Ph + Impedance Testing: The CCI Edits Can Ease Things for You

Time is a crucial element while selecting between 91037 and 91038.

When your physician's note proposes impedance and pH tests being carried out together, you would turn to the 9103x series of your medical CPT manual. Easy? Not exactly. Take the following scenario in point.

Scenario: The motility specialist carries out impedance + pH test for over an hour. The patient, who complains of recurrent as well as painful heartburn, leaves the office with the catheter in position till the next day.

Dilemma: Can you bill 91038 by itself, or do you require to add 91034 at all?

The key is to recognize what each code involves, but you should not just base your choice on the obvious. You must give weight to Correct Coding Initiative (CCI) edits, too. These guidelines should keep you on the right track.

1. Look for 91037-91038 for Impedance Catheter

While reporting esophageal function (impedance) tests, you would define it using two medical CPT codes:

91037 –- i.e. Esophageal function test, gastroesophageal reflux test including nasal catheter intraluminal impedance electrode(s) placement, recording, analysis as well as interpretation

91038 -- i.e. ...prolonged (greater than 1 hour, up to 24 hours)

Keep in mind the descriptors for 91037 and 91038 represent a time measurement, which implies that you must apply 91037 for testing that goes up to one hour. In case the monitoring goes for more than one hour, bill 91038 as a substitute. You should not bill both codes for the same test. You should apply only a single code to report the session.

What happens: In an impedance test, the catheter goes in the patient's body transnasally. This particular test measures bolus transit dynamics along with either pH measurement or esophageal muscular function in the assessment of symptoms involving chest pain, swallowing trouble, or chronic heartburn which is unresponsive to medication. At times, physicians would carry out these tests in conjunction with manometry or pH testing.

Together motility study (manometry) as well as esophageal function testing uses a nasal catheter. Though, the impedance probe is multi-purpose and measures more much more than the motility test (91010, Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report; 2-dimensional data) or the gastroesophageal reflux test (91034, Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation).

2. Single Code Defines Cather-Based pH Test

When a gastroenterologist carries out an esophageal acid reflux test using either a disposable or a reusable nasal catheter, you would then reportmedical CPT 91034.

Pointer: Medical CPT 91034 should be your go-to code irrespective of how long the nasal catheter remains in place. Generally, though, the physician will leave the catheter in place for about a day. Earlier, you had to differentiate between standard and "extended" pH monitoring. Currently, only single code (91034) defines a catheter-based pH service.

How to Code Cosmetic Ptosis Repair

Having issue how to code Cosmetic Ptosis repair. For more on this and all 2011 CPT updates visit a medical coding guide like Supercoder.

There is this Medicare patient of ours who'll be having a leva to resection on his right eye for ptosis. The ophthalmologist wants to do this as a bilateral procedure; however the patient's left eye is a non-seeing eye. As the operation on the right side may be medically necessary, but the left side would likely be considered cosmetic, how should I go about coding this surgery?

Well, you should report each side of the bilateral procedure on a separate line, appending modifiers LT (left side) and RT (Right side), linking each side to the appropriate diagnosis code explaining the necessity for the surgery.

In this situation, one side will be medically necessary, while the other will be cosmetic – the procedure will not benefit the vision on the non-seeing eye.

Here's what you need to do: Before the surgery, have the patient sign an advance beneficiary notice of non-coverage (ABN) prior to surgery, stating that he's aware that Medicare will not cover the procedure carried out on the left eye. Ensure your ABN is in layman's terms and specifies the specific reasons for non-coverage. (you shouldn't use CPT Code, ICD 9 codes on the ABN form).

You must also specify the estimated cost of the service on the ABN. The original signed ABN indicating the patients decision ( be sure the patient has chosen one of the options) to accept financial responsibility, is maintained by the practice and a fully executed copy must be provided to the patient. Append modifier (Waiver of liability statement on file) to the procedure done on the non-seeing eye to indicate that the patient was informed before and has selected the option to be responsible for the non-covered service and unpaid amount.

For instance: The patient has congenital ptosis (743.61), and his left eye is non-seeing. The ophthalmologist carries out levator resection (67904, Repair of blepharoptosis; [tarso] levator resection or advancement, external approach) bilaterally. Code as follows:

Line 1: 67904-RT linked to 743.61

Line 2: 67904-LT-GA linked to V50.1 (Elective surgery for purposes other than remedying health states; other plastic surgery for unacceptable cosmetic appearance).

If your documentation shows that the procedure was medically necessary on the right side, Medicare will reimburse the full amount for 67904-RT. The cosmetic diagnosis linked to 67904-LT-GA will prompt the carrier to deny the specific service due to the diagnosis and non-coverage of cosmetic services, and the explanation of benefits (EOB) received by the patient will confirm that the patient is responsible for payment.

Don’t assume ICD-10 diagnosis codes -- 424.1 will split under the new cardiology codes next year

 The coming year there will be major code changes when ICD-10 comes into effect. Like any other practice there will be major changes for cardiology codes. For instance, there will be new code set divides for diagnosis code 424.1 under ICD 9-CM that is used to report aortic valve disorders, and you need to ensure that you are updated with all the code changes to keep your practice compliant and profitable. A disorder of the aortic valve refers to a problem with the valve between the aorta and the left ventricle.

When ICD-10 becomes effective then there will be a range of codes specifying 424.1 that will be from 135.0 – 135.9. There will be a range of codes to choose from for multiple aortic valve disorder codes in the I35. - range under ICD-10. ICD-10 will have separate codes for stenosis, insufficiency, stenosis with insufficiency, other, and unspecified.

