Transcript CPT Coding for the Emergency Department

Focused Surgical CPT Coding Series:
• Digestive System
Karen Scott, MEd, RHIA, CCS-P, CPC
Karen Scott Seminars and Consulting
Memphis, TN
[email protected]
Agenda
Discussion of the common Digestive
System Coding Problem Areas
Factors that impact APC Payment
Training issues for physicians and other
documenting personnel
Lip and Mouth Procedures
• Most are status T procedures
• Need to know how much of the lip is
excised/reconstructed
• Height of the lip, complex, bilateral, primary
vs. secondary
• Full thickness-through the whole lip
• Cleft lip repaired in two sections-first is
primary and second surgery is secondary in
CPT lingo
Mouth
• Laceration repair
– 40830 closure 2.5 cm or less $159.25
– x0831 closure over 2.5 cm or complex
$474.35
– Complex-extensive damage/crushing;
require complex suturing such as
Retention sutures
Tongue
• Lesion excision depends on where
lesion is located
– If tongue flap is created, this makes a
difference in reimbursement
• x1113 Excision of tongue lesion, posterior 1/3
$1040.05
• x1114 with local flap $1417.55
New Sleep Apnea Codes
• X1512 Base suspension
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Helps support pharynx to keep airway open
Titanium screw placed in mandibular cortex
Permanent suture placed through posterior tongue base
Secure anteriorly around screw
Typically requires general anesthesia
• X1530 Ablation of tongue base
– Destruction of tissues using radiofrequency
– One or more sites
– Creates submucosal lesions, scar forms and retracts
thereby reducing volume of tissue
Tonsillectomy
• Tonsils and Adenoids
– Included in same APC regardless if tonsils
and adenoidectomy together or by self
$1417.55
Esophagus
• Open or through orifice
• An esophagoscopy is coded based on the
organs actually observed during the
procedure.
Esophagus only will take the coder to one
range of codes, where examination including
the stomach or small intestine will be in a
separate range of codes.
• Most of the scopes take to APC 141 $541.59
(Status T)
EGD
• Hard to locate in alphabetic index
• CPT main term is endoscopy, upper
gastrointestinal
• Coded according to type of procedure
done with the scope
• Also group to APC 141 $541.59
More on EGDs
• With biopsy-single or multiple means only
one code per session for any number of
biopsies
• CPT does allow use of two or more codes in
same “family” if documentation justifies
each procedure
• Some insurance companies bundle some of
the procedures together so they may not be
separately payable
• May need modifier
• Check NCCI edits list
Injection
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x3235 –submucosal injection(s)
Can inject a number of substances
India ink for marking
Saline to “puff” up a polyp for better
grasping
• Adds to length of time and risk for
patient
Case Study
• Preoperative Diagnosis:
Abnormal Upper GI x-rays
Postoperative diagnosis:
1. Polypoid lesions at the GE junction
2. Rule out inflammation versus
carcinoma
3. Deformed pylorus and duodenal
bulb
Procedure:
Esophagogastroduodenoscopy
Surgery Information
• This is a 45-year-old white male admitted with a
history of vomiting and coffee-ground emesis.
Gastroscopy is being done at this time for
evaluation. Using an Olympus XQ10 gastroscope,
with the patient in the left lateral position, the scope
was passed through the pharynx and advanced into
the esophagus, distal esophagus and the GE
junction. There were large polypoid folds at the GE
junction. Biopsies were taken from this area. The
GE junction was at 24 cm with the hiatus at 30 cm,
revealing a 4 cm hiatal hernia. Scope was passed
into the stomach, body , antrum and all were normal.
The scope was passed into the
pylorus which was deformed. No ulcer was seen.
What procedure was performed?
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Physician said EGD
Did surgery get to the “D”?
Find it under “Endoscopy, upper GI”
Make sure to read entire report
Biopsy also performed
43239 EGD with biopsy, single or
multiple
PEG Tube Insertion
• Percutaneous Endoscopic Gastrostomy
• Hard to locate in index
– Gastrostomy
• Insertion
– Percutaneous
» Endoscopic
» Non Endoscopic
• PEG tube-x3246
– Percutaneous (through the skin) placement of gastrostomy
tube using direct (EGD) guidance
– APC 141
Non PEG Placement
• Gastrostomy tube insertions without scope
• Moved last year
– 43750 deleted, leads to x9440
• Under fluoroscopy
• x3830 open procedure, APC 422, $1612.94
• X3831 neonatal, APC 141
• X43832 Janeway procedure, Inpatient Only
List
Change/Repositioning
• X3760 Change of tube without imaging
or endo guidance APC 121 $206.26
• X3761 Repositioning through
duodenum for enteric feeding APC 141
$541.59
Removal of Polyps
• Though EGD, sigmoidoscopy, colonoscopy,
etc.
