Q: I need further clarification regarding documentation of toxic metabolic encephalopathy. I’m trying to code two different cases in which a physician documents acute mental status change secondary to an infectious process . In each case, the patient’s metabolic panels don’t appear to be abnormal; however, one of the patients is septic. The physician thinks that documenting and coding sepsis separately from encephalopathy would result in unbundling. However, I disagree because coding the sepsis separately demonstrates severity. What is the correct logic to use in each of these cases?
QUESTION: I work in an urgent care setting and need to know if we can bill an administration code for injection of Toradol. For example, a patient comes in, and the provider performs an E/M and administers 60mg Toradol intramuscular. I have not been charging for it, thinking it’s bundled into the E/M.
Our coding experts answer questions about reporting dialysis for ESRD patient in ED, coding for sequential infusions, procedures on the inpatient-only list, replacement code for C9732, and new drug HCPCS codes.
Q: A patient has been diagnosed with peritonsillar cellulitis and oropharyngeal cellulitis. The physician documents that he performed a “needle aspiration of the left peritonsillar abscess.” In the body of the operative report, the physician states, “An 18-gauge needle was inserted and 1 cc of pus was aspirated. This was sent for aerobic, anaerobic, C&S [culture & sensitivity], and gram stain. I then put the 18-gauge needle in again and multiple passes were obtained without any aspirate.” Because ICD-9-CM does not include a code for “aspiration of peritonsillar abscess” some coders wanted to use ICD-9-CM procedure code 28.0 (incision and drainage of tonsil and peritonsillar structures) while others want to report code 28.99 (other operations on tonsils and adenoids). Which code is correct?
QUESTION: A patient complained of intractable pain from compression fracture (sustained the day prior to admission). The guidelines state if pain is not documented as acute or chronic, don't assign codes from the 338 category. Should we query the physician if the pain was acute or chronic rather than just using the fracture code if it appears that pain control was the main reason for the visit?
In this month's issue, our coding experts answer questions about how to differentiate between modifiers -52, -73, -74, coding for negative pressure wound therapy, and billing the technical component of pathology services.
QUESTION: I'd like to address our coders' questions on how to code poisoning due to bath salts. Internet research has led me to many different options: codes 977.8 (other specified drug/medicinal), 970.89 (other CNS stimulant), 969.70 (psychostimulant, unspecified), among others. What would you suggest? There don't seem to be any guidelines out there and the coding for this seems to be all over the place.
QUESTION: A patient is admitted with pneumonia and atrial fibrillation and both are present on admission. The patient receives antibiotics for the pneumonia and a pacemaker during the stay, but undergoes no other procedures. Does the procedure automatically make ICD-9-CM code 427.31 for the atrial fibrillation the principal diagnosis?
QUESTION: Our laboratory medical director sent out a notification to our medical staff, patient care departments, and order entry personnel that a physician order that read “CBC” or “CBC with differential” would be completed as a CBC with automated or manual differential and coded using CPT ® code 85025 (blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC, and platelet count] and automated differential WBC count). Should we code 85025 when the order just reads CBC and when we do a manual differential with the CBC?
Our coding experts answer your questions about correct use of modifier –PD, coding infusions to correct low potassium levels, payment for HCPCS code J2354, appropriate reporting of IV push followed by infusion of the same drug, and the difference between modifiers –AS and -80.
QUESTION: The vendor for our cochlear implants has stated it’s standard to provide our operating suite with the cochlear device and two external speech processors. Should we report HCPCS Level II code L8614 (cochlear device, includes all internal and external components) for the one device and two external speech processors even though one processor is sent home with the patient? If so this means that we should charge the patient for the device and two processors as one price under revenue code 278.
QUESTION: A patient was exposed to shingles, for which a coder reported ICD-9-CM code V01.79 (exposure to other viral diseases, including HIV). This poses a problem for billing as code V01.79 is a confidential diagnosis, requiring special release of information from the patient and would remain on the insurance record. As an RN and certified coder, I believed code V01.71 (exposure to varicella) is the correct code because the varicella virus causes both chicken pox and shingles. However, I am being overridden by the chief business office. Which code is correct?
QUESTION: I've always coded labile hypertension with ICD-9-CM code 401.9 (unspecified essential hypertension) because I couldn't find a more specific one. My supervisor stated that I must use ICD-9-CM code 796.2 (elevated blood pressure reading without diagnosis of hypertension) because it means the patient's blood pressure was high without a history of hypertension. The physician's diagnosis is labile hypertension. What code would you use?
QUESTION: Do you predict coder productivity will decline as a result of ICD-10? If so, what do you think the declines will be six months after implementation?
Our coding experts answer your questions about payment for items in OPPS Addendum B and skin substitutes, incomplete documentation for IV infusions, coding for amputation of finger and aftercare, facility codes for peritoneal dialysis
QUESTION: When would you use the table labeled as not otherwise classified drugs at the end of the HCPCS Level II Table of Drugs and Biologicals? Many other drugs are not assigned a HCPCS code and are not in this table.
QUESTION: Our pulmonologists are not comfortable documenting acute respiratory failure unless the patient is on a ventilator. Also, they rarely document chronic respiratory failure, even in chronic obstructive pulmonary disease (COPD) patients on continuous home oxygen. I’m trying to develop standard query forms for acute and chronic respiratory failure and am running into these obstacles. How do you recommend handling this problem?