To ensure correct coding you need to ensure that you document correctly if the aortic valve disease is rheumatic or not. You also need to ensure that you have adequate knowledge regarding whether the condition is congenital because it will affect the choice of codes that will be used. Since there will be multiple code options for aortic valve disorders under ICD-10, documentation needs to be specific about the type of disorder to identify the most specific code.

There are some tips that can be followed to code correctly. If the documentation shows stenosis and insufficiency then only the code 135.2 should be used instead of I35.0 and I35.1 together. Insufficiency can also be documented by using incompetence or regurgitation. When 135.8 is used the term “other” specifies that the physician documented the type, but ICD-10 will not have any code that will specify the documented type. The "unspecified" in I35.9 would mean that the physician did not document the type.

Document Now to Save Yourself Trouble Later on

If Medicare carries out an audit and figures out that your documentation is not in proper order, you could find yourself having to repay them for all the claims they find problems with.

Medicare only sees the front portion of the form when you send in a CMS-1500 form. What Medicare fails to see is what is on the other side of that form, which is your documentation. They presuppose that your document is right until they carry out an audit.

If Medicare carries out an audit and figures out that your documentation is not in proper order, you could find yourself having to repay them for all the claims they find problems with. That is the reason why it is vital to cautiously document the medical necessity of the visual field exam in the patient's medical record.

According to experts, one of the weak areas of optometrists is the "interpretation and report" portion of several codes. For instance code 92083 provides one example. As per your record of a visual field, "Informed patient test for OD showed small area we need to watch; have return in three months." In a postpayment audit, Medicare will not accept this billing. Here's why? Interpretation and report" needs assessment of both eyes.

Bear in mind: All three visual field codes have a TC and PC. When you bill 92083, you are telling Medicare you performed both the TC and the PC. It is better to have a form just for visual fields, apart from your regular notes.

This may sound excess, but remember that in case of an audit, such a form could save you money.

For further details on this and for other medical coding updates, sign up for a one-stop medical coding guide like http://www.supercoder.com/.

493.2x: Your Physician's Notes are Your Best Bet Here

You should have the right information ready prior to referring to your ICD-9 coding manual to save yourself from trouble.

It always helps to have the right documentation in place. When a patient comes to the pulmonologist with asthma or bronchitis, and symptoms of chronic obstructive pulmonary disease, your physician's notes may be your best choice.

You should have the right information ready prior to referring to your ICD-9 coding manual to save yourself from trouble. Ensure the documentation supports the physician's diagnosis. After this, be on the lookout for any associated acute conditions. When you face the situation, ask these three important questions that can help you breathe easily through your lung diagnosis coding.

Check whether the patient has status asthmaticus or acute exacerbation before using 493.20

If a pulmonologist diagnosed a patient with both asthma and chronic obstructive pulmonary disease, go to the v493.x section of ICD-9 and choose from the three options: 493.20, 493.21, and 493.22. For some payers, 493.20 is default code. It is always better to check with your pulmonologist first to see if the patient has status asthmaticus or acute exacerbation before settling with 493.20.

Note of caution: A diagnosis of 'status asthmaticus' is the most acute presentation and takes precedence over any type of COPD; as such you should primarily list the most acute diagnosis addressed if the physician documents both findings. On the claim, you should report 493.21, and not 493.22 (an acute exacerbation). If status asthmaticus is documented by the provider with any type of COPD or with acute bronchitis, the status asthmaticus should be sequenced first. It supersedes any type of COPD including that with acute exacerbation or acute bronchitis.

Don't report 466.0 for obstructive chronic bronchitis

When your pulmonologist documents chronic obstructive bronchitis with an episode of acute bronchitis, you should code 491.22. You should not report 466.0 (Acute bronchitis) for the obstructive chronic bronchitis since this code fails to capture the patient complexity of an acute-on-chronic illness, as in 491.22.

Get thorough documentation from your pulmonologist

If you are coding COPD, full details are very important. The documentation should include a listing of signs, symptoms, and conditions. A mere entry of “shortness of breath and cough" may not just be enough. Since cardiopulmonary diseases manifest themselves in this fashion, these symptoms can represent a progression of chronic illness or other acute issues, either related or not related to the patient's chronic disease. As such, clinical evaluation, based on a detailed history, is of prime importance. In order to determine a new illness or a progressing/exacerbating chronic illness, the physician may order blood studies, along with radiographical and physiological evaluations. Just listing COPD as the diagnosis does not reflect the patient's present status. Including the signs, symptoms, or the exacerbation will aid in justifying the medical necessity of the studies ordered. The payer will better understand that these aren't routine surveillance studies.

Don't Trip Up Your Foot and Ankle Claims

Be aware of some of the more common foot procedures your family physician might face if you want to get the rightful reimbursements for your foot and ankle claims.

You need to be aware of some of the more common foot procedures your family physician might face if you want to get the rightful reimbursements for your foot and ankle claims.

You should have sound basic knowledge

Sudden impact or simple wear-and-tear can cause toe, foot and ankle problems. As such you need to be aware of the differences between these diagnoses or you may miss a subtle difference and report the wrong code.

One thing to bear in mind is that you might require modifiers to help differentiate work on different areas of the feet or for that matter toes. These modifiers include LT and RT, TA-T9 and sometimes 59 depending on the service your physician provides. These modifiers become all the more important if the FP carries out the same procedure on more than one foot or toe.

