Don’t Let 2010’s Thrombosis Codes Derail Your Claims

Acute vs. chronic will be 1 key to your 2010 ICD-9 choice.

Whether you code for a hematologist in a Coumadin clinic or treat cancer patients who develop thromboembolic disease as a side effect, be sure you catch the big changes coming down the pike for embolism and thrombosis coding.

CMS is offering a sneak peak at the added, deleted, and revised codes youll need to know when ICD-9 2010 goes into effect Oct. 1, 2009. CMSs proposed Inpatient Prospective Payment System rule includes a list of the expected changes to ICD-9 2010 (http://edocket.access.gpo.gov/2009/pdf/E9-10458.pdf, page 409).

Heres Why Phlebitis Documentation Is Elusive

In 2009, your coding options are 451.0-451.9 (Phlebitis and thrombophlebitis) and 453.0-453.9 (Other venous embolism and thrombosis).

Problem: Thrombophlebitis is a term that is now rarely used, due to the lack of clinical significance of phlebitis, according to Patrick Romano, MD, MPH, professor of medicine and pediatrics at University of California at Davis, in his Phlebitis and Thrombophlebitis presentation to the ICD-9 Coordination and Maintenance Committee. He presented the proposal on behalf of the Agency for Healthcare Research and Quality.

Coding has paralleled this reduced use of thrombophlebitis, with 453.x (embolism and thrombosis) reported much more frequently than 451.x (phlebitis and thrombophlebitis), Romano said.

An expansion of the 453.x (embolism and thrombosis) range should help you choose codes more in line with current clinical terminology. As described below, the new codes offer options based on location as well as the acute vs. chronic nature of the problem. (See the new codes in the chart on page 62.)

Keep in mind: If you report embolism and thrombosis codes based on a catheter complication, you  will need to consider additional codes for complication (such as 996.xx [Complications peculiar to certain specified procedures]) and an E code (such as E878.8 [Surgical operation and other surgical procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at the time of operation; other specified surgical operations and procedures]), says Cindy Parman, CPC, CPC-H, RCC, principal with Coding Strategies Inc. in Powder Springs, Ga.
Need for Upper Extremity Codes Answered

Trend: The increased use of PICC lines, central catheters, and tunnel dialysis catheters has increased incidence of DVT (deep venous thrombosis) in thorax and upper extremities, typically the axillary, subclavian, [and] brachiocephalic vein, Romano said.

But ICD-9 2009 doesnt offer the same specificity in upper extremity codes that it does for lower extremities.
451.x lower: The 2009 451.x codes allow you to distinguish phlebitis and thrombophlebitis involving:
" Superficial vessels of lower extremities (451.82)
" Deep veins of upper extremities (451.83)
" Upper extremities, unspecified (451.84).

451.x upper: But the 2009 embolism and thrombosis 453.x range doesnt offer codes to distinguish superficial thromboses or upper extremity thromboses, Romano said. You have to resort to 453.8 (Other venous embolism and thrombosis; of other specified veins). (Note that ICD-9 will delete 453.8 in 2010.)
ICD-9 2009 also doesnt offer codes for venous thrombosis affecting thorax and neck vessels, as the ICD-9-CM Coordination and Maintenance Committee Meeting, March 19-20, 2008, Diagnosis Agenda indicates (www.cdc.gov/nchs/data/icd9/agendaMa08.pdf).

453.x lower: ICD-9 2005 introduced 453.40-453.42 (Venous embolism and thrombosis of deep vessels of lower extremity &) which distinguished distal DVT from proximal DVT in the leg, Romano said.
453.x upper: This change did not address upper extremity or upper thoracic clots, Romano said.
The result is that you cant choose a specific code for upper extremity clots unless the physician uses the terminology of thrombophlebitis, Romano said, which is unlikely.

As indicated in the chart on page 62, the 2010 codes will allow you to choose more specific codes. To report the most specific option, you will need to know the location:
" Superficial veins of upper extremity
" Deep veins of upper extremity
" Axillary veins
" Subclavian veins
" Internal jugular veins.

Keep Watch for Chronic Vs. Acute
Your 2010 coding options wont be divided only based on location -- youll need to know whether the condition is acute or chronic, as well.

Why it matters: Physicians may keep DVT and pulmonary embolism patients on oral anticoagulation for three to six months or more. The patient may require a subsequent hospital admission to treat a complication, such as anticoagulant-related bleeding. When rehospitalized, these patients are generally coded with 451 or 453,

Romano said, but the condition is no longer acute.

So the ICD-9 responded to the need by including acute or chronic in the new 453.x code descriptors.
Revision red flag: ICD-9 2010 will revise a few codes, as well, to stay consistent with the acute vs. chronic wording, adding acute to the beginning of the 453.4x descriptors:
" 2009: 453.40 -- Venous embolism and thrombosis of unspecified deep vessels of lower extremity
" 2010: 453.40 -- Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity.
" 2009: 453.41 -- Venous embolism and thrombosis of deep vessels of proximal lower extremity
" 2010: 453.41 -- Acute venous embolism and thrombosis of deep vessels of proximal lower extremity.
" 2009: 453.42 -- Venous embolism and thrombosis of deep vessels of distal lower extremity
" 2010: 453.42 -- Acute venous embolism and thrombosis of deep vessels of distal lower extremity.
Resource: You can download Romanos presentation slides at www.cdc.gov/nchs/about/otheract/icd9/maint/classifications_of_diseases_and1.htm. Under Proposals (3/19-20, 2008), click on the Attachment 4 to Minutes --Romano link.

