Q: The CPT Assistant advice on how to apply modifier -59 to CPT code 29874 (knee arthroscopy with removal of loose/foreign body) seems to conflict with NCCI edits. Do the NCCI edits override the advice in CPT Assistant ?
Q: Can you please help me determine the query opportunities and code assignment/sequencing argument related to a patient who was admitted with pneumonia, congestive heart failure, acute respiratory failure, and encephalopathy?
Our experts answer questions about hitting MUEs on injections and infusions, setting multiple prices for the same CPT codes, payment rates for cancer centers, and more.
Q: We have trouble billing multiple units of injections and infusions – mostly CPT add-on codes 96375 and 96376–that are done during observation stays and exceed the medically unlikely edits number. What is the correct way to bill these and get paid?
Q: One of my coworkers thought we needed the phrase “unable to clinically determine” as an option on every multiple-choice query we send. My take on it is that if we have “other” with an option for free text, that would cover us for compliance. Further, I thought it was inappropriate to include this option in some cases, as it may offer an option that is preventing me from obtaining the detail and specificity I need.
Q: I am the coding manager for our inpatient coding department. I am wondering if I should create an audit plan to monitor new coders or difficult diagnosis. If so, is there anything specific I should consider when trying to implement a plan?
Q: Facilities often have two charges for services performed in an operating room (OR) suite. For example, a facility performs a colonoscopy and an esophagogastroduodenoscopy, which took a total of 20 minutes in the procedure room. The facility charged two set-up fees plus an additional five minutes of OR time. Would this be considered a duplicate charge?
Q: If a patient is admitted to the hospital with diabetic ketoacidosis (DKA) and cholelithiasis, and is treated for both, would you code the cholelithiasis as the principal diagnosis because the patient had his or her gallbladder removed?
Q: We have claims that are hitting an edit between a procedure HCPCS code and the new codes for moderate sedation (99151–99153). Since moderate sedation is no longer inherent in any procedure beginning January 1, why are these scenarios hitting an edit?
Q: My hospital’s coding team keeps having trouble distinguishing between J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) and J44.1 (chronic obstructive pulmonary disease with [acute] exacerbation. Is there any guidance out there that can help clarify their differences? We would appreciate any help.
Q: We just heard about a new add-on HCPCS code for 2017, C1842 (retinal prosthesis, includes all internal and external components; add-on to C1841) for the Argus Retinal Prosthesis, but are not sure how to report it along with C1841 (retinal prosthesis, includes all internal and external components). It has nearly the same description as C1841, so this is confusing.
Q: I have a question about coding a medically induced coma. For example, how would I report a patient on a Precedex drip for alcohol withdrawal, supported with mechanical ventilation, and intensive nursing care?
Q: We have an off-campus, provider-based department that is “non-excepted,” so we have to report modifier –PN (nonexcepted service provided at an off-campus outpatient, provider-based department of a hospital). Is that just for the services that would be paid under the OPPS if the department were “excepted”?
Q: I manage an inpatient coding department, and I am considering having them cross-trained. Are all coders usually cross-trained? And where would be the best place to train my staff?
Q: I notice the parenthetical remarks underneath the new 2017 CPT spinal epidural injection codes (62321, 62323, and 62327) indicate that fluoroscopy, CT, and ultrasound codes are not to be reported with the code. However, the code descriptors only include fluoroscopy and CT, without any mention of ultrasound (76942). Is ultrasound included in the description for 62321?
Q: If a complication is clearly documented as unavoidable or due to a complex situation, should it be coded even if an intervention was done to correct it?
We want your coding and compliance questions! The mission of Coding Q&A is to help you find answers to your urgent coding/compliance questions. To submit your questions, contact Briefings on Coding Compliance Strategies Editor Amanda Tyler at atyler@hcpro.com .
Q: For the new 2017 epidural injection CPT® codes, the longer-term injections (63234-62327) indicate they are to be used if they are administered on more than a single calendar day. What if we start the administration at 10 p.m. and then discontinue the administration at 1 a.m.? That would be two calendar days. Can we used those codes or should we use the shorter-term injection series (62320-62323)?
Q: We are a critical access hospital and don’t get paid under the OPPS. We get reimbursed based on our cost of procedures, tests and services. Is modifier –JW (drug amount discarded/not administered to any patient) applicable to us beginning in January?
Q: When coding and trying to sequence a diagnosis such as pneumonia and chronic obstructive pulmonary disease, I understand that there is a “use after” mandate, but how are coders to know which codes the “use additional code” note is providing sequencing advice for?
Q: If a patient is extubated post-operatively, but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate?
Q. Since ICD-10-CM code O24.415 (gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs) has been added for 2017, do we need to add which specific drug is being used by the patient when reporting the code?
Q: What is the correct procedure code for an esophagogastroduodenoscopy? Our coder coded 0DQ68ZZ (Repair, stomach, via natural or artificial opening, endoscopic), which groups to DRG 326, the same as an esophagectomy. The relative weight is 5.45. This does not seem right. Could you please clarify?
Q: We are struggling with how to report the functional status codes that are required when a physical therapist provides therapy services post-operatively. We have a process for doing that for our “regular” therapy patients, but are struggling with how to implement this for the outpatient surgeries.