Be aware of the difference between Bunions and Hallux Valgus

A bunion is an enlargement of bone or tissue around the metatarsophalangeal (MTP) joint of the great toe. It's often caused by patients wearing shoes that are too narrow around the toe box and can cause pain and deformity of the toes.

Remember: A common mistaken belief is that "hallux valgus" and "bunion" refer to the same thing. Even though CPT code lists bunion procedure codes like 28290 as "hallux valgus corrections," doctors who carry out these are not necessarily correcting a hallux valgus, according to ICD-9 terminology. If you look up 735.0, the definition reads, "Angled displacement of the great toe, causing it to ride over or under other toes."

As such, you should not report 735.0 unless the patient has an angular deformity of the great toe. As per this definition, a person could have a bunion but not necessarily a hallux valgus deformity; however experts say that the above definition is not actually followed. Hallux valgus is simply a valgus deformity of the distal great toe and does not have to overlap for a physician to call it hallux valgus.

If the patient's great toe is not overlapping or impinging upon the second toe, but he still has an obvious bunion, take a look at 727.1; this code specifically says 'bunion' and the ICD-9 definition is "enlarged first metatarsal head due to inflamed bursa; results in laterally displaced great toe."

For more on this particular topic and for other coding updates, sign up for a one-stop medical coding guide like http://www.supercoder.com/ and stay informed.

See Which Audit Process You Need to Follow for Your Practice

Remember that the same audit process and timeline will not work for every practice to identify the needs of your practice.

Internal audits are a way to ensure you're on track and nothing has gone wrong. See to it that your pediatric practice conducts regular internal audits if you don't want to lose money and overlook billing mistakes that could result in missed billing opportunities.

But before starting your audits, you should explain to everyone in your practice why you should go for an internal audit and how an internal audit will benefit your practice.

Internal audit charts: Internal chart audits make it possible to find and fix coding mistakes and self report rather than letting the payer find them. If your staff members are not willing to participate, let them know that the point of the audit is to improve coding down the line.

Types of internal audits:

Prospective audit: Your practice assesses new claims before you file them. Such an audit helps you identify and rectify problems prior to sending the claim, which could mean you will discover improper coding or charges that would have been missed otherwise. However, remember that this kind of chart audit can delay billing.

Retrospective audit: Your practice takes a look at paid claims. On the other hand, this type of audit do not delay billing but causes your office to be proactive in finding problems before you submit the claim.

But remember that the same audit process and timeline won't work for every practice to identify your practice's needs.

What should be done: Your practice must determine for itself what types of audits your staff can reasonably compete and what effects on claim submission timing and cash flow your practice can handle.

You should remember that an audit is much more than coding; it involves documentation, coding, billing and data input, denials management and office process following policies and procedures.

Orthopedic Coding: Additional Neurostimulator & Arthrodesis Codes

Your orthopedic practice will enjoy the additional neurostimulator and arthrodesis codes as far as the new and revised CPT codes for your orthopedic practice in 2011 is concerned.

This time your orthopedic practice will enjoy the additional neurostimulator and arthrodesis codes as far as the new and revised CPT codes for your orthopedic practice in 2011 is concerned. You'll be required to report arthrodesis procedures that include discectomy, osteophytectomy and spinal cord decompression with two just-in bundled codes: 22551, 22552.

Since 22552 is an add-on code, you would report it with 22551 to reflect any additional interspace the neurosurgeon treats below C2. Prior to this, bundled procedure would have been reported as 63075 for the discectomy, osteophytectomy and spinal cord/nerve decompression and 22554-51 for the arthrodesis. This is one of several code pairs which were used together more than 90 percent of the time, leading CMS to request a bundled code from CPT.

Now you'll be able to describe fully tibial and cranial neurostimulator services with four new codes: 64566, 64568, 64569 and 64570. And if your neurosurgeon carries out chemodenervation, you'll have a new code to code for work on the salivary glands: 64611.

This year don't let code descriptor changes trip you up when you turn to 20664 for halo application, as the revision this time does away with the phrase "requiring general anesthesia:" 20664 (Revised). Add-on allograft codes 20930 and 20931 received changes, which will be for 2011: 20930 (Revised) and 20931 (Revised).

The development of many bone graft extenders including demineralized bone matrix and bone morphogenic protein led to frequent questions regarding the appropriate coding for these materials. The revision of 20930 places these materials in the same category as other non-structural bone extenders that are not obtained directly from the patient being tended to." Closed vertebral facture code 22315 now deletes the phrase with or without anesthesia: 22315 (Revised) and code 22851.

More Documentation Requirements add to Physician Burden

More Documentation Requirements add to Physician Burden
Medical Coders need to look on Medical coding because more documentation is requirements add to physician burden.
Medical Coding, Code lookup

Home health agencies will have less control over new doctor-related payment condition. Agencies are hoping for some big changes to one troublesome provision in the 2011 proposed payment rule – the face-to-face doctor encounter requirement.


The mandate for the face-to-face encounter was in the Patient Protection and Affordable Care Act health care reform law enacted this year. However, the CMS version of the requirement is more stricter than the law calls for.


For instance: The proposed rule also requires that the encounter be for the primary reason home care services are required and that doctors furnish 'unprecedented' physician documentation about the encounter and why the patient meets homebound criteria.


