Perfect your Twin Delivery Claims

You need to be well-versed with procedure and diagnosis codes if you are to code right for your ob-gyn practice.

Do you know how to report a twin cesarean delivery? A simple answer would be 59510 with modifier 22 attached. But this may not as simple as that. The fact is you will need to adjust your twin delivery reporting depending on an insurance company's preference. Here are two tricky twin situations to help your understanding so that you submit picture perfect claims in no time.

First Scenario:

Cesarean deliveries and what should be done in such instances

A doctor delivers twin deliveries (the same will be the case if the doctor carries out triplets by cesarean; in this situation, you should report 59510 with modifier 22 added. Since the ob-gyn made only one incision, he carried out only one cesarean. However the modifier shows that the doctor carried out a significantly more difficult delivery owing to the presence of multiple babies.

This can also depend on the carrier. For example, Colorado Medicaid allows you to bill for both babies, even though the physician makes only one incision. See to it that you include a letter with the claim that outlines the added work that the ob-gyn carried out to give the carrier a clear picture of why you are asking for more reimbursement.

Second scenario: The babies come out on different days.

Once in a while, multiple-gestation babies will be born of different days. Say for instance, a patient is at 38 weeks gestation and carrying twins in two sacs. One membrane ruptures and the ob-gyn delivers the baby vaginally. A couple of days later, the second ruptures and the second baby delivers vaginally too.

In this situation, you should report the first baby as a delivery only (59409) on that date of service (DOS). For the second one, you should go for the global code (59400), taking that the physician provided prenatal care, on that date of service. The reason why you should not bill the global first is that you're still offering prenatal care owing to the retained twin. You need to attach a letter explaining the situation to the insurance company. ICD-9 diagnosis codes will be important to the payment. See to it that you make use of the outcome codes (say for instance V27.2).

And when the ICD-10 system comes into effect in 2013, you will have to change how your report some of the codes like V27.2, 651.01, O30.001, O30.002, among others.

+33225: Find out Which Primary Code this Case Study Supports

Here's a real-life case study to see if you can pinpoint the codes this documentation does – and does not – back up.

Start by analyzing the report excerpt

An incision was made along the left deltopectoral groove, and an ICD pocket was dissected out, was prepared with extensive dissection.

Three different guidewires were advanced into the left subclavian vein utilizing the Seldinger technique across the open pocket. Then the middle of these wires was used to further a coronary sinus sheath for placement of the left ventricular lead. With some difficulty, we're able to further the coronary sinus sheath in the mid coronary sinus and an angiogram was got. After this a left ventricular lead was then advanced in the lateral cardiac vein and the tip was advanced to the near LV apex. Electrical testing was carried out at three difficult locations and the rest of these noted a lead impedance of 840 ohms and an R wave value of 17.1 mV.

After this, the bipolar right ventricular defibrillator active fixation lead was advanced to the right ventricle, various areas were checked and the lead was finally fixated along the RV.

Hereafter the bipolar right ventricular defibrillator active fixation lead was advanced to the right atrium. Various areas checked and the lead was finally fixated along the RV septum and tested.

Then a bipolar screw in type right atrial lead was advanced to the right atrium while the lead was fixated to the right atrial wall. After this the coronary sinus sheath was removed with the cutting device maintaining a good lead position of the LV lead.

After this, all the three leads were then sutured to the pectoral fascia over the Silastic sleeves. The ICD pocket was irrigated. Soon the leads were then attached to the ICD/BiV device. Post this, the ICD was placed in the pacer pocket after a standard dose of thrombin material in the pocket. The ICD pocket was sutured closed.

The patient was provided propofol and the following establishment of sufficient general anesthesia. Ventricular fibrillation was encouraged. The advice analyzed and delivered three separate DC countershocks, at last at 36V and the patient converted back to normal sinus rhythm. Patient was made to wake up from sedation without obvious side effects.

Add-On Code

The case study appears to be a new implant of a Biventricular Defibrillator with follow-up testing at implant. While going through the first two paragraphs, you should focus on the terms describing placement of the left ventricular lead via the coronary sinus. The right code for this portion is +33225.

Tips for documentation: You may see this lead referred to as either a left ventricular (LV) lead or coronary sinus lead.

For that add-on code, add the primary code

The next few paragraphs of the documentation describe lead fixation for the RV and RA. What's more, the cardiologist attaches the leads to the device, places the device in the pacer pocket, and sutures the pocket closed. One code 33249 covers all of this.

Add-on note: CPT lists 33249 as a proper primary code for add-on code +33225.

Defib Testing gets you the final code

The last paragraph of the case study excerpt describes 93641. As far as defib testing is concerned, you want to see impedance in the documentation.

Term tip: The defibrillation threshold is the minimum energy amount required during ventricular arrhythmia to defibrillate the heart dependably. Being aware of the patient's DFT helps the cardiologist confirm that the cardioverter-defibrillator (ICD) programming will provide enough of a shock to defibrillate the patient's heart.

