Q: How many times should Glasgow Coma Scale information be captured? If you have the ambulance, ED physician, and attending physician all recording the score, should each be reported?
Q: A patient fractured all metatarsals last year and had open reduction and internal fixation. The patient now has a nonunion of the fracture sites and is going back to the OR for an amputation. What would be the appropriate ICD-10-CM seventh character to report?
Q: We are an independent outpatient end-stage renal disease clinic. When we administer a blood transfusion (we do not bill for the blood) can we bill HCPCS code A4750 (blood tubing, arterial or venous, for hemodialysis, each) for the tubing used in the procedure and also A4913 (miscellaneous dialysis supplies, not otherwise specified) for miscellaneous supplies pertaining to administering the blood?
Q: I have a question about coding infusion/injections in the ED prior to a decision for surgery. A patient comes into the ED with right lower abdominal pain. The physician starts an IV for hydration, gives pain medication injections, then does blood work and an MRI to rule out appendicitis. The blood work comes back with an elevated white blood count, so the patient is started on an infusion of antibiotics. Then the MRI results come in with a diagnosis of appendicitis. So a surgeon is called in to consult and take the patient to surgery. Can we bill the infusions/injections prior to the decision for surgery? I realize that once the decision is made, then the infusion/injections are off limits and are all included in the surgical procedure. But up until that time, can the ED charge the infusions/injections? They are treating the patient’s symptoms and can’t assume the patient will have surgery until the decision is made by the surgeon.
Q: Our business office wants us to start using modifier -PO (services, procedures, and/or surgeries furnished at off-campus, provider-based outpatient departments) for services that are provided in some of our outpatient departments, but not all. We want to hard code this to our charge description master but are not sure why some services will get this modifier and some won't.
Q: I have been told by our billers that infusion codes reported in the ED along with an E/M code that has modifier -25 (significant, separately identifiable evaluation and management service on the same day of the procedure or other service) require another modifier. I thought that -25 is the only modifier that should be submitted, unless the provider started a second infusion at a second site on the body. This is the first time I’ve been told the infusion coder need a modifier if the E/M has modifier -25 appended. All of my educational articles tell me that the two can be reported together. Have I missed an update somewhere along the way?
Q: I have a question regarding facility coding for evaluation and management (E/M) levels, not for an ED physician, but for facility-level nursing in the ED. If a specialist is called to evaluate or consult on a patient, the nursing intervention is what the facility-level criteria is based on. For example, a patient has difficulty walking, a nurse assists the patient to get an x-ray, takes vitals, does an initial assessment, then provides discharge instructions of moderate complexity. I would code this scenario as a level 3.
Q: We had a patient come into our ED with a severe head injury. To protect his airway, we intubated the patient. Can we report an emergency endotracheal intubation (CPT ® code 31500) and CPR (92950) together if only bagging happens and no chest compressions?
Q: I am a coder in a hospital outpatient setting. Our physicians document drug use in social history. For example, marijuana use is documented as just "marijuana use" without any further information regarding a pattern of use or abuse. Based on that information, can I report ICD-9-CM code 305.20 (cannabis abuse, unspecified)? How would this be reported in ICD-10-CM?
Q: When the surgeon documents excision of a complex pilonidal cyst with rhomboid flap closure, is the flap closure coded separately or is it included in CPT ® code 11772 (excision of pilonidal cyst or sinus; complicated)?
Q: Should modifiers for laterality be used for CPT ® code 31624 (bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage)?
Q: A patient arrives at the interventional radiology department to have an inferior vena cava (IVC) filter inserted for portal hypertension and an iliac stent for May-Thurner syndrome. The physician is unsuccessful in accessing an appropriate portal vein branch, despite a few attempts to pass a wire into small portal branches, and aborts the placement. The plan is to reschedule and return with a transplenic approach. Do we code the attempted IVC filter placement with modifier -74 (discontinued outpatient procedure after anesthesia administered) and the complete iliac stent procedure? Or do we code the extent of the IVC filter placement (that being venography) with the complete procedure? Or do we only code the completed procedure?
Q: We have a patient with chronic severe low back pain, etiology unknown, on MS Contin®, an opioid. Due to the patient’s history of drug-seeking behavior and cannabis abuse, the physician orders a drug screen prior to refilling the prescription. With the changes to drug testing codes in 2015, what would be the appropriate laboratory CPT ® codes to report?
Q: We are trying to verify whether we should bill for two units of the CPT® code when the provider performs a service with and without magnetic resonance angiography (MRA), such as an MRA of the abdomen, with or without contrast material (code 74185). The description of the MRA CPT codes say "with or without," not with and without for billing all non-Medicare payers. We realize for Medicare we are to use HCPCS codes C8900-C8902.