PQRI Participation Doesn’t Have to Be Hard

Question: Reporting on PQRI measures seems complicated. Im not sure my office has the time to report. How does our practice register for PQRI reporting, and how much do I have to report to earn my 2 percent payment on Medicare billing?

Michigan Subscriber

Answer: Your practice does not need to sign up or register to take part in the PQRI initiative. Simply send your claims with the correct Category II PQRI tracking codes, and you are part of the program. However, the later you begin, the less money you will be entitled to from the bonus program. The CMS PQRI Web site, www.cms.hhs.gov/PQRI, has additional information.

What you need to report: For claim-based submissions, you have two full-year participation options in 2009:

1. Report at least three PQRI measures (or one to two measures if less than three apply to the eligible professional), for 80 percent of applicable Medicare Part B patients;

2. Or, report all measures in one measure group, documented either for:

" 30 consecutive Medicare Part B fee-for-service (FFS) eligible patients from Jan. 1 through Dec. 31,2009, or

" 80 percent of applicable Part B FFS patients for each eligible professional (with a minimum of 30 patients) during the Jan. 1 through Dec. 31, 2009,reporting period.

For registry-based submission of measures groups,you must report:

" All measures for one measure group for 30 consecutive patients (Patients may include, but may not be exclusively, non-Medicare Part B FFS patients), or

" All measures for one measure group for 80 percent of applicable Medicare Part B FFS patients with a minimum of 30 patients.

CCI 10.1 Makes 52281 Component Of Many Cystourethroscopy Codes

Harder to bill for dilation of urethral stricture or stenosis separately
CPT code 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female) became a component of several other cystourethroscopy codes.

The column 1 codes with this code are 52007-52010, 52214-52234, 52250-52277, 52282, 52290-52300, 52305, 52317-52330, 52334-52510, 52606, 52614, 52620-52640 and 52700. You can't use a modifier to override these edits.

52281 was already a component of 52235 (Cystourethroscopy with fragmentation of ureteral calculus) and 52240 (cystourethroscopy, with fulguration...LARGE bladder tumors).

Often, coders bill 52281 separately for urethral dilation along with procedures like a cystoscopic examination, retrograde pyelogram and urethral stent placement for a urethral stone.

"There are a lot of commercial carriers that already lump it into a lot of the other codes," says Terry Vennell, billing manager for Knight, Boline & D'Amico in Harrisburg, Penn. "I'm not surprised that it's been included in a lot of them." Her practice doesn't bill 52281 frequently, "but I could see where someone would want to bill it separately."

"If they have to do a urethral dilation while they're doing something else, like a cystoscopy with full duration or cystoscopy with biopsy, I don't bill separately for the 52281," adds Vennell.

"I think they would typically do that with other procedures," says Laura Siniscalchi, a senior consultant with Deloitte and Touche in Boston. "That'll be an issue" for coders, she adds.

Separately, 76000 (Fluoroscopy, up to one hour) and 76001 (Fluoroscopy, more than one hour) became components of cystourethroscopy codes 52005-52007, 52310-52346 and 52351-52355. You can use a modifier to override these edits.

Separately, axillary lymphadenectomy code 38740 became a component of mastectomy code 19240. Chemotherapy code 96530 became a component of pump implantation codes 62367 and 62368. Muscle and range of motion testing codes 95831 and 95833 both became components of 95834, while 95832 became a component of 95833.

Needle oculoelectromyography code 92265 became a component of needle electromyography code 95868 (cranial nerve supplied muscles, bilateral). And ambulatory blood pressure monitoring code 93788 (Scanning analysis with report) became a component of 93784 (Recording, scanning analysis, interpretation and report).

62 vs. 80

Modifier 62 (Two surgeons): You should look to modifier 62 when your urologist participates in a surgery with another physician. For you to appropriately use this modifier, both surgeons should be working as primary surgeons and they must each have distinctly separate parts in the same CPT procedure , according to the modifier’s code description.

Modifier 80 (Assistant surgeon): If your urologist only acts as a "second pair of hands" in the operating room, assisting the primary surgeon, you should append modifier 80 to the procedure code. An assistant surgeon does not have to provide his own operative notes, but the primary surgeon should note the second physician’s name as the assistant surgeon in his operative report.

596.54 Will Translate to ICD-10 Easily

The one-to-one code matchup makes updating your superbill a snap.

When your urologist treats a patient for neurogenic bladder -- for example, a pediatric patient who undergoes the Mitrofanoff procedure -- you would likely use ICD-9 Diagnosis code 596.54 (Neurogenic bladder NOS).

ICD-10 difference: When ICD-10 takes over on Oct. 1, 2013, you'll still have just one neurogenic bladder diagnosis code: N31.9 (Neuromuscular dysfunction of bladder, unspecified).


Physician documentation: Your physician is already documenting that the patient has a neurogenic bladder and you likely have ICD-9 code 596.54 on your superbill already. You won't have much to change in 2013. You'll just need to switch 596.54 to N31.9 on the superbill.

Try 726.4 for This Overuse Injury

Question: We performed an MRI for a patient with intersection syndrome of the wrist. Which diagnosis code should I report?

Michigan Subscriber

Answer: Your best option is 726.4 (Enthesopathy of wrist and carpus).

Here's why: One of many other terms for intersection syndrome is abductor pollicus longus bursitis, and ICD-9 includes wrist bursitis under 726.4.


Other terms you may see for this overuse syndrome include peritendinitis crepitans, crossover tendinitis, squeaker's wrist or oarsman's wrist. The condition typically develops where the wrist's first dorsal compartment muscles cross the second dorsal compartment muscles.