Add modifiers to at least one code

Code 93641 requires modifier 26 (PC) to indicate you are claiming only the physician work (and practice expense and malpractice expense) for this service. For this code, the Medicare Fee Schedule (Physician) lists a PC/TC indicator of "1". This means you may use modifier 26 with the code.

You may require a modifier on 33225 because it is an add-on code for 33249. However you may need a 59 modifier on the 93641, depending on the carrier. You should not need one, however you never know with carrier's software.

Source URL : - http://www.supercoder.com/coding-newsletters/my-cardiology-coding-alert/electrophysiology-33225-decide-which-primary-code-this-case-study-supports-article

Your practice should hit these points

In a case such as this, the doctor would normally use fluoroscopy, too; but again it is not documented in this case.

No documentation of fluoroscopy means you shouldn't bill fluoroscopy. When fluoroscopy is documented, you should report 71090-26.

ICD-9: The case-study excerpt also does not mention indications for you to choose ICD-9 diagnosis codes.

What's more, check your local requirements for diagnosis codes that support medical necessity for 33225.

Settle On Which Primary Code This Case Suggests: +33225

Start by analyzing the report excerpt An incision was made along the left deltopectoral groove, and an ICD pocket was dissected out, was geared up with extensive dissection. Three different guidewires were advanced into the left subclavian vein using the Seldinger technique across the open pocket.

The middle of these wires were then used to further a coronary sinus sheath for placement of the left ventricular lead. With some complexity, we were in the end able to advance the coronary sinus sheath in the mid coronary sinus and an angiogram was obtained. After this a left ventricular lead was advanced in the lateral cardiac vein and the tip was advanced to the near LV apex. Electrical testing was done at three separate locations and the rest of these noted a lead impedance of 840 ohms and an R wave value of 17.1 mV. After this, the bipolar right ventricular defibrillator active fixation lead was advanced to the right ventricle, various areas were checked and the lead was lastly fixated along the RV. Next the bipolar right ventricular defibrillator active fixation lead was advanced to the right atrium. Various areas checked and the lead was in the end fixated along the RV septum and tested. Post this, a bipolar screw in type right atrial lead was advanced to the right atrium and the lead was fixated to the right atrial wall. Then the coronary sinus sheath was removed with the cutting device maintaining a good lead position of the LV lead. All three leads were then sutured to the pectoral fascia over the Silastic sleeves; the pocket was then irrigated. Pretty soon the leads were attached to the ICD/BiV device.

Then the ICD was placed in the pacer pocket after a standard dose of thrombin material in the pocket. Pocket was then sutured closed. The patient was given propofol and the following establishment of adequate general anesthesia. Ventricular fibrillation was induced; the advice analyzed and delivered three different DC counter shocks, at last at 36V and the patient converted back to normal sinus rhythm. Patient was awakened from sedation minus obvious side effects. Find your first stop at an add-on code The case study appears to be a new implant of a Biventricular Defibrillator with follow-up testing at implant. While making your way through the first two paragraphs, you should train eyes on the terms describing placement of the left ventricular lead through the coronary sinus. The proper code for this portion is +33225. Documentation tip: You may see this lead referred to as either a left ventricular (LV) lead or coronary sinus lead.

Add the primary code for that add-on code The next few paragraphs of the documentation describe lead fixation for the right ventricle (RV) and the right atrium (RA). Also the cardiologist attaches the leads to the device, places the device in the pacer pocket, and sutures the pocket closed. All of this is covered by one code: 33249. Add-on note: CPT code lists 33249 as a proper primary code for add-on code +33225. Remember that ‘add-on' codes are always carried out in addition to the primary service or procedure and must never be reported as a stand-alone code.

Defib testing earns the final code The last paragraph of the case study excerpt describes 93641. With defib testing, you want to see impedance in the documentation. Generally physicians will state something like ‘Ventricular fibrillation was induced. The device analyzed and delivered 3 separate DC countershocks, at last at 36V and the patient converted back to normal sinus rhythm. The high-voltage impedance was 45 ohms. Term tip: The defibrillation threshold (DFT) is the minimum energy amount required during ventricular arrhythmia to defibrillate the heart reliably. Knowing the patient's DFT aids the cardiologist confirm that the cardioverter-defibrillator (ICD) programming will provide enough of a surprise to defibrillate the patient's heart.

Ensure your practice hits these points In a situation like this, the doctor would typically use fluoroscopy, as well; however, it is not documented in this case. No documentation of fluoroscopy means you should not bill fluoroscopy. When fluoroscopy is documented, you should go for 71090-26. ICD-9: What's more, the case study does not mention indications for you to select ICD-9 diagnosis codes. Minus a VT [ventricular tachycardia] diagnosis or information relating to primary prevention criteria, this cannot be coded. Either you have to have a payable diagnosis for the ICD or data to support adding a Q0 modifier to 33249. What's more, check your local requirements for diagnosis codes that support medical necessity for 33225.