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?
Our experts answer questions on port reassessment, laparoscopies, reporting multiple biopsies, rejected drug claims, post-reduction film, nipple revisions, and more.
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: In ICD-10-PCS, which root operation would we report for an obstetrical delivery? Would it change for a cesarean section versus a manually assisted vaginal delivery?
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?
Q: Can you ask a yes or no question in a query based on clinical information from a previous echocardiogram report or other diagnostic result from a previous admission?
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: What recommendation would you give to the coder when the clinical indicators in the chart do not support sepsis but it’s in the final diagnostic statement?
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.
Our experts answer questions about followup visits in the ED, skin substitutes, flu vaccines, osteoporosis and fractures in ICD-10-CM, ICD-10-CM external cause code, modifier for discontinued cardioversion, and modifier -25
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.
Our experts answer questions about NCCI edits for injections, modifier -25, modifier -59, laminotomy with insertion of Coflex distraction device, billing mammogram for needle placement, and auditing electronic orders.
Q: A patient presents with altered mental status/encephalopathy due to a urinary tract infection (UTI). The patient has a history of dementia. The final diagnosis is encephalopathy due to UTI. Should we code the encephalopathy as a secondary diagnosis because it’s an MCC and not always a symptom of a UTI?
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?
Q: A patient undergoes placement of a MediPort ® to receive chemotherapy for lung cancer. What principal diagnosis should we report? Should we report V58.81 (fitting and adjustment of vascular catheter) or 162.9 (malignant neoplasm of bronchus and lung unspecified)?
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?
Our experts answer questions about billing vasectomy and sperm analysis , coding for ED visit when the patient is admitted for surgery, billing glucose reading before a PET scan, documentation required for the functional limitation codes, and appropriate reporting of observation.
Q: Our facility has a question about how other hospitals address this scenario: Patient is discharged to home (discharge status code 01). No documentation exists in the medical record to support post-acute care. Several months later, our Medicare Administrative Contractor (MAC) notifies us that the patient indeed went to post-acute care after discharge. The MAC retracts our entire payment. We need to resubmit the claim with the correct discharge status code. We are reluctant to do so because nothing in the medical record supports the post-acute care provided. Are other hospitals amending the record? If so, which department is adding the amended note?
Q: The patient comes in for a cardioversion, but the international normalized ratio results were unsatisfactory. The physicians canceled the cardioversion. Would modifier -73 (discontinued outpatient/hospital ambulatory surgery center procedure prior to the administration of anesthesia) be appropriate?
Q: Which ICD-10-CM external cause code should we report if a patient falls while on an escalator? This is the first time that the patient has been seen for such a fall.
Q: A clinician goes to a patient's home and does not perform an evaluation and management, but performs a catheter replacement. How should we code this encounter?
BCCS recently spoke with advisory board member Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, about the role of state HIM associations in ICD-10-CM/PCS coder education. The following is a summary of that conversation. Bryant serves as the president of the California Health Information Association (CHIA), which has approximately 5,000 members to date. For more information, visit http://californiahia.org .
Q: Some of our providers see patients in our local nursing facilities. When these patients are admitted to our hospital, must we retain this documentation in our own records?
Q: My question pertains to CPT® vasectomy code 55250. This code includes "unilateral or bilateral (separate procedure) including postoperative semen examination(s).” The CPT manual states that a reference laboratory that performs the semen analysis may bill separately for this service. May we bill CPT code 89321 ( semen analysis; sperm presence and motility of sperm, if performed .) in addition to 55250 when the laboratory performs the semen analysis and the surgeon only performs the vasectomy?
Q: What advice can you offer for sequencing pulmonary edema and congestive heart failure when both appear to meet the definition of principal diagnosis?
Q: We get an NCCI edit when billing an intramuscular/subcutaneous injection (CPT® code 96372) during the same encounter as billing an injection, infusion, or hydration. Should we append modifier -59 (distinct procedural service)? Does it matter if an IV line is already in place before intramuscular/subcutaneous administration?
Q: How will I report the initial insertion of a dual-chamber pacemaker device in ICD-10-PCS? The physician inserted two leads—one into the atrium and one into the ventricle–using a percutaneous approach into the patient’s chest.
Our experts answer questions about hydration, excludes notes in ICD-10-CM, L codes for neurostimulator devices, physician supervision for hyperbaric oxygen therapy, E/M service with wound care, and pass-though drugs.
Q: A patient suffered a nontraumatic intracerebral hemorrhage six months ago and is now being seen for long-standing aphasia as a result of the stroke. How would we code this in ICD-10-CM?
Q: A surgeon’s dictated report for a right hip hemiarthroplasty states the following: Of note, while drilling one of our transosseous suture holes with a 2.0 mm drill bit, the end of the drill bit broke off inside of the trochanter. It seemed to be quite deep into the bone and was not retrievable. As such, it was left in place. Should we report 998.4 (foreign body accidentally left during a procedure) for this case?
Q: If a patient has a spinal deformity on L5-S1 and we use the appropriate codes from 2280X and then the physician performs an arthrodesis/fusion on the same level, can we bill the appropriate fusion codes (225XX-226XX) as well? My impression is no, but I would love to get some insight into this question.
Our experts answer questions about modifiers for diagnostic interventional procedures, Medicare recognition of CPT ® code 9066, reporting add-on code for psychotherapy with interactive complexity, reporting G0378 for all payers, and wound care coding.
Q: A physician's office collects a pap specimen and sends the specimen to the hospital lab for processing. The physician's office lists ICD-9-CM code V72.31 (general gynecological examination with or without Papanicolaou cervical smear) as the diagnosis for this service. What is the proper diagnosis code for the hospital to use for billing when only processing the specimen?
Q: Using the ICD-10-CM guidelines for the seventh character extensions for fracture codes, how should I identify each of the following? Avascular necrosis following fracture Cast change or removal Emergency treatment Evaluation and management by a new physician Follow-up visits following fracture treatment Infection on open fracture site Malunion of fracture Nonunion of fracture Medication adjustment Patient delayed seeking treatment for the fracture or nonunion Removal of external of internal fixation device Surgical treatment
Q: We received an outpatient radiology report (exam performed 7/11/12) where the radiologist states: CLINICAL INDICATION: LUMBOSACRAL NEURITIS EXAM: LUM SPINE AP/LAT CLINICAL STATEMENT: LUMBOSACRAL NEURITIS COMPARISON: MAY 23, 2012 FINDINGS: There is posterior spinal fusion L-3-L-5 with solid posterolateral bridging bone graft. Pedicle screws and rods are stable in position. There are bilateral laminectomy defects at L3-L-4. The vertebral body and disc space heights are preserved. The spinal alignment is maintained without evidence of spondylolisthesis. No acute fracture is identified. No lytic or blastic lesions are seen. The sacroiliac joints are unremarkable. IMPRESSION: Stable postsurgical changes with solid posterolateral fusion graft. Would you use the following ICD-9 codes: V67.09, 724.4. or 724.4, V45.4? Our coders disagree.
Our experts answer questions about, modifier -25, cardioversion performed during an ED code, denials for multiple port film line items, and procedure discontinued after administration of anesthesia.
Q: Can you clarify the requirements surrounding the use of E codes? We have been working on documentation concerns related to patient safety indicator (PSI) 15 and wonder if E codes are required. Can a facility simply decide not to use them?