According to industry experts, the proposed face-to-face encounter requirement is riddled with problems for home health agencies. To start with, agencies have very little influence over whether their patients make it to a physician for a visit.


It is absolutely not proper to place a requirement on home health providers for which they have no control whatsoever, as a consultant puts it. “How is the staff of the home health provider supposed to ensure that the patient goes to the physician and that the physician documents right in her office records?"


One can make appointments for patients; however we cannot ensure they keep them; that their transportation is unfailing, that they feel well enough to make the trip. In fact, there are many reasons that patients fail to see the doctor despite the best efforts of the home care staff to make it happen.


For more on this, sign up for a one-stop medical coding website http://www.supercoder.com/. Such a site comes with a code lookup tool that will help you in your coding.

Pathology/Lab | Stain Codes from Microbiology, Hematology and Surgical Pathology Earn Proper Payment

"Clinical labs and anatomic pathologists use special stains to aid in microscopic examination of tissues or cells, but they shouldnt necessarily report the same codes for the same stain. Coders must know which CPT code to use based not only on the type of stain but also on the stain substrate and the reason for the procedure. Many special stain processes are described by 85535-85536, 87205-87207 and 88312-88313. Without properly applying these codes, laboratories may sacrifice payment for legitimate staining services, says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, laboratory coding and compliance consultants in Longwood, Fla.

Codes 88312 -88313

Two special stain codes appear as add-on codes in the CPT surgical pathology section: 88312 (special stains [list separately in addition to code for surgical pathology examination]; group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each) and 88313 (... group II, all other [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, each). In their most straightforward application, these codes describe the special staining of any surgical pathology tissue specimen. For example, an acid fast stain carried out on a transbronchial lung biopsy for diagnosis of disease such as tuberculosis would be reported as 88312, in addition to the surgical pathology service (88305, level IV surgical pathology, gross and microscopic examination, lung, transbronchial biopsy). Similarly, a trichrome stain to evaluate fibrosis observed in a liver biopsy (88307) is reported as 88313.

Despite the fact that 88312 and 88313 are add-on codes in surgical pathology, they also describe special staining services for specimens other than surgical pathology tissues. For example, if a trichrome stain for ova and parasites is carried out on a direct smear from a stool sample, the service is reported as 88312. There is no code in the microbiology section for this stain, so the service must be reported with one of the special stain codes from surgical pathology, Dettwyler says. A directional note in the microbiology section of the CPT manual states, For complex special stains, see 88312, 88313.

Another point coders find confusing about the ova and parasites stain is the fact that a trichrome stain is reported with 88312, even though trichrome is listed as an example under 88313. But in the ova and parasites stain, the trichrome is used to identify microorganisms, and should therefore be listed as 88312 because its definition lists group I for microorganisms, Dettwyler says. The trichrome stain described by 88313 is a tissue dye technique used to highlight connective tissue, muscle, cytoplasm and nuclei, and is therefore considered a group II stain.

Although CPT directs the use of 88312 or 88313 for special stains on specimens other than tissue, some laboratories have reported denials from both Medicare and third-party payers. Sometimes the problem is that a clinical laboratory has certification for microbiology and parasitology, but not for anatomic pathology, Dettwyler says. Then when the lab reports codes from the surgical pathology section, such as 88312 or 88313, payment is denied. Labs can appeal the denials and ask the carrier to add these special stain codes to those allowed under the labs certification specialty.

Yet another use of 88313 for nonsurgical specimens is the reporting of iron stains for bone marrow aspiration requiring physician evaluation. Although there are separate codes for iron stains for blood and bone marrow smears (85535-85536), a note following these codes directs coders, For iron stains on bone marrow or other tissues with physician evaluation, use 88313. Further, CPT directs coders to special stain codes 88312 and 88313 in a note under the bone marrow aspiration codes (85095 and 85097).

For example, a pathologist may evaluate bone marrow aspiration smears, plus a cellblock made from the clot, and also interpret an iron stain for the diagnosis of iron-deficiency anemia (280). These services are reported as 85097 (bone marrow; smear interpretation only, with or without differential cell count), 88305 ( cell block, any source) and 88313x2 for the iron stain if it is carried out on both the aspirate and the cell block.

Codes 85535-85536

Hematology code 85535 (iron stain [RBC or bone marrow smears]) describes technologist appraisal of sideroblastic or reticuloendothelial bone marrow iron stores. Code 85536 (iron stain, peripheral blood) was added in CPT 2001 to report microscopic analysis by a medical technologist for abnormal iron accumulations in peripheral blood. Because the wording allows reporting a red-blood-cell iron stain with either code, 85536 should be used for peripheral blood smears, and 85535 reserved for RBCs other than peripheral blood.

For example, if a physician suspects sideroblastic anemia and requests an iron stain on peripheral blood, the stain is reported as 85536. The stain may be reported in addition to the pathologists evaluation of the smear (85060, blood smear, peripheral, interpretation by physician with written report).

CPT 2001 also added a note following 85536 directing coders to use 88313 for physician evaluation of iron stains on bone marrow or other tissues. For instance, a pathologist may evaluate a bone marrow biopsy (85102, bone marrow biopsy, needle or trocar) and decalcify the specimen (88311, decalcification procedure [list separately in addition to code for surgical pathology examination]) to permit an iron stain evaluation (88313) of the bone marrow.