Q: I am never sure of correct sequencing when the admission is for flu, pneumonia, and asthma. The patient presented in the emergency department (ED) with shortness of breath, still tight after nebulizer treatment in the emergency room. The patient was kept for observation for one day, then was admitted. Documentation includes: Fever 101.8 in ED; respiratory rate (RR) 24; white blood cell count (WBC) 12.6 Influenza and upper respiratory tract infection Mild persistent asthma in exacerbation due to the above (wheezing, tachycardia in the ED, 130s); acute hypoxic respiratory failure (PO 90%). Superimposed RLL community-acquired pneumonia (CAP), per chest x-ray Can you suggest proper sequencing and if queries are needed?
Q: We have a new pharmacy director and he wants to monitor all separately payable drugs to ensure that we receive appropriate reimbursement. We’re trying to figure out how to do this because the payment is subject to change each quarter. Do you have any suggestions?
Q: I am with a CDI program that is starting to explore severity of illness/risk of mortality (SOI/ROM). I personally have been reviewing for SOI/ROM for quite a while. I usually designate the impact (MCC/CC/SOI/ROM) after the billing is done and see if what I queried for made a final impact, and only take credit for those that do. I was told that regardless of the actual final impact on SOI/ROM, we should be taking credit for any SOI/ROM clarification as SOI/ROM impact. Which is the most accurate, “correct” way to capture the CDI impact for these types of clarifications?
Q: Is it true that if the patient has hypertension and heart disease such as coronary artery disease that the coder may code the hypertension from the I11 (hypertensive heart disease) series of codes?
Q: During an ICD-10-PCS Fusion, when a physician documents the use of a “structural allograft spacer” in the medical record, what sixth character would we use when coding this? Some colleagues say to use A (interbody fusion) and some say to use K (nonautologous tissue substitute). What would be the correct way to code this?
Q: Our surgeons perform a lot of blepharoptosis repairs. Because each patient is different, different amounts of eyelid tissue has to be removed. One of our surgeons wants to set a maximum amount that is included in the procedure and then charge a blepharoplasty to cover anything over and above this maximum. We are trying to figure out how to even start to operationalize this. It seems to us that this is just a “patient differential” in the surgery like you have in any other surgery. Is there any guidance or standard for this?
Q: What exactly are diagnostic-related groups (DRG) 067 and 068 (nonspecific cerebrovascular accident [CVA] and pre-cerebral occlusion without infarct, respectively)? How do they differ from transient ischemic attack (TIA) or CVA?
Q: When our pharmacy mixes medications for infusion, they sometimes have to waste a part of the vial that was opened. They log this in the pharmacy log, which they keep in the department. We have been billing the full amount of the drug that was in the vial and have had no issues with getting paid. Our pharmacist came from a regional meeting and told us that this is going to change.
Q: Is it appropriate to assign ICD-10-CM code Y95 (nosocomial condition) based on the documentation of healthcare-associated pneumonia (HCAP) or hospital-acquired pneumonia (HAP)? It is appropriate to assign the code for documented healthcare-associated conditions. Should this still be queried for specificity, and should the hospital-acquired condition (i.e., pneumonia) be coded as bacterial, viral, or something else?
Q: Can a hospital that is not a critical access hospital (CAH) bill professional charges on UB-04 claims, Type of Bill (TOB) 013X? I have not read anywhere that hospitals cannot bill this way, but usually when discussing revenue 96X and other professional revenue codes there is mention of CAHs only.
Q: When a patient presents with acute respiratory failure, as well as an overdose, is it ever appropriate to assign the acute respiratory failure as principal diagnosis, since it is an acute condition that would have occasioned the admission to the hospital?
Q: We operate a partial hospitalization program (PHP) and just heard from our billing office that there are new requirements for submitting claims. They want us to close out accounts weekly in order for them to bill them. We have done 30-day accounts prior to this and don’t see why they want to change things. Is there a certain timeframe required for billing these services? This is a huge inconvenience to make this work for the business office.
Q: A patient has multiple labs on the same date of service. We receive the following NCCI edit: “Code 80048 is a column two code of 80053. These codes cannot be billed together in any circumstances.” Should we only bill code 80053?
Q: I am never sure of correct sequencing when the admission is for flu, pneumonia, and asthma. Can you suggest proper sequencing, and if queries are needed?
Q: I have a patient with stage IV lung cancer that presented with fatigue, cough, and loss of appetite. Initially, they thought he had pulmonary nodular amyloidosis, but when they did an echocardiogram on day one they found a pericardial effusion. How would this be sequenced and coded?
Q: Are there any new HCPCS codes for recently released biosimilar products on the horizon? Our physicians and pharmacists are being contacted by the manufacturer about purchasing and using them, but we want to be sure we can report them appropriately.
Q: We are currently using a hybrid medical record, so we have standard query forms with multiple-choice options that cannot be modified at this time. We wanted to include a statement so our query doesn’t seem leading. Is our approach to the multiple-choice query format appropriate?
Q: Our providers are reluctant to document a correlation between symptoms and a true diagnosis. Do you have any good ways to get them to do this? For example, our providers document "diabetes" but they often don't include additional details that should be there (e.g., gestational diabetes or type II diabetes mellitus in pregnancy).