• Need to know how many and method used
• Codes say tumor(s), polyp(s), or lesion(s)
• Method of removal is key to coding
– Snare technique (cold biopsy)
– Hot biopsy forceps or bipolar cautery
– Ablation (destruction)
ERCP
• Endoscopic retrograde
cholangiopancreatography
• Exam of the liver and biliary systems
using scope
• Starts off like an EGD then look at
gallbladder, and ducts
• All group to APC 151 $1334.45
• Except x3268, Insertion of tube/stent into
duct and 69 removal foreign body and/or
change tube/stent APC 034, $1591.17
Fundoplasty
• Watch open vs. laparoscopic with same
procedure names
• Example:
• Nissen procedure
– X3280 Lap $4437.26
– X3324 Open Inpatient Only
Gastric Bypass
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Open
Scope
Band/restrictive device
All SI C, inpatient only
Lower GI Scopes
• proctosigmoidoscopy is the examination of
the rectum and sigmoid colon.
• sigmoidoscopy involves the entire rectum,
sigmoid colon and may include a portion of
the descending colon.
• colonoscopy examines the entire colon, up
to the terminal ileum.
• Code book terminology states if physician
gets past the splenic flexure, then this meets
definition of colonoscopy
Removal of Polyps
• Ablation
– Does not have to be a secondary procedure
• Removal by hot biopsy forceps/bipolar cautery
• Snare technique
– Hot snare, cold snare, snare
• One code per technique, not per polyp
• Can be on multiple polyps or multiple times on a
single polyp.
• Biopsy with removal of same polyp, use removal
only
• Removal of one with bx of another, use two codes,
probably with modifier 59
Clarification of Forceps
• A forceps/cold biopsy/cold biopsy
forceps/biopsy is not a snare.
• Polypectomy does not automatically mean
snare polypectomy.
• Snare code should not be reported for
removal of polyps using forceps
• Some polyps are removed in pieces if a
single application of the technique is
inadequate.
Payments
• All Status T procedures
– Diagnostic scopes
– Surgical scopes
– Colonoscopies
– APC 143 $563.60
Modifier –52 Reduced Services
• Book definition differs from CMS
definition
• CPT : service partially reduced or
eliminated at “physician’s discretion”
• Medicare: Discontinued procedure
without the intent for anesthesia.
• 50% will be paid if-52 is used
Modifiers for Discontinued Services
52 Reduced Services
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MM4250
. The -52 modifier is used to indicate that a
service that did not require anesthesia was
partially reduced or discontinued at the
physician’s discretion.
The physician may discontinue or cancel a
procedure that is not completed in its entirety
due to a number of circumstances, such as
adverse patient reaction or medical judgment
that completion of the full study is
unnecessary.
The modifier is reported most often to identify
interrupted or reduced radiological and
imaging procedures.
Hospitals should continue to use modifier -52,
as appropriate, to report interrupted
procedures that do not require anesthesia.
Hemorrhoids
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Need to know internal, external
removal or destruction
method of removal
Complete (x6250) –dissection of hemorrhoids
from muscle
• Most group to APC 149 $1448.73
• Simple ligation goes to code x6945 and pays
$695.11
• Stapling x6947 APC 150 $1921.05
New Destruction Code
• X6930 By thermal energy
• Other destruction codes deleted due to
redundancy
Cholecystectomies
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Open or laparoscopic?
47560-47561 APC 130 $2190.81
47562-47564 APC 131 $2900.10
47570, 47600-47620, open, are on inpatient only list
Caution when lap procedure is converted to open
Remember to check for additional procedures that
impact code, such as
• operative cholangiogram
• Exploration of common bile duct
Abdominal Laparoscopies
• Follow same pattern as other scopes
• Example: Views abdomen, pelvic
organs, peritoneum, omentum
• Biopsies may be taken using brushing,
washing, suctioning cells in solution
• Or by Using biopsy forceps
Initial Placement
• Percutaneous, under fluoro guidance
includes contrast injection, image
documentation and report
• Also includes NG or OG tube placement used
to insufflate stomach prior to gastro tube
placement
• X9440 Insertion gastrostomy tube X9441
duodenostomy of jejunostomy tube
• X9442 cecostomy or other colonic tube
Hernias
• Hernia repairs include the location of the
hernia and the type, such as:
Recurrent- Previously repaired surgically.
Sliding- The abdominal contents "slide" in
and out of the hernia. Colon or cecum as
part of hernial sac. It may include the urinary
bladder.
Incarcerated-When the contained organ
cannot be manually reduced to normal
placement.
Strangulated-The hernia is incarcerated and
blood supply is compromised.
More on hernia repairs
• At times, the age of the patient is included in
the appropriate code.
• Read the notes surrounding the codes
thoroughly for instructions such as "use
additional code".
• Mesh is included in repair except for open
incisional (at site of previous incision)
hernias
• Most group to APC 154 $1954.06
Laparoscopic
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Lots of new laparoscopic hernia repairs
Use same format as open
Mesh included if used
Use unlisted X9659 if don’t find specific
lap code
• DO NOT use one of the open codes
Training/Inservice to Physicians
• Documentation of exact procedures performed
with scopes
• Bilateral vs. unilateral
• Repeat procedures
• Remember that coding rules/Medicare
rules/physician language does not always match
up. You are the expert in CPT coding!
We can’t do it without good documentation and
Team Effort!
How To Keep Up
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www.cms.gov
Your FI/MAC Web Site
www.ahima.org
Resources
– CPT Assistant
– 2009 CPT Book
– 2009 CPT: An Insider’s Guide
– Coder’s Desk Reference for Procedures
Ingenix