Codes 87205-87210

The 87205-87210 family of codes reports special microbiology stains for direct smears from various sources. The stains are 87205 (smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types), 87206 ( fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types) and 87207 ( special stain for inclusion bodies or intracellular parasites [e.g., malaria, coccidia, microsporidia, cytomegalovirus, herpes viruses]). The stain substrate includes direct smears from sources such as blood, urine, stool, sputum, synovial fluid, cerebrospinal fluid (CSF) or vaginal smears.

Codes 87205 -87207 describe special stains used to indicate the presence of disease-causing organisms in direct smears, says Kathleen Ohrt, MT (ASCP), SM, microbiology technical specialist at Beebe Medical Center in Lewes, Del. These tests are often run concurrent with a culture. Although some of the same stains may be used to identify cultured organisms, the 87205 family of codes should not be used for cultures, Ohrt says. Stains and other tests to identify cultured organisms are included in the codes for presumptive and definitive identification, she says.

Some clinical examples illustrate how to use codes 87205-87210:

For a urine or vaginal smear evaluated for bacteria using a Giemsa stain, report 87205.

For a vaginal smear evaluated for Trichomonas or Monilia using a wet mount such as KOH or saline preps, report 87210 (wet mount for infectious agents [e.g., saline, India ink, KOH preps]).

For a Giemsa stain of a peripheral blood smear for suspected malaria, report 87207. Regardless of the fact that Giemsa stain is listed under 87205, in this case it is used as a special stain for the sporozoan malarial organism, Plasmodium, rather than a bacteria or fungi, and should be reported as 87207. Note that the peripheral blood is typically concentrated for this stain, which is separately reportable as 87015 (concentration [any type], for infectious agents).

Report an acid-fast bacilli (AFB) stain of a sputum smear with 87206. This may be an acid fast stain, or a fluorescent stain, Ohrt says. Typically, the sputum is also concentrated, which is reported separately according to CPT direction for thick smear preparation, use 87015.

For a synovial fluid smear, either a Gram stain for bacteria, or Giemsa or Wright stain for cells should be reported with 87205.

Gram staining of a direct CSF smear to indicate the presence of bacteria such as meningococci is reported as 87205. The CSF would typically be cultured at the same time, reportable as 87070 (culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive identification of isolates), Ohrt says.

Special staining of a direct smear from a herpetic vesicle for inclusion bodies, such as the Tzanck stain for herpes simplex virus, would be reported with 87207. Note that this is the only code from this family listed in the physician fee schedule with modifier -26 (professional component). If a pathologist provides a professional interpretation and report of a special stain for inclusion bodies or intracellular parasites, 87207-26 should be reported for the service, Dettwyler says.

Remember that not all microbiology staining of direct smears is reported with 87205-87210. A note associated with these codes in the CPT manual directs coders, For complex special stains, see 88312, 88313. Recall the earlier example of a stool smear trichrome stain for ova and parasites reported with 88312.

Because CPT directs coders to special stain services listed in divergent parts of the pathology and laboratory section, coders should be familiar with all of these codes."

Get Reimbursed for Nonelective Abortions

Technological advances enable physicians to detect pregnancy in its earliest stages but make coding for spontaneous or missed abortions more complicated. When a patient presents with no prior pregnancy diagnosis, tools such as ultrasound and beta subunit HCG (human chorionic gonadotropin, a pregnancy test that helps determine the stage of pregnancy) confirm pregnancy and enable physicians to determine how far it has progressed. When a patient presents with a pregnancy that has already terminated through nonelective abortion, coding for diagnosis and procedural care can be a challenge, especially for very early-term pregnancies. Often, women who did not seek medical attention for early diagnosis of pregnancy will not identify a delayed menstrual cycle as the loss of a pregnancy and will not be aware that conception occurred. If a pregnancy is diagnosed and terminates, either by spontaneous or induced means, the abortion codes should be used to report the related physician services.

Abortion Terminology


Familiarization with the common types of abortions is the first step to assigning the right ICD-9 and CPT codes.

Complete: The complete expulsion or extraction from its mother of a fetus or embryo; complete expulsion from the uterus of any other product of conception.

Elective: Without medical justification but done in a legal way.

Incomplete: Part of the products of conception have been passed but part (usually the placenta) remains in the uterus.

Induced: Expulsion of the fetus and products of conception brought on purposefully by drugs or mechanical means.

Inevitable: Characterized by rupture of the membranes in the presence of cervical dilation in a pre-viable pregnancy.

Missed: Death of the fetus in utero prior to 22 weeks, with retention of the products of conception.

Septic: An infectious abortion complicated by fever, endometriosis or parametritis.

Spontaneous: An abortion that has not been induced artificially. The term is usually limited to pregnancies of less than 22 weeks gestation.

Editors note: CPT codes for induced abortion (59840-59857) do not distinguish between elective (not medically necessary) or nonelective (medically necessary) abortions. ICD-9 codes 634.x-637.9 describe spontaneous (nonelective) (the fourth digit indicates the contributing complication), legally induced (elective), illegally induced (elective) and unspecified abortion (nonelective).

Spontaneous vs. Missed Abortion

Carla Bryan, CPC, practice manager at Womens Care, a two-physician, one-nurse midwife ob/gyn practice in Hartsville, S.C., says that when determining the right CPT code for a nonelective abortion, the first parameter is whether surgery was required to complete the process. If the patient presents with a spontaneous abortion that is complete (meaning there were no products of conception retained in the uterus), we treat the patient and code it as an evaluation and management (E/M) visit, with no other CPT code, since nothing else was done. Code 634.x (spontaneous abortion) is used for diagnosis. If Bryans physician must evacuate a dead fetus from the uterus through a dilation and curettage (D&C), 632 (missed abortion) is used for the diagnosis, and 59820 (treatment of missed abortion, completed surgically; first trimester) or 59821 (treatment of missed abortion, completed surgically; second trimester) is used for the D&C. By using the code for missed abortion, you indicate that there are retained products of conception that must be surgically removed. A spontaneous abortion code implies that there are no retained products in the uterus and, therefore, no procedural code, she says.

