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AMA Coding Guidance

Code Set Updates

Hot Topics

Coronary Artery Bypass Grafts in ICD-10-PCS

   By Lynn Kuehn, MS, RHIA, CCS-P, CHAP, FAHIMA

The ICD-10-PCS (Procedure Coding System) is the new system that will be implemented for hospital inpatient coding on October 1, 2013. The codes are seven characters in length and each character has a specific meaning.

1 2 3 4 5 6 7
Section Body System Root Operation Body Part Approach Device Qualifier

Character 3 is called the “root operation” and describes the intent of the procedure. There are 31 unique root operations in ICD-10-PCS and the system includes guidelines to help with the coder select the correct root operation. The root operations describe procedures such as resection (to completely remove a body part), dilation (to expand the diameter of a tubular body part) or repair (to restore a body part to its normal structure and function). One of the most challenging things about learning the system is learning the various root operations and their definitions.

Coronary artery bypass grafting (CABG) is a classic example of the root operation called Bypass. The root operation Bypass is defined as “altering the route of passage of the contents of a tubular body part,” with a tubular body part being a hollow structure that allows passage of solids, liquids or gases.

In CABG procedures the body part value (character 4) identifies the number of coronary artery sites that were bypassed and the qualifier (character 7) identifies the vessel that was “bypassed from,” which is the new source of blood flow for the coronary artery(ies). ICD-10-PCS doesn’t identify each coronary artery individually. Rather, all of the coronary arteries are treated as a combined body part and the body part value is assigned based on the number of artery sites that were bypassed using the same type of device.

The devices available for coding coronary bypass procedures are autologous venous tissue (such as the greater or lesser saphenous vein), autologous arterial tissue (such as the radial artery), synthetic substitute (such as GORE-TEX® grafts) or nonautologous tissue substitute (such as arterial or venous tissue from a cadaver source). In addition, there is a device value that indicates that no device was used. To qualify as a device in ICD-10-PCS, venous or arterial tissue must be completely disconnected from the original blood supply (a free graft) and moved to the new location as graft material. Therefore, when the left internal mammary artery (LIMA) is used, it is not completely disconnected but rather, it is disconnected from the muscle it supplies and remains connected to the left subclavian artery. The open end is reattached to one of the coronary arteries to create the bypass. The source of the blood is the left internal mammary artery and no device is used because it was not a free graft. Arterial tissue can be either transferred to a new location (left internal mammary artery) or a free graft (radial artery from the arm). Venous tissue is always used as a free graft (obtained from elsewhere in the body or a cadaver) and used to create a bypass from the aorta to a coronary artery location. When free grafts are used and harvested through a separate incision, an additional code is assigned for the excision of the graft.

A typical CABG case might be the following:

    Graft 1. Left internal mammary artery (LIMA) used to create a bypass to the left anterior descending coronary artery (not a free graft)

    Graft 2. Greater saphenous vein used to create a bypass to the circumflex coronary artery from the aorta (free graft)

The first graft is coded as 02100Z9, with no device value in character 6 (Z) because the LIMA is not a free graft. The qualifier value is a 9 to indicate that the blood source (or the vessel bypassed from) is the left internal mammary artery.

The 2nd graft is coded as 021009W, with the device value of 9 indicating autologous venous tissue (the free greater saphenous vein graft) and the qualifier value of W to indicate the vessel bypassed from as the aorta (the source of the blood to the graft).

In addition, the excision of the greater saphenous vein would be coded separately as 06BQ4ZZ and the use of the cardiopulmonary bypass machine would be coded separately, using codes from the Extracorporeal Assistance and Performance section of ICD-10-PCS.

It should be noted that the guidelines provide different instructions on coding bypass procedures in other locations than the coronary arteries. The body part and qualifier characters are assigned differently when the tubular body parts are in other locations, such as the gastrointestinal or genitourinary system.

