exact code from current CPT based on service actually performed.
64612 / 64616 / 64617	Other anatomic chemodenervation families used for specific clinical regions when applicable.	Do not generalize across indications.
95873 / 95874	Electrical stimulation or needle-EMG guidance families that may be reportable with selected chemodenervation services when medically necessary.	CMS article says do not report 95874 with 95873.

Representative ICD-10-CM Diagnosis Crosswalk

ICD-10-CM	Clinical context	Crosswalk control
G81.*	Hemiplegia/hemiparesis families	Use specific laterality/dominance where required.
G82.*	Paraplegia/tetraplegia families	Clinical indication and treatment goals must be documented.
I69.*	Sequelae of cerebrovascular disease	Use the specific neurologic deficit/sequela supported by the chart.
G35.*	Multiple sclerosis families	2026 ICD-10 updates may affect specificity; verify current code set.
G80.*	Cerebral palsy families	Use specific type when documented.

HCPCS Level II Crosswalk

HCPCS / Family	Operational use	Control
J0585	OnabotulinumtoxinA product code family.	Bill units based on current HCPCS definition and product actually administered.
J0586	AbobotulinumtoxinA product code family.	Product-specific units are not interchangeable.
J0587	RimabotulinumtoxinB product code family.	Verify current payer policy.
J0588	IncobotulinumtoxinA product code family.	Verify product, units, NDC and authorization.
J0589	Additional botulinum toxin product code appearing in certain CMS articles.	Verify current HCPCS and payer adoption before use.

Modifier Matrix

Modifier	Use	Control
JW	Reports discarded amount from applicable single-dose container when Medicare rules require.	Drug wastage documentation must support claim.
JZ	Attests zero discarded amount from applicable single-dose container when Medicare rules require.	Apply only when rule applies.
RT / LT	May apply to certain payer/site reporting scenarios.	Do not substitute for procedure-specific bilateral rules.
50	Do not assume bilateral modifier is valid for chemodenervation code families.	CMS article examples note bilateral indicator considerations; verify MPFS/payer.

CODING CONTROL — VALID CODE ≠ COVERED SERVICE

A syntactically valid CPT, HCPCS or ICD-10-CM code does not establish medical necessity, authorization, benefit eligibility or payment. Reconcile diagnosis, procedure, units, modifiers, site of service, provider, authorization and current payer/MAC policy before billing.

Primary coding sources: CMS 2026 Therapy Code List · CMS NCCI · CMS MUE.

08

DRUG HCPCS

Botulinum Toxin HCPCS Crosswalk

HCPCS	Operational product context	Control
J0585	Botulinum toxin product family (onabotulinumtoxinA context).	Verify current HCPCS unit definition, NDC, authorization and wastage.
J0586	Botulinum toxin product family (abobotulinumtoxinA context).	Units are product-specific.
J0587	Botulinum toxin product family (rimabotulinumtoxinB context).	Verify payer policy.
J0588	Botulinum toxin product family (incobotulinumtoxinA context).	Verify product/units.
J0589	Additional botulinum toxin product code appearing in certain CMS articles.	Confirm current code set.
J7318; J7320–J7332	Hyaluronan product-code families used by Medicare articles for selected products.	Exact product and billing unit change over time; verify current HCPCS.

09

VISCOSUPPLEMENTATION

Hyaluronan HCPCS Families

Medicare MAC articles use product-specific HCPCS including J7318 and J7320–J7332 for selected hyaluronan products. The exact product, unit definition and series requirements must be verified for the current date of service.

CMS Hyaluronan Billing & Coding Article

10

DME/O&P

DME, Orthotics, Prosthetics & Mobility HCPCS

Use item-specific E-, K- and L-code families for DME/O&P. Do not treat therapy-management codes as substitutes for supplier HCPCS. Verify supplier enrollment, written order, medical-necessity documentation, prior authorization and Medicare DMEPOS policy.