If Its Not Technically a Pregnancy

What procedural codes apply when the patient enters the exam room unaware that she is pregnant, and the diagnosis is something other than a missed abortion? One example is when a physician performs a D&C for a blighted ovum (631, other abnormal product of conception). The code for dilation and curettage, nonobstetrical (58120) doesnt appear to be the answer, but the correct code depends on when or if the blighted ovum and pregnancy were discovered.

The treatment for a blighted ovum, which is a fertilized egg that fails to develop a fetus within it, may be the same as a missed abortion, but only if a pregnancy has been confirmed. Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature and an independent coding educator, explains the distinctions. A blighted ovum may reabsorb before it is detected, or the patient may exhibit signs of miscarriage. The patient may come in with unexplained vaginal bleeding before she realizes that she may have been pregnant, and a pregnancy test comes back negative. If this is the case, Witt explains, and there is a negative pregnancy test, the proper code for the D&C is 58120 (dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) even if the pathology report indicates a blighted ovum after the fact.

On the other hand, if the patient has been diagnosed as pregnant either prior to or at the same visit, and then begins bleeding, the patient may spontaneously abort (E/M code only) or may require surgery to remove the contents. The blighted ovum may not show up until the pathological reports come back, but because there was a positive pregnancy test, 59812 is used to indicate treatment of incomplete abortion, any trimester, competed surgically.

Although unusual, a patient with a blighted ovum may complain of a missed period only. The physician is likely to order a pregnancy test and do an ultrasound. If the pregnancy test is positive, and the ultrasound reveals a blighted ovum (but no symptoms of abortion, i.e., discharge or vaginal bleeding), the physician will perform a D&C, and 59820 or 59821 would be used along with code 631.

With a blighted ovum, says Witt, you are not inducing abortion because there is no fetus; rather you may be helping along what nature has already started. She adds that, before tests revealed pregnancy at its earliest stages, physicians were more inclined to let nature takes its course and let the body either expel or reabsorb the blighted ovum. But D&Cs or other abortion methods are now employed much more frequently to treat incomplete abortions or induce abortions when a pregnancy is not viable.

Improve Your Hyperplasia Diagnosis Coding Skills Before Oct. 2013 Hits

You won't find one-to-one matches for all your existing ICD-9 codes.

In case a pathology report comes back along with a hyperplasia diagnosis, then there are five possible ICD-9 codes you can report. On the other hand, in ICD-10, you'll only have three choices.

Hyperplasia defined: When hyperplasia takes place, this means the patient has a rise in the number of cells. In the instance of endometrial hyperplasia, this implies that the cells have multiplied in the endometrium, or the inner lining of the uterus.

An endometrial intraepithelial neoplasm is essentially a precancerous lesion in the endometrium that makes the uterine lining more prone to endometroid endometrial adenocarcinoma.

ICD-9-CM Codes: Here are the ICD-9 codes that apply:

621.30 (Endometrial hyperplasia, unspecified)

621.31 (Simple endometrial hyperplasia without atypia)

621.32 (Complex endometrial hyperplasia without atypia)

621.33 (Endometrial hyperplasia with atypia)

621.35 (Endometrial intraepithelial neoplasia [EIN])

ICD-10-CM Codes:

N85.00 (Endometrial hyperplasia, unspecified)

N85.01 (Benign endometrial hyperplasia)

N85.02 (Endometrial intraepithelial neoplasm [EIN])

ICD-10 Change: In the incident of 621.30 and 621.31, you have a one-to-one relationship between your ICD-9 codes and ICD-10 counterparts (N85.00 and N85.01 respectively). Though, ICD-10 rolls 621.32, 621.33, and 621.35 into N85.02.

Documentation: Additional terms for N85.00 contain "hyperplasia (adenomatous) (cystic) (glandular) of endometrium" and "hyperplastic endometritis." A note listed beneath N85.01 includes "endometrial hyperplasia (complex) (simple) excluding atypia. Furthermore, another note under N85.02 is "endometrial hyperplasia with atypia."

Watch out: Assume the provider doubts hyperplasia. He identifies and documents "endometrial thickening" in an ultrasound examination. What diagnosis should you report? JSimply because the provider documents endometrial thickening does not imply that the patient actually has endometrial hyperplasia. A lot of coders make this mistake. You must not code this as hyperplasia as physicians don't always take the thickening of the uterus "abnormal;" in fact; it's simply a monthly "ramp up" for all women. For ICD10, this condition has been referred to R93.8 (Abnormal findings on diagnostic imaging of other specified body structures). You will discover this in the index by searching the term "thickening, endometrium.

Medical Billing and Coding Tips: You should not report hyperplasia until the provider has executed a biopsy, and you have a pathology report that confirms this condition.

ICD-9-CM to ICD-10-CM Transition Update: You have an Excludes1 note in the N85.-- classification, you'll see an Excludes1 note that prevents you from reporting these codes with endometriosis (N80.-), inflammatory diseases of uterus (N71-), noninflammatory disorders of cervix, excluding malposition (N86-N88), polyp of corpus uteri (N84.0), plus uterine prolapse (N81-).