Q: If a patient is given Reglan ® intravenously at 12:20, 13:00, and 13:20, would this be considered an IV push because the clinician did not document a stop time?
Q: Our electronic health record system only provides for a "yes/no" choice under smoker. How can we capture the additional details necessary for an ICD-10-CM code assignment?
Q: I have a question regarding a National Correct Coding Initiative (NCCI) edit. I reported CPT ® code 80053 (comprehensive metabolic panel) and 84132 (potassium; serum, plasma or whole blood), resulting in an NCCI conflict. This code pair does allow modifier -59 (distinct procedural service) to be appended to one of the codes to be paid for both tests. Does it matter if we append modifier -59 to the primary code or the secondary?\ In my case, sometimes the secondary code is already dropped into the system and now the edit is asking me to append the modifier. Can I add modifier -59 to 80053 whether it's the primary code or not?
Q: Would it be appropriate to report CPT ® code 75984 (change of percutaneous tube or drainage catheter with contrast monitoring [e.g., genitourinary system, abscess], radiological supervision and interpretation) for the following procedure: A small amount of contrast was injected through the indwelling nephrostomy drainage catheter. This demonstrated the catheter is well positioned within the renal collecting system. There is a small amount of thrombus attached to the tip of the pigtail catheter. The existing catheter was cut and a guidewire was advanced through the catheter into the renal collecting system. The existing catheter was removed over the wire and exchanged for a new 10 French nephrostomy tube. The catheter was secured to the skin with 2-O suture and covered with a sterile dressing.
Q: Is it correct to append modifier -52 (reduced services) to a procedure code when the physician performed the procedure, but did not find a mass? This was unexpected, so the surgeon went deeper into the subcutaneous tissue and still did not find anything. This is the outpatient note for a patient with a history of breast cancer and a new lump on her arm with an indeterminate ultrasound: Under local anesthesia and sterile conditions, a vertical incision was made over the area of the palpable abnormality. We dissected down beneath the subcutaneous tissues. I could encounter no definitive mass or lesions in this area. We went down to the fascia of her bicep. Her biceps appear normal, and the skin and subcutaneous tissue appear normal. My presumption is that this represented some sort of venous anomaly, and I either popped it or incised it during our entry into the skin, and it is now resolved. Would CPT ® code 24075-52 (excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm) be correct to report?
Q: When would we use codes from ICD-10-CM category E13 (other specified diabetes mellitus)? If it's secondary diabetes but not due to an underlying condition or drug and is not chemically induced, what kind of diabetes could it be?
Q: If the physician does not perform a formal myelography and just administers an injection before the patient goes straight for computed tomography (CT), which CPT ® code would we report in 2015? The 2015 combination codes are for use when the same radiologist or physician who performs the injection reads his or her own study.
Q: I have a question regarding CPT ® code 99184 (initiation of selective head or total body hypothermia in critically ill neonate, includes appropriate patient selection by review of clinical, imaging, and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling) in the 2015 CPT Manual . What if the neonate is in the hospital for several weeks? The total body hypothermia is performed, the baby improves, but remains in the hospital and then needs the procedure performed a second time. Can we report it a second time if several weeks have elapsed?
Q: We have a patient diagnosed with neuropathy due to poorly controlled insulin-dependent Type 1 diabetes mellitus. What should we report in ICD-10-CM?
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.
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?
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?
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.
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.
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: 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?
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: 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?
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: 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: 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: 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.
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: 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.
Q: A patient received Toradol 30 mg IV and Zofran 4 mg IV at 14:38. He also had normal saline wide open with documented start of 14:30 and stop of 15:40. Is the hydration chargeable as 96361 (intravenous infusion, hydration; each additional hour) even though the initial service is not 90 minutes? Is the hydration a concurrent service?
Q: In ICD-9-CM we only have one type of Excludes note. ICD-10-CM uses Excludes1 and Excludes2. What is the difference between the two types of Excludes notes and how do they relate to Excludes notes in ICD-9-CM?
Q: The rule our institution has followed with respect to HCPCS coded medications without a local coverage determination (LCD) is to limit prescribing to the FDA-approved indications. The question that arises is how closely do the physicians need to follow the package insert? For example, the drug basiliximab does not have an LCD and the FDA indication is: For acute kidney transplant rejection prophylaxis when used as part of an immunosuppressive regimen that includes cyclosporine and corticosteroids. Generally, physicians performing transplants at our institution do not use steroids or cyclosporine. They use tacrolimus, sirolimus, mycophenolate mofetil, and/or mycophenolate sodium. If the physician performs a transplant without cyclosporine or steroids, do we need to have the patient sign an advanced beneficiary notice?