4 Important Items You Don't Want to Miss In the Anesthesia Record

Extra units for reimbursement might be lurking in places other than the charge ticket.
Anesthesia coders have an edge over co-workers in other specialties: you have more resources when it's time to comb through charts for all the info you need. Use that access to the anesthesia record, charge ticket, and surgical report to find every detail that might help you in achieving medical billing and coding accuracy.
Unique challenge: A lot of practices use a charge ticket along with the anesthesia record. Many times, inconsistencies occur when information is transferred from the anesthesia record to the charge ticket. It's vital to compare the charge ticket to the anesthesia record, to ensure all key components are accounted for.
Read on for important medical billing and coding information you must focus on in your provider's anesthesia record.

1. Line Placements
Line placement is one service you can code together with the anesthesia service, so don't miss that chance.
Watch for notes concerning Swan-Ganz catheters (93503, Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes), arterial lines, CPT codes 36620-36625 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; …), or central venous catheter placement, CPT codes 36555-36571. Your provider must also evidently document the line's purpose, like additional monitoring or for use in postoperative pain management prior to the procedure.

2. Diagnosis and Procedure
You should know the procedure being carried out in order to select the accurate anesthesia code. General information concerning the patient's diagnosis and any past or present health conditions that can affect the procedure might change your coding.

Here's why: Conditions like hypertension, past coronary or pulmonary problems, or chronic diseases can escalate the anesthesiologist's risk or help explain the need for anesthesia. For instance, the anesthesiologist might need to take extra precautions during surgery on an obese patient with hypertension. A diagnosis of claustrophobia or Parkinson's can support medical necessity for anesthesia during "standard" procedures like an MRI.

3. Type of Anesthesia
Did the physician or CRNA offer general anesthesia, a regional, or observed anesthesia care (MAC)? The answer to this medical billing and coding question can definitely affect your coding, for instance when you need to append modifier G8 (Monitored anesthesia care [MAC] for deep complex, complicated, or markedly invasive surgical procedure) or G9 (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition) to the claim.

4. TEE, Fluoro, BIS Monitoring
You can sometimes distinctly report other services the anesthesiologist delivers during the procedure. Watch for documentation of these, including:

• Transesophageal echocardiography (TEE) probe placement (93313, Echocardiography, transesophageal, real-time with image documentation [2D] [with or without M-mode recording]; placement of transesophageal probe only). Ask your providers to specify "monitoring" or "diagnostic" when they use TEE so you can code appropriately.
• Fluoroscopic guidance for blocks or catheters used to provide postoperative pain management or placement of a central venous or Swan-Ganz catheter. These services are signified by CPT codes like 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) and +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting [List separately in addition to code for primary procedure]).

How ICD-10 Disproportionally Affects Some Specialties

The whole health care industry is worried about the transition to ICD-10 code sets, but perhaps some should be more concerned than others. According to new research published in the Journal of the American Medical Informatics Association (JAMIA), the ICD-10 changeover is likely to impact certain specialties more so than others.

The research, conducted by a team at the University of Chicago, suggested that mappings between ICD-9-CM and ICD-10-CM were more convoluted for some specialties than for others. Specifically, the researchers found that hematology and oncology were positioned for the easiest transition, while obstetrics, psychiatry and emergency medicine were facing the most challenges in the changeover.

The researchers found that nearly half of infectious disease code mappings (42 percent) and 27 percent of emergency room diagnoses remain convoluted, meaning that the ICD-9 codes and ICD-10 codes have complex and non-reciprocal mappings. Musculoskeletal, injury and poisoning clinical classes were also found to include a large number of difficult-to-translate codes. The researchers identified five mapping motif categories that indicate the way ICD-9 codes translate to ICD-10 codes. These five categories include: identity, class-to-subclass, subclass-to-class, convoluted and no mapping. According to the research, one percent of ICD-9 codes had no corresponding codes in ICD-10.

In addition to studying how the ICD-10 transition will impact various specialties, the researchers created an online portal clinicians can use to see how convoluted code conversion will be. This portal will be a helpful tool for clinicians to see how much their codes will change and the level of documentation that will be needed to support ICD-10 codes.

So what should you do if you are in one of these specialties facing a more difficult transition to ICD-10 codes? Start preparing as early as possible. Invest in staff training and focus on the most commonly used codes and most complex mappings. Be aware that the more complex the transition is for your specialty, the more financial impact the transition could have on your practice.

Source:http://www.successehs.com/item/icd-10-s-unequal-impact-how-icd-10-disproportionally-affects-some-specialties.htm

719.41 Could Be Peri-Scapular Pain Diagnosis

Question: What is the correct diagnosis code for peri-scapular pain?

Wisconsin Subscriber


Answer: The most accurate diagnosis in many cases is 719.41 (Pain in joint; shoulder region). If the patient experiences pain further up his or her neck, 723.1 (Cervicalgia) might be a better choice. Read your physician's notes carefully to pinpoint the location of pain.

Use 795.08 For Unsatisfactory Smear

ICD9-Cm 795.08 Unsatisfactory cervical cytology smear

Question: Which diagnosis should I use for a patient who comes in due to an unsatisfactory Pap smear - code 795.09 or 795.08?

Florida Subscriber


Answer: You should report 795.08 (Unsatisfactory smear). In the past, you would have reported 795.09 (Other abnormal Papanicolaou smear of cervix and cervical HPV), but as of 2004, ICD-9 revised the codes to indicate that 795.08 is now the correct code to use for an inadequate sample. This ICD-9 revision is another reason why you have to keep up with ICD-9 changes each year.

ICD-9-CM code 795.08 is a specific, billable medical code that can be used to indicate a diagnosis on a reimbursement claim.