You'll also discover another Excludes1 note under N85.02 preventing you from reporting this particular code with malignant neoplasm of endometrium (with endometrial intraepithelial neoplasia [EIN]) (C54.1).

11040 and Wound Closure: Watch Out for These Conditions to Explain Separate Reporting

Concentrate on the level of wound repair to maximize your reimbursement.

A lot of clinical scenarios do not need dermatologists to carry out debridement as a distinct service from wound closure. Though, recognizing the times when it is essential can help your practice get the full reimbursement it is worthy of. Follow the expert medical billing and coding advice given below and know what CPT codes apply.

In case you're considering reporting debridement distinctly from a wound closure, ensure that your dermatologist's notes clearly document that the wound was contaminated and needed instrumentation and saline or other substances to cleanse and debride the wound. You would require doing a sharp removal to use the debridement code.

Don't miss: In case you report a debridement code, for instance 11040 (Debridement; skin, partial thickness), along with your wound closure CPT codes, append modifier 59 (Distinct procedural service) to the debridement code. This tells the payer that you recognize that debridement is mostly bundled into wound repair, however that clinical circumstances needed the dermatologist to carry out debridement as a separate service.

1. Watch Out for Wound Repair With the Debridement

CPT® specifies that you might also report debridement CPT codes independently of repair CPT codes once the dermatologist gets rid of large amounts of devitalized or contaminated tissue or once the dermatologist carries out debridement without immediate primary repair of a wound.

The dermatologist might clean debris from the wound excluding repairing the wound as it was not deep enough to need repair or the dermatologist delayed the repair because of an extenuating circumstance.

For instance: The dermatologist may not have sufficient time to repair the wound at that particular time, or the patient may present with a more important skin condition that needs medical attention first. In such an instance, you can bill debridement for full, distinct payment minus a wound repair code.

Even though dermatologists most commonly clean a wound instantly before they repair it, you wouldn't report a debridement code separately. Don't miss: The debridement procedure may also require a repair procedure that will affect your medical billing report.

2. Don't Oversee Intermediate Wound Closure for Your Extensive Debridements

In case the dermatologist carries out a simple repair with nominal amounts of debridement, for example, you must only report a simple repair code (12001-12021). In case that same wound requires extensive cleaning or removal of particulate matter, you may, as an alternative, report an intermediate repair code (12031-12057).

Money opportunity: There is an important difference in payment between simple plus intermediate repair CPT codes . Reporting code 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) will reimburse you about $93.60, whereas 12031 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) may pay $235.20.

Reader Question: Coding for Plaquenil Toxicity Observation

"Question: What is the best way to code for Plaquenil toxicity observation: first, if the patient was referred by the family doctor for a baseline exam prior to the start of treatment; second, if the patient returns six months after the start of treatment to assess ocular changes; and, third, if the patient returns six months later and shows adverse ocular changes?

Marie Stamper, CMM
Ward Eye Center, FL

Answer: Plaquenil (hydroxychloroquine) is a drug used to treat malaria, lupus erythematous, ormost commonlyrheumatoid arthritis. A potential side effect of the drug is ocular change that can affect the patients vision; the patient should be monitored regularly to check for these changes. You should use an evaluation and management services (E/M) office or other outpatient visit code (99201-99215) for the procedure code. For the diagnosis code, use V58.69 (long-term [current] use; of other medications) for the primary diagnosis, and then the diagnosis code which applies to the systemic condition for which the patient is taking Plaquenil (e.g., 714.2, other rheumatoid arthritis with visceral systemic involvement). For the baseline exam done before the patient is taking Plaquenil, use an E/M code with the arthritis as the primary diagnosis. And if you do see adverse changes during a follow-up check for Plaquenil toxicity (in most parts of the country you should still use V58.69 as the primary diagnosis), but use the changes as a secondary diagnosis, as well as the arthritis (or whatever the reason is for the drug to be taken), a few Medicare carriers will want the ocular change as the primary diagnosis and the V58.69 code as secondary. If you are submitting electronically, it is likely best to use the ocular change diagnosis since you can only enter one diagnosis in the field. You can always list the V58.69 code in the note or comment field. In general, you should always list as primary the diagnosis code which most clearly indicates the medical necessity for an ophthalmologist to see the patient.
"

Proper modifier use is key to surviving these kidney stone scenarios

ESWL is ESWL is ESWL right? Wrong. Multiple stones in each kidney fragmented stones and stent placements are just a few of the things that can complicate coding for extracorporeal shockwave lithotripsy (ESWL).

ESWL represented by 50590 (Lithotripsy extracorporeal shock wave) is one of the most frequently performed procedures in urology practices as well as a popular and effective treatment for renal calculus (kidney stones). Our experts give you the facts for seven tricky ESWL coding scenarios.
Problem: The urologist performs ESWL to break up multiple stones in the same kidney. Can you bill Scenario 2: Stones in Right Kidney and Right Ureter
Scenario 3: Stones in Both Kidneys

Bilateral procedure) in this case.
Remember: Use -LT (Left) and -RT (Right) modifiers to indicate which kidney the ESWL targeted Center says. If the left kidney stone is treated first use 50590-LT; for the second ESWL use 50590-RT-58.
Problem: Three days after an ESWL a patient returns for a stone obstructing the ureter. In the operating room the urologist places a stent. Problem: A patient with another stone presents within the global postoperative period of a previous ESWL. Since it's a new stone the urologist did not write in the preoperative note for the first ESWL that a second ESWL would be staged. How should you report this procedure?