Q: A patient went to the operating room under anesthesia for cataract extraction and repair of retinal detachment of the same eye. The surgeon successfully removed the cataract. The surgeon then accessed the back of the eye to begin to repair the detachment. After reviewing the condition of this eye area, the surgeon determined that the eye was in such bad shape it could not be saved, so the detachment was not repaired and surgery was ended. The patient was under anesthesia and the retinal detachment repair procedure was begun (although barely) but then cancelled. Should we report this procedure since the facility incurred expenses for the surgical attempt at repair?
Q: How should we bill for the physician in the following situation? A patient who has end-stage renal disease (ESRD) comes into a hospital’s emergency department (ED) with an emergent condition (dialysis access clotted or chest pain that is ruled out), but misses his or her dialysis treatment. Part of the treatment is dialysis performed in the ED or as an outpatient. The hospital bills G0257 (unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility) as per CY 2003 OPPS Final Rule guidelines and Pub 100-04, Chapter 4, section 200.2
Q: Is nursing documentation of completion of physician-ordered procedures, such as splinting/strapping, Foley catheter insertion, etc., sufficient to assign a CPT ® code for billing the procedure on the facility side in the ED?
Q: CPT ® code 85660 (sickling of RBC, reduction) has a medically unlikely edit of one unit. We test blood for transfusion for sickle cell before we provide it to a sickle cell patient. If we test three units of blood prior to administering the blood to the patient, which modifier is more appropriate: -59 (distinct procedural service) or -91 (repeat laboratory test)?
Q: What CPT ® code best describes the Bier block procedure? We are toiling over this and the most recent CPT Assistant says to use 64999 (unlisted procedure, nervous system). But the article referenced is from 2004. We just want to make sure there is nothing more recent.
Q: It appears that one requirement for using CPT ® codes 15002–15005 with application of negative pressure wound therapy (NPWT) is that the wound must be healing by primary intention. Can you explain this? We have never used these codes with preparation for vacuum assisted closure (VAC) placement, but it doesn't make sense, as NPWT is almost always used for wounds healing by secondary intention. Our physicians appreciate any clarification.
QUESTION: I work for a gastrointestinal (GI) practice and I have a question regarding the correct sequence for adding diagnosis codes to a claim. I have advised our physicians and billers that the primary diagnosis code is always the reason for the visit. I am a little confused about the remaining diagnosis codes the physician will write down in no specific order. Billers will report codes in the order the physicians write down the diagnoses and not always the reason for the visit. For example, a patient is referred for a consult due to weight loss. The patient comes for the consult and the physicians may put down 787.29 (other dysphagia), 401.1 (benign hypertension), 783.21 (abnormal loss of weight), 787.99 (change in bowel habits) in this order and leave it up to the person entering the info to figure it out. I would report 783.21 first since that was the reason for the visit but then I’ve been putting the GI codes next and then anything else last. What is the correct sequence when adding diagnosis codes to a claim?
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.
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?
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?
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: 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: 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: We are a small anesthesia group and we are concerned about the specificity for ICD-10-CM. If we submit a claim with an unspecified code and the surgeon submits a claim with more specificity, will we still get paid?
QUESTION: Can you explain the difference between modifier -80 (assistant at surgery by another physician) and –AS (physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery)? Medicare requires us to use both modifiers for our physician assistants. We have been instructed to use -AS first and -80 second for all Medicare claims submissions. Is this correct?
QUESTION: I would like to know the correct codes to use when a patient comes into the ER after smoking synthetic marijuana and has symptoms of palpitations, seizure, or anxiety. Some physicians document ingestion, while others document abuse. What is the proper way to code considering we do not have a specific code for this new drug on the market?
QUESTION: We have a question in regards to hydration that we are trying to figure out. Does the physician specifically have to state in his or her documentation that the IV is for hydration purposes or can a coder figure it out through critical thinking and using the process of hierarchal injection/infusion coding when reading the record? For example, X IV fluids are being used for an antibiotic and after the antibiotic, the IV fluids continue at 125/hr for hydration. Does the physician need to document "for hydration"? Our physicians do not want to write that. Do you have any good advice on this?
QUESTION: We are a nondialysis facility, so when a patient is in observation for some other reason and must undergo hemodialysis, we report code G0257 (unscheduled or emergency dialysis treatments for an ESRD [end stage renal disease] patient in a hospital outpatient department that is not certified as an ESRD facility). But how should we code peritoneal dialysis when a patient is in observation or inpatient for other problems? I have received three different codes from different coders. I cannot really find any information on this anywhere.
QUESTION: The 2012 CPT ® Manual includes the typical time physicians spend at the bedside and on the patient’s hospital floor or unit for initial observation care codes 99218, 99219, and 99220. Do these codes only apply when the counseling and/or coordination of care support the respective 30/50/70 minutes of time? Do you know if CMS has published any new guidelines related to these times?