Description

Unsatisfactory cervical cytology smear

Short Description
Unsat cerv cytlogy smear

Incision vs. Excision of Hemorrhoids

Question: Please explain the difference between codes 46083 and 46320. The definitions of both codes seem to mean the same thing. We do a lot of incision and drainage (I&D) for thrombosed hemorrhoids and need to know how this should be coded.

Delaware Subscriber


Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.



Answer: Code 46083 (incision of thrombosed hemorrhoid, external) is for an incision, in which a puncture is made in the hemorrhoid and the blood is allowed to drain, relieving pressure, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator based in North Augusta, S.C. Code 46320 (enucleation or excision of external thrombotic hemorrhoid) describes excision or enucleation, in which the thrombosed area is cut out completely, much like excision of a cyst or tumor. If you are doing I&D, you should use 46083.

781.99 Is Best Sensory Integration Disorder Choice

Question: What diagnosis should we submit for sensory integration disorder?

Nevada Subscriber

Answer: Sensory integration disorder is not a recognized diagnosis in ICD-9, so the most accurate choice is 781.99 (Other symptoms involving nervous and musculoskeletal systems).


Also known as sensory integration dysfunction, SID is a neurological disorder that results from the brain's inability to integrate certain information received from the body's five basic sensory systems. Physicians often detect SID in young children. Signs can include (but are not limited to) oversensitivity to touch, movement, sights, or sounds; a tendency to be easily distracted; an activity level that is unusually high or unusually low; difficulty in making transitions from one situation to another; and delays in speech, language, or motor skills or academic achievement.

44139 Doesn't Apply to Lap. Takedown

Question: If my physician performs colectomy (44140) and takes down the splenic flexure, I can report add-on code 44139.


If my physician does this same procedure laparoscopically (44204), how can I get reimbursed for takedown of the splenic flexure?


Maryland Subscriber


Answer: The code you-re looking for is +44213 (Laparoscopy, surgical, mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]). CPT added this code in 2006 to accompany primary procedure codes 44204-44208.


If the surgeon performs laparoscopic partial colectomy with takedown of the splenic flexure, you-d report 44204 (Laparoscopy, surgical; colectomy, partial with anastomosis) as the primary procedure, with add-on 44123 for the takedown.


Claiming 44123 correctly will add 3.5 physician work relative value units -- or approximately $125 dollars on average, for Medicare payers -- to your reimbursement.


The "open" equivalent of 44213 is, as you note, +44139 (Mobilization [take-down] of splenic flexure performed in conjunction with partial colectomy [list separately in addition to primary procedure]). CPT instructions direct you to use add-on 44139 only with primary codes 44140-44147 (Colectomy, partial-).

410.31 or 410.32 for Follow-Up?

Question: The patient is seen in the hospital for a 410.31, and then is discharged. The patient is scheduled to be seen in the office for a follow-up visit. For this follow-up visit, which is less than 8 weeks from the myocardial infarction, is it appropriate to use the fifth digit of "2" on the MI (410.32), or would you still use 410.31?

Answer: You should use 410.32 (Acute myocardial infarction of inferoposterior wall; subsequent episode of care) for this follow-up visit. ICD-9 notes with the 410.xx fifth digit options state that you should "use fifth-digit 2 to designate an episode of care following the initial episode when the patient is admitted for further observation, evaluation or treatment for a myocardial infarction that has received initial treatment, but is still less than 8 weeks old."

You should report 410.31 (Acute myocardial infarction of inferoposterior wall; initial episode of care) only during the initial episode of care. The fifth digit "1" applies until the patient is discharged, regardless of where the cardiologist provides the care. Notes in the ICD-9 manual clarify that you use "1" for the first episode of care, "regardless of the number of times a patient may be transferred during the initial episode of care."

If documentation doesn’t specify the episode of care (initial or subsequent), you should use fifth digit "0" (Episode of care unspecified).
If the patient returns more than eight weeks after the infarction, you should use 414.8 (Other specified forms of chronic ischemic heart disease). Notes with this code specify it is appropriate for "any condition classifiable to 410 specified as chronic, or presenting with symptoms after 8 weeks from date of infarction."

Follow these tips to Refresh your ERCP Coding Knowledge

Have you been meeting denials lately when your gastroenterologist performs an endoscopic retrograde cholangiopancreatography (ERCP)? Here’s a quick refresher for you to get the payment you deserve and lead you in the right direction.

Know the Reason for the Procedure
Gastroenterologist can perform an ERCP procedure for diagnosis or therapeutic purposes. "A typical scenario for an ERCP is that the patient has continued epigastric pain in the ER, as an inpatient, or as an observation patient. A CT scan is done which is abnormal. Because of the abnormal CT, our physicians will perform an esophagogastroduodenoscopy (EGD) for the epigastric pain, then an ERCP for the abnormal CT," says Heather Copen, RHIT, CCS-P, Financial Advocate-Goshen OB/GYN and Goshen GI, IU Health-Goshen Physicians, Goshen, Indiana.

Over the past couple of years, procedures such as endoscopic ultrasound and magnetic resonance cholangiopancreatography, which are low-risk or risk-free, are being increasingly used for diagnosis and have decreased the use of ERCP for strictly diagnostic purposes. "We never do ERCPs for screening procedures," adds Copen.

ERCP is carried out with therapeutic intent for the following reasons:

• Removal or destruction of stones in the biliary or the pancreatic ducts;
• For the placement/removal of stents;
• For conducting a sphincterotomy; and
• For investigating the cause of dilation of the biliary or pancreatic ducts.