Solution: If the second ESWL is for a different stone in the same kidney and done within the postoperative period of the first ESWL Center advises using modifier -79 (Unrelated procedure) to indicate an unrelated procedure. "It's unrelated to the first surgery " Center says. "Even though it's the same procedure it's a different stone."

Kidney stones do tend to recur most often within months or years after an ESWL treatment. If a urologist performs another ESWL on a patient after the global period for the previous one has expired report code 50590 without modifiers Center says.
Problem: The urologist performs an ESWL for a renal pelvic stone. After one month the physician realizes the stone was incompletely fragmented by the ESWL and decides to perform 50081 (Percutaneous nephrostolithotomy or pyelostolithotomy with or without dilation endoscopy lithotripsy stenting or basket extraction; over 2 cm). The diagnosis for both procedures is 592.0 (Calculus of kidney).

Solution: When a procedure is performed in a global period for the same diagnosis as was linked to the initial procedure - and the second procedure was not planned or staged at the time of the initial procedure - the second procedure must be more extensive than the original procedure to be separately billable. The coder should bill 50081 with modifier -58 appended. This will bring full payment for 50081 but a new 90-day global period would begin.

In this particular clinical scenario modifier -58 is used on a more invasive second procedure during the 90-day global period of the first unsuccessful surgery. This procedure was not prospectively planned or staged and documentation of this fact is not necessary as was needed in Scenario # 3 above.

However: This is a good scenario to bounce off your carriers Delebreau says. "If it's group insurance and it's the same stone I usually don't hesitate to use a -58 because it's related " she says. She had heard different advice about Medicare though so she investigated.

"I checked with some representatives and I explained situations like this where they're going back to re-treat the same stone " she says "and I've been told that I could still use the -58 as long as it's the same stone."
Problem: Using cystourethroscopy and a ureteral catheter a urologist displaces a stone out of the ureter and back into the kidney with plans to perform ESWL on the stone later. How should you code both procedures?

Solution: For the first procedure in which the stone is moved into the kidney use 52330 (Cystourethroscopy [including ureteral catheterization]; with manipulation without removal of ureteral calculus) Center says. "After the cysto and stone manipulation into the renal pelvis using the ureteral catheter the doctor would take the patient over to the ESWL machine " she says.

Since 52330 is bundled into code 50590 bill 50590 for the ESWL and 52330 for the stone manipulation with modifier -59 (Distinct procedural service). 

For further details on this and for other medical coding updates, sign up for a one-stop medical coding guide like  http://www.supercoder.com/

HCPCS 2013: Here’s How Coding For Oncology And Hematology Is Going To Change In The New Year

CPT® 2013 brings in a number of changes for all practices, but for oncology and hematology coders, HCPCS is where they should be focused in right now. Take a look at the coding changes for HCPCS 2013.

Changes in doxil reporting 

HCPCS 2013 deletes both J9001 (Injection, doxorubicin hydrochloride, all lipid formulations, 10 mg) and Q2048 (Injection, doxorubicin hydrochloride, liposomal, Doxil, 10 mg).

In place of Q2048, you get a new code J9002 (Injection, doxorubicin hydrochloride, liposomal, Doxil, 10 mg).

However code Q2049 (Injection, doxorubicin hydrochloride, liposomal, imported Lipodox, 10 mg) will remain valid for imported Lipodox, which has been used to alleviate the Doxil shortage.

Seperation of Erwinaze from other asparaginase

HCPCS 2013 adds a new code J9019 (Injection, asparaginase [Erwinaze], 1,000 IU) for the chemotherapy drug asparaginase, which is sold under the name Erwinaze.

HCPCS has also updated the definition of the code J9020 as follows:

•       2012: J9020, Injection, asparaginase, 10,000 units
•        2013: J9020, Injection, asparaginase, 10,000 units, not otherwise specified.

New permanent code for Adcetris

HCPCS 2013 adds a new specific code, J9042 (Injection, brentuximab vedotin, 1 mg), for the targeted antibody-drug conjugate Adcetris.

Steer Clear of Ophthalmic Mitomycin Code

HCPCS 2013 revises code J9280 for mitomycin, which is used to treat a variety of cancers. The term "injection" has been added to the definition:

•       2012: J9280, Mitomycin, 5 mg
•      2013: J9280, Injection, mitomycin, 5 mg.

J7178 Completes the Fibrinogen Transition

 

HCPCS 2013 deletes two human fibrinogen concentrate codes:

•       J1680, Injection, human fibrinogen concentrate, 100 mg
•   Q2045, Injection, human fibrinogen concentrate, 1 mg.

 

You now have a new code J7178 (Injection, human fibrinogen concentrate, 1 mg) instead. 

Use code J1741 for IV Ibuprofen

HCPCS 2013 deletes C9279 (Injection, ibuprofen, 100 mg) and adds J1741 (Injection, ibuprofen, 100 mg).

Watch Units for Relistor

HCPCS 2013 adds new code for Relistor, which is used to treat patients with opioid-induced constipation: J2212 (Injection, methylnaltrexone, 0. 1 mg).

To calculate units, you should divide the amount administered by 0.1. So for a 12 mg dose, divide 12 by 0.1 for a total of 120 units.

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