Jugna Shah, MPH, and Valerie A. Rinkle, MPA, examine the 2014 OPPS Final Rule and explain which services are now packaged, including drugs and biological that function as supplies when used in diagnostic or surgical procedures, clinical diagnostic lab tests, and device removal procedures.
Q: I have a question regarding CPT® code 22558 (arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace; lumbar). I perform this exposure as a vascular surgeon, with the orthopedic surgeon preforming the spinal surgery. If I perform an anterior exposure for a spine deformity using code 22808 (arthrodesis, anterior, for spinal deformity, with or without cast; two to three vertebral segments), do I bill 22558 for the exposure?
Q: I am looking for information about to how to bill for a transnasal-endoscope approach in removing a skull-base tumor. I have never been comfortable with the doctors wanting to use CPT ® 61600 (resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; extradural) to bill a non-invasive procedure. I am perplexed about which CPT code(s) to report for this type of procedure.
Q: A patient presents with lower back pain and the physician documents findings of stenosis, degenerative “changes,” and mild facet arthropathy. Which diagnosis codes should we report? I would code 724.02 (stenosis, lumbar region, without neurogenic claudication) and 721.3 (lumbosacral spondylosis without myelopathy) for the facet degeneration. Another coder has stated that I cannot code 724.02, as the 721.3 diagnosis code will exclude the use of 724.02. Can you help with this scenario?
CMS did not finalize a proposal to collapse all evaluation and management visits into three codes, but did change clinic visit level coding. Jugna Shah, MPH, and Valerie A. Rinkle, MPA, review some of the major changes to E/M levels for 2014 and the new codes introduced. introduced.
Skin and dermatology coding includes unique challenges with its extensive terminology and the need to calculate wound and lesion sizes. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , discusses common documentation problems and how coders can improve their efficiency and proficiency.
Q: When we send in a claim for CPT ® code 29898 (arthroscopy, ankle, surgical; debridement, extensive) to Aetna with modifier –AS (non-physician assisting at surgery) for our physician’s assistant, Aetna will deny the claim saying “assistant not covered.” However, that procedure code says it is covered for an assistant surgeon. I have sent appeal after appeal and printouts from the American College of Surgeon’s (ACOS) Coding Today website showing this procedure code is payable to Aetna, and Aetna still denies the claim. Medicare pays on this claim, why wouldn’t Aetna?
Q: How does CPT ® define "final examination" for code 99238 (hospital discharge day management; 30 minutes or less)? Does the dictation have to include an actual detailed examination of the patient? We have been coding 99238 for discharges that include final diagnosis, history of present illness, and hospital course along with discharge labs, medicines, and home instructions. Very few contain an actual exam of the patient. Have we been miscoding all this time?
Jugna Shah, MPH, and Valerie A. Rinkle, MPA, look at drug administration coding, beginning with documentation, in order to highlight the information coders need to ensure accuracy. They also review the hierarchy coders must follow when coding for injections and infusions.
Q: When a procedure is performed by laparoscopy, but only a code for the open approach is listed, do you use the unlisted procedure code? For example, the physician documented: laparoscopic pyloromyotomy, hypertrophic pyloric stenosis. We used CPT ® code 43520-22 (pyloromyotomy, cutting of pyloric muscle, Fredet-Ramstedt type operation, with the increased procedural services modifier) but the coding department corrected with 43659 (unlisted laparoscopy procedure, stomach). We are a pediatric surgical practice. I feel because the procedures are very common and performed often, our revenue will drop by using unidentified procedure codes, but I want to code them correctly.
Q: We recently had a situation where a patient had come in to have his port re-assessed. He had been complaining of the port being difficult to access. Preliminary x-ray showed the port accessed, with great blood return. Patient has an allergy to IV contrast, so we just flushed the port, and did not give the contrast. The port remained accessed. How do we code this? Do we use 36598 (contrast injection[s] for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report) with a modifier -52 (reduced services)? The other option is a modifier -73 (discontinued outpatient procedure prior to anesthesia administration) or -74 (discontinued outpatient procedure after anesthesia administration). However we have no documentation regarding anesthesia, and I'm not sure the patient would even get anesthesia for a procedure such as this.
Packaging still causes confusion amongst healthcare providers and the number of packaged services will greatly expand if CMS finalizes certain parts of the 2014 OPPS proposed rule. Valerie A. Rinkle, MPA, and Kimberly Anderwood Hoy Baker, JD, CPC , discuss what changes could come in 2014 and how to avoid common packaging errors.
Q: The patient has had a previous bilateral mastectomy and is now coming in for a revision of bilateral areola with a dermal fat graft to the left nipple and excision of excessive skin and subcutaneous tissue from both breasts. This would be CPT ® code 19380 (revision of reconstructed breast) with modifier -50 (bilateral procedure) and 19350-50 (nipple/areola reconstruction) for both procedures. I cannot locate information that tells me if the nipple revision on the reconstructed breast is part of the 19380 or can be separately coded with 19350.
Some of the most sweeping changes in OPPS history were proposed in the 2014 rule, including new packaging rules, quality measures, and changes to evaluation and management. Jugna Shah, MPH, and Dave Fee, MBA, look at some of the changes and how they could impact providers.
Jeanne L. Plouffe, CPC, CGSC , and Jennifer Avery, CCS, CPC-H, CPC, CPC-I , review procedures performed on the gallbladder and how to determine the correct ICD-9-CM diagnosis codes.
CMS’ proposed 2014 OPPS rule is set to introduce many changes, such as more packaged services, including lab tests and add-on codes. Jugna Shah, MPH; Dave Fee, MBA; Kimberly Anderwood Hoy, JD, CPC; and Valerie A. Rinkle, MPA, offer their insight on what effect these changes could have for providers.
Q: A patient comes into the ED with chest pain. An EKG (CPT® code 93005) is performed. The patient goes directly to the catheterization lab for catheterization (code 93454). Is a modifier appropriate for the EKG?
Modifiers are sometimes essential to ensure proper payment, but choosing the correct one can be tricky. Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS; Katherine Abel, CPC, CPMA, CEMC, CPC-I; and Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, discusssome confusing modifiers and how to use them accurately.
Q: We have a patient with documented age-related osteoporosis. She bent over to pick up a newspaper from a table and fractured a vertebrae. Should we code the fracture as pathologic or traumatic?