Although you might notice your gastroenterologist performing an ERCP with therapeutic intent for some particular reason, it is quite common to see the procedure being conducted for more than one reason.
For example, the gastroenterologist might also place a stent in addition to removing of stone in the biliary duct. For this reason, it becomes necessary to scan the operative procedure in detail to know all the procedures that have been performed or you may risk losing reimbursement for additional work.

What to Do When Stent Is the Intent

If your gastroenterologist performs an ERCP with the intent of placing of a stent, then you will often see the procedure performed with a sphincterotomy in addition to the stent placement.

You would report it with 43268 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct). At time, your gastroenterologist might place more than one stent. In case the stents are placed in the same duct, then you should report the procedure with 43268. But if the stents are placed in different ducts, you can report the second stent by using 43268 twice. If multiple stents are placed, you can use the modifier 59 (Distinct procedural service) for your claims.

Example: If your gastroenterologist placed two stents in the biliary duct and another in the pancreatic duct, then you report the procedure with the CPT® code 43268 and 43268-59. You would need to support your claim with adequate documentation to inform the payer where the stents.

In case your gastroenterologist removes a previously placed stent and then inserts another stent in its place, you report the procedure with 43269 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of foreign body and/or change of tube or stent) and then with 43268. Carefully read through the procedure note to ascertain where the stent is being removed and where is it being placed.

"When a stent is removed and replaced in the same duct, then only the 43269 would be reported. If a stent is removed from the pancreatic duct but then a stent was placed in the common bile duct, you would report 43268 with a -59 modifier," says Copen. She further shares what she does. "I put a note on the claim that states that the 43269 was the pancreatic duct and the 43268 was the common bile duct. If one stent is placed in the common bile duct and one placed in the pancreatic duct, I report the 43268 twice. The second 43268 gets a -59 modifier and again I note that one is the common bile duct and the other is the pancreatic duct. This is allowable because the wording for the CPT® codes states bile or pancreatic duct, not both, so when a physician does both stents, then they are billable separately."

Know the Method in Stone Removal

When your gastroenterologist is performing a stone removal through ERCP, you report the procedure with 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts). The code remains the same irrespective of whether a balloon or a basket is used to remove the stone. "The CPT® code 43264 states that it is a removal of calculus/calculi from bilary and/or pancreatic duct. The code is also used for stone removal with balloon because a removal is a removal, no matter how it is removed," says Copen.
Warning: Stone removal with balloons should not be confused with dilation using balloons to relieve strictures that are reported with 43271 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct[s]). A stone removal with balloon should be reported with 43264. "The CPT® code 43271 specifies that it is a balloon dilation of the ampulla, biliary, and/or pancreatic duct(s) which would make this code unsuitable to use for removal of a stone with a balloon. The balloon dilation would be used if there was a stricture or stenosis of the ampulla, biliary, and/or pancreatic duct," says Copen.

If your gastroenterologist destroys the stone with lithotripsy, you report the procedure with 43265 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method).

Coding Tips: If your gastroenterologist performs a removal procedure with a basket or balloon and a lithotripsy in the same session, it is quite common to assume that these two procedures are mutually exclusive and cannot be reported together.

However, you should note that CPT® allows you to report both the procedures. As per multiple procedure payment reduction policy, you need to report 43265 first as this is of higher RVU value and you get a total claim. 43264 should be reported with modifier 51 (Multiple procedures), depending on payer’s preference, for consideration of both the claims.
Don’t Forget These Additional Procedures
Your gastroenterologist might also perform additional procedures such as a sphincterotomy along with stone removal. When your gastroenterologist needs to gain access to the bile duct or pancreatic duct, it is often necessary to cut the major papilla orifice with a wire. This is sphincterotomy or papillotomy and is a separate service not included in the other ERCP therapeutic codes.

In such a case, you need to report the primary procedure of the removal and then report sphincterotomy as a separate procedure with 43262 (Endoscopic retrograde cholangiopancreatography [ERCP]; with sphincterotomy/papillotomy). "If a sphincterotomy is performed with a stone removal and a stent placement then the three different codes are billable," says Copen. "When multiple sphincterotomies are performed at the same session than only one code would be allowed." This can occur when your gastroenterologist needs to gain access to both the major papilla and the nearby minor papilla.

If multiple sphincterotomies have been performed, you report the procedures using 43262 with modifier 59 (Distinct procedural service). Additionally, if your gastroenterologist took long at a difficult procedure which required multiple sphincterotomies in a single session, you append modifier 22 (Increased procedural service). "If the sphincterotomy is performed multiple times during the same session, then I would suggest putting a -22 modifier with the stipulation that the doctor documented the difficult procedure and the need to perform it multiple times," says Copen.

During the ERCP, your gastroenterologist might use a camera to visualize the bile duct or the pancreatic ducts. In such a circumstance, CPT® allows the use of an additional code and you report it with +43273 (Endoscopic cannulation of papilla with direct visualization of common bile duct[s] and/or pancreatic duct[s] [List separately in addition to code[s] for primary procedure]). You need to use this code if you see that your gastroenterologist performed a cannulation to view the ducts. The tiny camera device will often be referred to as a "Spyglass™" catheter.

CPT® Assistant Holds the Key to 2014’s Vascular Embolization Code Changes

Four new vascular embolization codes debuted in January, and the latest CPT® Assistant has a must-read article for anyone who performs these services. You’ll benefit from five separate examples that will help you identify and count surgical fields. The article also reveals at-a-glance lists of which services are included and which services you may report separately. A bonus Q&A section addresses confusing scenarios, such as how to code when there are multiple indications for embolization or when stent placement is performed at the same session.

The newest CPT® Assistant also has you covered whether you need more information on using complex chronic care E/M codes or you’re searching for clues on 2014’s radiation oncology changes. Search SuperCoder.com’s Code Connect by code or keyword to get the latest on these topics.

