Q: I work in a large, provider-based orthopedic clinic with a rheumatology department that has many patients who are very ill with several comorbid conditions. Does the physician need to document every comorbid condition that impacts his or her medical decision making for each encounter? Do we need to code every comorbidity each time in order to meet hierarchical condition category (HCC) requirements?
Q: Do any general guidelines exist for queries on outpatient services? We are beginning the process of developing such a query system for our hospital outpatient services and clinical documentation team.
Q: A patient was in a hyperbaric oxygen chamber for eight minutes and the physician had to abort the treatment because the patient was feeling anxious. Which HCPCS/CPT ® code should the hospital bill: HCPCS code C1300 (hyperbaric oxygen under pressure, full body chamber, per 30 minute interval) or an E/M code? Which code should the supervising physician bill: CPT code 99183 (physician or other qualified healthcare professional attendance and supervision of hyperbaric oxygen therapy, per session) or an E/M code?
Q: What if the provider states that diabetes is due to the adverse effects of a drug, but doesn't tell us which drug? How do we report that in ICD-10-CM?
Q: We're not sure what to report in this situation: A patient comes to the ED and goes into respiratory failure. The respiratory therapist comes in to put patient on a vent in the ED, then the patient is transferred to another facility. We can’t report CPT ® code 94002 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day) because it is for inpatient/observation, per the definition. We wondered about using 94660 (continuous positive airway pressure ventilation [CPAP], initiation and management) for the CPAP. The lay description seems to be basically the same as 94002, except for “applies to ventilation assistance using adjustments in volume and pressure on the initial day…" Would 94660 be appropriate?
Q: We're wondering about how to use CPT ® code 73225 (magnetic resonance angiography [MRA], upper extremity, with or without contrast material) in our hospital. When providing an MRA of an upper extremity with and without contrast material, should we bill this service twice (since CPT indicates with or without contrast material) or only once?
Q: My physicians perform procedures in the office such as angioplasties, catheter insertions, venograms, and repairs of grafts and fistulas. What is the proper way to code the medications they administered during the procedures?
Q: A patient comes into the ED with sickle cell crisis and is in a lot of pain. The physician states the patient needed “aggressive” pain control for treatment, because what was given in the beginning provided only minimal relief. Could I code using CPT ® code 99285 (ED visit for evaluation and management of a patient, including a comprehensive history, comprehensive exam, and high complexity medical decision making)?
Q: We are coding for pain management procedures and have been doing dual coding in ICD-9-CM and CPT ®. With a medial branch block ablation at two levels for L3-L4 and L4-L5 for a bilateral injection, we are coding: ICD-9-CM procedure code 04.2 (destruction of cranial and peripheral nerves) CPT codes 64635 (destruction by neurolytic agent, paravertebral facet joint nerve[s], with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single facet joint) and 64636 (destruction by neurolytic agent, paravertebral facet joint nerve[s], with imaging guidance [fluoroscopy or CT]; lumbar or sacral, each additional facet joint [List separately in addition to code for primary procedure]), each with modifier -50 (bilateral procedure) appended. What would be your recommendation for the ICD-10-PCS code? Currently we are coding 015B3ZZ (destruction, lumbar nerve, percutaneous) twice. We are not sure if we should be picking this code up twice or only once.
Q: I work for general surgeons. Here is a common scenario: The surgeon is called in to see patient in the ED for trauma or consult. The patient is admitted, but our physician is not the admitting physician. I would tend to bill the ED code set, but do I have to use the subsequent hospital care codes instead?
Q: If the clinical impression is physical assault, vomiting, blunt injury to abdomen, and head injury with loss of consciousness, can I code the history of hypertension, diabetes mellitus, headache, bipolar disorder, and depression?
Q: I read that CPT ® code 20680 (removal of implant; deep, e.g., buried wire, pin, screw, metal band, nail, rod, or plate) is commonly used for deep hardware removal. What would be the proper code for removal on one screw that has already made its way out, is not under any muscle, and is easy to visualize?
Q: My office often has denials of evaluation and management (E/M) visits with our OB patients when using HCPCS modifier -GB (claim being resubmitted for payment because it is no longer covered under a global payment demonstration). Would coding with V22.2 (pregnant state, incidental) as a secondary diagnosis possibly alleviate this issue?
Q: I have been told to use the general surgery CPT ® codes in the 20000 series for reporting excisions of sebaceous cysts when the surgeon must cut into the subcutaneous layer. I don’t agree with this, since the 20000 codes do not give ICD-9-CM code 706.2 (sebaceous cyst) as a billable diagnosis code. Because a sebaceous, epidermal, or pilar cyst begins in the skin and may grow large enough to press into the subcutaneous layer, I think we should report an excision code from the 11400 series, and if need be, the 12000 codes for closure.
Q: My question is about the time interval requirement of the CPT ® add-on code 96376 (each additional sequential intravenous push of the same substance/drug provided in a facility [list separately in addition to code primary procedure]), which says that more than 30 minutes must pass between administrations of same substances in order to report it. In our ED, cardiac patients are frequently started on heparin—a bolus given for less than 16 minutes and a drip given over several hours. These are frequently charted in the electronic record as having been given at the same time. In this case, is it still appropriate to report 96365 (intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour) for the first hour of drip and 96376 for the bolus, or must the administration be given greater than 30 minutes apart?
Q: When coding excision of a breast mass with needle localization using stereotactic guidance, we report CPT ® code 19125 (excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion) and new code 19283 (placement of breast localization devices, percutaneous; first lesion, including stereotactic guidance). The 3M system says Medicare NCCI edits consider this separate reporting of codes that are components of the comprehensive procedure if billed for services provided to the same beneficiary by the same physician on the same day. These codes will be rebundled by the Medicare payer and payment will be based on code 19125 only. Does that mean to only report 19125 for this kind of case? If there is an excision of a lesion by one surgeon and needle localization done by a radiologist, can we report 19125, with 19283 and modifier -59 (distinct procedural service)? We can’t find any official reference for this issue for 2014. How do we code excision of a breast mass with needle localization now?
Q: I am auditing a note for a fusion. The note lacks detail, therefore is hard to justify. The patient had a prior hardware placement. The note describes dissecting down, debridement of necrotic bone, and tissue work done. This is the entire note, after describing dissection, “Vigorous irrigation with 10 liters of saline and antibiotics was carried out. Hemostasis was maintained. The right S1 screw and rod portion was removed as it was notably loose. Additional decortication and onlay bone grafting was performed at L1-S1. Drains were placed…” They coded: 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) Add-on code 22614 (each additional vertebral segment) x4 22852 (removal of posterior segmental instrumentation) In the procedures performed area of the note, they state: Hardware removal, lumbar Revision fusion L1-S1 with onlay bone graft Irrigation and debridement of lumbar spine wound Since there is nothing in the note regarding autografting, I assume this is an allograft? Should this be coded? Also is that documentation enough to justify arthrodesis? Modifier -GC (this service has been performed in part by a resident under the direction of a teaching physician) was appended, although the language was not added for this. I can only assume a resident dictated this.
Q: Can we report CPT ® code 32609 (thoracoscopy; with biopsy of pleura) with 32666 (thoracoscopy, surgical; with therapeutic wedge resection, initial unilateral)? We have researched thoroughly and were not able to find a clear answer.
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.