11

UNITS

Timed vs Untimed Therapy Services

Medicare therapy billing uses time-based methodology for many 15-minute codes and one-unit reporting for untimed services. Document actual treatment minutes by service and clinician/assistant. Do not infer units from appointment length.

CMS Therapy Services

12

ASSISTANTS

PTA / OTA Coding

CMS requires CQ with GP and CO with GO when assistant rules apply. Use the current de minimis methodology rather than a blanket assistant modifier.

CMS CQ/CO Billing Examples

13

DRUGS

JW/JZ Drug-Wastage Control

For applicable Medicare single-dose containers, use JW for discarded drug and JZ when no drug is discarded, subject to current Medicare rules. The medical record and inventory/wastage record must reconcile with billed units.

14

SITE OF SERVICE

Professional vs Facility Coding

Do not assume the same coding/payment logic across physician office, hospital outpatient, CORF, rehabilitation agency, SNF or other settings. Check MPFS, OPPS/OCE and payer-specific rules.

15

NCCI

NCCI PTP Edits

CMS PTP edits identify code pairs that generally should not be paid together unless a clinically appropriate NCCI-associated modifier is allowed and supported.

CMS NCCI PTP Edits

16

MUE

Medically Unlikely Edits

MUEs are units-of-service edits. They are not coding recommendations and are updated at least quarterly.

CMS MUE Files

17

AUTHORIZATION

Authorization-to-Code Reconciliation

The authorization should be reconciled to the code family actually scheduled and performed. A diagnosis or procedure change can invalidate an authorization even when clinically reasonable.

18

DENIAL PREVENTION

Coding Denial Failure Modes

Failure	Control
Wrong therapy modifier	Discipline-specific GP/GO/GN edit before claim.
PTA/OTA modifier omitted or overused	Time-by-clinician capture plus CQ/CO rules.
EMG/NCS same-day mismatch	EDX coding review before claim.
Drug HCPCS/product mismatch	NDC, vial, units and authorization reconciliation.
NCCI edit	Current-quarter PTP edit check.
Excess units	Time documentation + MUE review.

19

AUDIT

Pre-Bill Coding Audit

Reconcile the clinical note, authorization, code family, diagnosis, units, modifiers, provider, site, drug/device record and payer edits before transmission.

20

GOVERNANCE

Annual & Quarterly Update Calendar

Annual: CPT/HCPCS and ICD-10-CM. Quarterly/as released: NCCI PTP, MUE, drug ASP, payer policy and many MAC article changes. Assign an owner and implementation date for every change.

21

LICENSING

CPT Licensing & Public-Site Use

CPT is proprietary to the AMA. This GoHealthcare library uses code numbers and paraphrased operational labels rather than reproducing full descriptors. Organizations should maintain appropriate CPT licensing for internal/public uses requiring licensed content.

AMA CPT Licensing

22

RELATED

Related GoHealthcare Resources

PM&R Specialty HubPhysical TherapyOccupational TherapySpeech-Language PathologyElectromyography (EMG)Nerve Conduction Studies (NCS)Clinical Guidelines Library

23

REFERENCES

Authoritative Coding References

• CMS Annual Therapy Update
• CMS Therapy Services
• CMS NCCI
• CMS NCCI Policy Manual
• CMS EDX Coding Article
• CMS Botulinum Toxin Article
• CMS Hyaluronan Article
• CMS DMEPOS
• AMA CPT Licensing

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DEVELOPED BY

Pinky Maniri

Founder & Chief Executive Officer, GoHealthcare Practice Solutions

Educational and Coding Disclaimer

This material is for educational and operational reference only and does not constitute medical, legal, coding, reimbursement or payer-contract advice. CPT is a registered trademark of the American Medical Association. Full CPT descriptors and official coding instructions should be obtained through properly licensed AMA resources. Verify current code sets, Medicare NCCI/MUE files, payer policy, authorization, benefit, provider and site-of-service requirements for the date of service.