• Complex chronic care: 98960, 98961, 98962, 98966-98968, 99071, 99075, 99078, 99339, 99340, 99358, 99359, 99363, 99364, 99374, 99375, 99377-99380, 99487-99489, 99495, 99496
• Fluid collection drainage, catheter: 10030, 32201, 44901, 47011, 48511, 49021, 49041, 49061, 49405, 49406, 49407, 50021, 58823
• Radiology simulation: 77280, 77285, 77293, 77295
• Vascular embolization and occlusion: 37204, 37210, 37241, 37242, 37243, 37243, 37244, 75894, 75898.

If you want advice targeted at overcoming common coding hurdles, you’ll find what you need in the CPT® Assistant FAQs. Search for these codes and keywords on Code Connect:

• Angiography: 36216, 36222, 36225, 36245-36247, 36253, 37241-37244, 37799, 75894, 75898
• Integumentary services: 15273, 15274, 15277, 15278, 19301, 19499
• Neuroma injection: 11900, 64455, 64632, 64999.

Source: http://codingnews.inhealthcare.com/hot-coding-topics/news-cpt-assistant-holds-the-key-to-2014s-vascular-embolization-code-changes/

36 Options Replace 996.01 in October 2014

When a pacemaker battery wears down unexpectedly or a lead becomes damaged, the patient may experience shortness of breath, fatigue, and other symptoms of arrhythmia or decreased heart function. ICD-9-CM categorizes these problems as “Mechanical complication of cardiac device.” ICD-10-CM says one big category just won’t do. Here’s how the new codeset splits your choices.
ICD-9-CM Code:
996.01, Mechanical complication of cardiac device, implant, and graft; due to cardiac pacemaker (electrode)
ICD-10-CM Codes: 
T82.110-, Breakdown (mechanical) of cardiac electrode
T82.111-, Breakdown (mechanical) of cardiac pulse generator (battery)
T82.118-, Breakdown (mechanical) of other cardiac electronic device
T82.119-, Breakdown (mechanical) of unspecified cardiac electronic device
T82.120-, Displacement of cardiac electrode
T82.121-, Displacement of cardiac pulse generator (battery)
T82.128-, Displacement of other cardiac electronic device
T82.129-, Displacement of unspecified cardiac electronic device
T82.190-, Other mechanical complication of cardiac electrode
T82.191-, Other mechanical complication of cardiac pulse generator (battery)
T82.198-, Other mechanical complication of other cardiac electronic device
T82.199-, Other mechanical complication of unspecified cardiac device

The appropriate 7th character is to be added to each code from category T82.-:
A, initial encounter
D, subsequent encounter
S, sequela

ICD-9 coding rules: ICD-9 offers an inclusion note under 996.0x showing the codes apply to breakdown (mechanical); displacement; leakage; obstruction, mechanical; perforation; and protrusion. If you need to code these complications for an automatic implantable cardiac defibrillator (AICD), you would use 996.04 (Mechanical complication of automatic implantable cardiac defibrillator) instead of 996.01.

ICD-10 changes: ICD-10 offers a long list of codes that cross to both 996.01 and 996.04. The codes differ based on whether the complication is a breakdown, a displacement, or “other.” Within each of those divisions, you’ll have to choose codes based on whether the problem relates to the electrode, generator, other, or unspecified device. You’ll also have to choose a seventh character based on the encounter.

Documentation: Ensure that your providers document all the information you need to choose among the long list of new codes: the nature of the complication (breakdown, displacement, etc.), the part of the device involved (electrode, generator, etc.), which encounter it is (initial, subsequent, sequela).
Coder tips: ICD-10 Official Guidelines explain proper use of the seventh characters:
Use A, initial encounter, while the patient is receiving active treatment for the injury. “Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.”

Use D, subsequent encounter, “for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following injury treatment.”

Use S, sequela, “for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn.” When you use S, “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 ‘S’ extension identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.”


Remember: CMS has finalized the ICD-10 compliance date of Oct. 1, 2014. When ICD-10 is implemented, you should apply the code set and official guidelines in effect for the date of service reported. Learn more at www.cms.gov/ICD10/ and www.cdc.gov/nchs/icd/icd10cm.htm#10update.

Source: http://codingnews.inhealthcare.com/icd-10/36-options-replace-996-01-in-october-2014/

Check Bundling Between Epidurals and E/M Depending on DOS

Question: I have done continuous epidural for my patient and injected different concentrations of Marcaine and normal saline to evaluate the response and identify psychosomatic disorder. Total time spent was 3 hours during which the patient was evaluated for response and monitoring vital signs. How should I bill for this procedure?

Chicago Subscriber
Answer: First and foremost, you have not made it clear as to what other services were provided. If the evaluation only included using the epidural to assess the patient, again depending on how (needle or indwelling catheter) and where the epidural was given, codes 62310 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic), 62311 (…lumbar or sacral [caudal]), 62318 (Injection[s], including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic) or 62319 (…lumbar or sacral [caudal]) can be reported.

Also, an appropriate E/M code can be selected to report the evaluation of the patient. Depending on the typical time of the E/M code selected and how much of the three hours was spent in evaluation and management, you may also be able to report a prolonged services code (or two) from the range 99354-99357.

However, if the date of service was after July 1, it is important to note that there is a CCI edit that bundles these services along with E/M codes wherein you cannot report the E/M service separately with these codes. But the edit carries the modifier indicator ‘1,’ which means that if the E/M service was separate and distinct, a modifier such as 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) can be appended to the E/M code to unbundle the edits.
Finally, there is a HCPCS code for Marcaine HCL (S0020, Injection, bupivicaine hydrochloride, 30 ml) and one for saline (A4217, Sterile water/saline, 500 ml), which may or may not be reportable, depending on the payer and the circumstances.

should we charge 75989 or 77012 for the CT guidance along with 32551?

You should report 75989 (Radiological guidance [i.e., fluoroscopy, ultrasound, or computed tomography], for percutaneous drainage [e.g., abscess, specimen collection], with placement of catheter, radiological supervision and interpretation) for CT guidance performed with chest tube insertion code 32551 (Tube thoracostomy, includes water seal [e.g., for abscess, hemothorax, empyema], when performed [separate procedure]).

A note with 32551 specifically points you to 75989 for related guidance, including CT guidance.
Although 77012 (Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiological supervision and interpretation) does describe CT guidance, it is specific to needle placement guidance. 

Which code applies to a KUB interpretation following ESWL

Code 74000 (Radiological examination, abdomen; single anteroposterior view) typically applies to a KUB (which stands for, but does not require imaging of, kidney, ureters, and bladder). Documentation should drive your final code choice, however. Append modifier 26 (Professional component) to 74000 if you need to indicate that the radiologist performed only the interpretation and report.


The physician who performs the ESWL to break up kidney stones should report 50590 (Lithotripsy, extracorporeal shock wave). 

Maximize Payment for A-Scans by Understanding Medicare vs. Commercial Payers

Ophthalmologists should bill for both eyes together when performing the technical component of an A-scan for reimbursement from Medicare. But for reimbursement from commercial payers, code each eye separately.

Correctly Code for Medicare Reimbursement

Medicares payment policy for 76519 (ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation) is one of the most confusing policies in existence. This procedure must be done before cataract surgery, and both A-scans and cataract surgery constitute a large part of a general ophthalmologists practice, so it is important for coders to know how to bill for 76519.

Medicare breaks down 76519 into technical and professional components. The technical portion is the actual measuring, which is done with equipment that takes two measurementsthe axial length of the eye and the shape of the corneaand turns them into a calculation for the power of the intraocular lens implant.

Note: Not all offices can do both with one piece of equipment. In fact many offices have to do the keratometry separately and feed the readings into the A-scan equipment for use in the IOL calculation.

Medicare will only allow one technical component in a 12-month period. If it has been more than 12 months since the last measurement was performed, then another technical component may be billed. The professional component takes place when the ophthalmologist actually selects the power and style of the lens to insert. Both eyes need to be synchronized to work together, so that perfect vision may not be the best power for an IOL. Medicare allows the professional component to be billed once for each cataract surgery, even if the professional component for the other eye (and technical component for both eyes) was done recently. Here are some Medicare billing scenarios, courtesy of Lise Roberts, vice president of Health Care Strategies of Syosset, N.Y.

Scenario 1: The patient has cataracts in both eyes that impair vision by approximately the same amount. The physician does the dominant eye (right eye in this example) first and plans to do the other eye soon after the first eye is healed. The A-scan and keratometry are performed to measure both eyes and the physician selects the power and style to implant into the dominant eye. The first claim will reflect 76519-RT. The Medicare Physicians Fee Schedule (MPFS) for 76519 includes payment for measuring both eyes and interpreting one eye. Later, when the physician selects the power and style of the IOL for the other eye the second claim will reflect 76519-26-LT. The MPFS for 76519-26 includes payment for the interpretation only, resulting in the selection of the power and style of the IOL.

News Brief: Look for Corrections to National CCI Version 6.1

Due to a large number of errors, the implementation of the national Correct Coding Initiative (CCI) version 6.1 has been delayed from April 1 to May 1, 2000. Users of any CCI edit products should make certain that they have a corrected copy of version 6.1 before its implementation on May 1, either in the form of an errata sheet or, in some cases, an updated book, says Laurie Castillo, MA, CPC, president of American Association of Professional Coders Northern Virginia Chapter and owner of Physician Coding & Compliance Consulting in Manassas, Va.

The National Technical Information Service (NTIS) publishes the CCI Edits , along with several other commercial resellers who purchase the raw data from NTIS. According to NTIS, all of its customers received an errata sheet soon after NTIS was made aware of the errors by the Health Care Financing Administration (HCFA).

We received 37 pages of changes from NTIS, confirms Tony Mistretta of the Medical Management Institute, one of the licensed resellers of the CCI edits. We have committed to making all the changes to the book by hand and sending out corrected manuals to our subscribers, he said.

Those who purchased CCI edits from a source other than NTIS and the Medical Management Institute also should look for corrections to version 6.1 in time for the May 1 implementation. For NTIS customers, this has been sent out in the form of an appendix, which must be cross-referenced to the version 6.1 product. Other resellers should have received the errata sheet from NTIS and made arrangements to get that information to their customers.

In response to direction from Congress, CCI edits were initiated in 1996 to reduce Medicare program expenditures by detecting inappropriate coding on claims, and denying payment. The CCI edits are basically a list of code pairs that Medicare will not reimburse together for the same patient on the same day, because they represent services that are bundled or would not ordinarily be performed together, states Castillo. Reporting two of these codes together for the same service represents fraudulent unbundling, which is the practice of breaking down a single procedure into its component parts, and billing for additional services, Castillo warns.

There are times, however, when two of these codes might legitimately be coded together, if they represent two services that are distinct and independent from each other, declares Castillo. In order to indicate that the codes represent separate services as opposed to unbundling of a single service, coders should use appropriate modifiers, such as CPT modifier -59 (distinct procedural service), she advises. 

Failure to Thrive 779.34 or 783.41 Depends on Exact Age

Question: What diagnosis should we submit for a newborn who is not gaining enough weight?
Florida Subscriber


Answer: The correct choice depends on the child's age. For an infant 28 days of age or younger, report 779.34 (Failure to thrive in newborn). If the infant is older than 28 days, select 783.41 (Failure to thrive). 

More partnerships between doctors and hospitals strengthen coordinated care for Medicare beneficiaries

Doctors, hospitals and other health care providers have formed 123 new Accountable Care Organizations (ACOs) in Medicare, providing approximately 1.5 million more Medicare beneficiaries with access to high-quality coordinated care across the United States, Health and Human Services Secretary Kathleen Sebelius announced today.

Doctors, hospitals and health care providers establish ACOs in order to work together to provide higher-quality coordinated care to their patients, while helping to slow health care cost growth. Since passage of the Affordable Care Act, more than 360 ACOs have been established, serving over 5.3 million Americans with Medicare.  Beneficiaries seeing health care providers in ACOs always have the freedom to choose doctors inside or outside of the ACO. ACOs share with Medicare any savings generated from lowering the growth in health care costs when they meet standards for high quality care.

“Accountable Care Organizations are delivering higher-quality care to Medicare beneficiaries and are using Medicare dollars more efficiently,” Secretary Sebelius said.   “This is a great example of the Affordable Care Act rewarding hospitals and doctors that work together to help our beneficiaries get the best possible care.”
“This program puts the control in the hands of physicians and allows them to take the lead in an innovative way to deliver the right care to the right patient at the right time,” said Kelly A. Conroy, executive director of the Palm Beach ACO and South Florida ACO.  “We are honored to be a Medicare Shared Savings Program Accountable Care Organization, and after 18 months in the program, can proudly say that we have seen measurable success.  We are so impressed with our participating physicians’ enthusiasm towards the cultural shift, and it demonstrates that physicians are primed for the future of medicine.”

The ACOs must meet quality standards to ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely. The Centers for Medicare & Medicaid Services (CMS) evaluates ACO quality performance using 33 quality measures on patient and caregiver experience of care, care coordination and patient safety, appropriate use of preventive health services, and improved care for at-risk populations.

The new ACOs include a diverse cross-section of health care providers across the country, including providers delivering care in underserved areas. More than half of ACOs are physician-led organizations that serve fewer than 10,000 beneficiaries. Approximately 1 in 5 ACOs include community health centers, rural health clinics, and critical access hospitals that serve low-income and rural communities.

Affordable Care Act provisions have a substantial effect on reducing the growth rate of Medicare spending.  Growth in Medicare spending per beneficiary hit historic lows during the 2010-2012 period, and this trend has continued into 2013. Projections by both the Office of the Actuary at CMS and the Congressional Budget Office estimate that Medicare spending per beneficiary will grow at approximately the rate of growth of the economy for the next decade, breaking a decades-old pattern of spending growth outstripping economic growth.

The next application period for organizations interested in participating in the Shared Savings Program beginning January 2015 will be in summer 2014.

More information about the Shared Savings Program, including previously announced ACOs, is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/News.html.

For a list of the 123 new ACOs announced today, visit: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2014-ACO-Contacts-Directory.pdf.

Source:http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-12-23.html

Use 250.8x to Represent Diabetic Hypoglycemia

Question: Our physician saw a hypoglycemic patient, but we aren't sure which hypoglycemia code applies. Do you have any advice on selecting an ICD-9 code?
Nevada Subscriber


Answer: If the patient has diabetic hypoglycemia, you should report 250.8x (Diabetic hypoglycemia).

If not, you should probably select one of the following codes, based on the physician's documentation:

 - 250.3x -- Diabetes with other coma (diabetic hypoglycemic coma)

 - 251.0 -- Hypoglycemic coma

 - 251.1 -- Other specified hypoglycemia 

 - 251.2 -- Hypoglycemia, unspecified.

 - 579.3 -- Other and unspecified postsurgical nonabsorption

 - 775.6 -- Neonatal hypoglycemia.

CPT® 2014 Introduces 4 New Consultation Codes

Interestingly, four new codes have been added that describe the work of two medical professionals who discuss a patient’s condition over phone or Internet.

A few years ago, Medicare and other carriers stopped recognizing consultation codes. But all that is about to change as CPT® 2014 has added four new consultation codes with effect from January 1, 2014.
So from the first day of the New Year, if two medical professionals discuss a patient’s condition via phone or internet, you’ll report the following codes:

• 99446 – Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
• 99447 – … 11-20 minutes of medical consultative discussion and review
• 99448 – … 21-30 minutes of medical consultative discussion and review
• 99449 – … 31 minutes or more of medical consultative discussion and review.

These codes are more likely to be used for complex or urgent cases where the situation makes it difficult for the consultation to provide a face-to-face service, reads CPT® 2014 guidelines. For example, the consultant may be located far away.
Questions related to time
Coders need to be alert to:

• Why these codes are broken into time
• How that time will be measured (reading, discussing, interpreting, further research, etc.).
• How will the time be documented
• Will it be documented

Tips you’d like to make note of:

• For consultations less than 5 minutes, avoid using these codes
• Major part of the service time reported (more than half) must be devoted to the medical consultative verbal/Internet discussion.
  • The consult includes review of related medical records, path/lab studies, imaging, medications, and similar date.
  • A single code covers all contact time and review time, so add together and calculate the total time spent when multiple calls/internet contacts are performed for a single consult.

The earlier you’re up to speed on the 2014 CPT^® changes, such as the above-mentioned new codes for inter-professional consultations, the more likely for you to see fewer payment delays for those services.