The ICD-10-PCS files are available in the MediRegs Coding Suite or from the CMS website at https://www.cms.gov/ICD10/11b15_2012_ICD10PCS.asp.

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New Opportunities for RAC Auditors as the OIG expands the Work Plan for 2012

   By Jana Gill, CPC

As with past years of OIG target issues, the 2012 Work Plan continues to address previous years’ problem areas, but also appear to be taking a deeper look into physician billing and specifically the use of modifiers that impact reimbursement. In the 2011 Work Plan, the OIG identified that providers were improperly billing evaluation and management services during the time of another global service. As defined in the CMS Claim Processing Manual, Chapter 12, Sections 40.1, “global services” for most minor procedure is 10 days and major procedures 90 days. Services included within the global period are defined as:

  • Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;
  • Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a surgical procedure;
  • Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications, which do not require additional trips to the operating room;
  • Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;
  • Postsurgical Pain Management - By the surgeon;
  • Supplies - Except for those identified as exclusions; and
  • Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary.

CMS also defines carve out services that are excluded from global reimbursement, which include:

  • The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure;
  • Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;
  • Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
  • Treatment for the underlying condition or an added course of treatment, which is not part of normal recovery from surgery;
  • Diagnostic tests and procedures, including diagnostic radiological procedures;
  • Clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment for complications.

In the 2011 Work Plan section for part B issue titled “Evaluation & Management Services During Global Surgery Periods,” the focus was directed towards the use of modifier -24 (Unrelated evaluation and management service by the same physician during the global period). If the modifier was appended to an evaluation and management services during the global period of another procedure, the claim would be paid in addition to global allowance. The diagnosis code would also be “key” to inform CMS that the problem met the definition of “unrelated.” Another likely finding may have been E/M services, without modifiers, billed and paid during the global period. This may have been the case where providers performing surgical services attempted to “break-out” the pre or postoperative care without understanding the basic CMS rules surrounding minor and major surgical services. Bottom line, if payment is wrongfully made by CMS, it becomes the responsibility of the provider to identify and remedy the incorrect payment before penalties are incurred.

As with many OIG audit targets, the scope of the review is broad based and provides little direction with regards to interpretation. Several modifiers impact payment depending on complications, staged procedures and multiple providers. As an automated review, RAC contractors can identify the same beneficiary where separate providers bill for the same procedure without breaking down intraoperative and postoperative services. An example of this may be where a patient is seen in the emergency room for a displaced fracture where the physician performs a closed reduction and refers the patient to orthopedic for follow-up. If the orthopedic surgeon only manages post-operative care, the modifier (-55) should be appended to the surgical CPT code thus splitting the “global fee” and calculating only a percentage of the total RVU (relative value unit). Likewise, the ER provider would only bill for the surgical portion using the same CPT code with modifier -54 (surgical service only).

Another area of potential vulnerability exists when deciding whether a patient returns to the OR during the global period based on complications versus staging or a “more extensive” procedural service. Both modifiers (-78 and -58) provide a means of additional reimbursement depending on the patient condition and ultimately documentation. The biggest difference between the modifiers is the RVU payment and the continuation of actual “global days”. Modifier -78 (return to the OR for a related procedure) only pays for the intraoperative portion of the global fee where modifier -58 (staged or related procedure) pays the entire fee and starts a new global period. Although many conclusions can be drawn based upon diagnosis, these claims would most likely fall to a complex review to determine proper use of the modifier and thus percentage of payment as a precautionary to this new issue. To learn more about other modifiers that impact payment, see the CMS Claim Processing Manual, Chapter 12, Section 40.2 along with the 2012 OIG Part B issue summaries.

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AMA Coding Guidance

November 2011 CPT Assistant   

 By Jennifer Ridell, CPC

Sleep Testing Guidelines Revisions

  

In an effort to update the Sleep Testing Guidelines to reflect changes since they were originally published, CPT 2012 includes updates to the guidelines for this section of codes. The codes in this section include 95805 - 95811, 95803, 95800, and 95801. The new guidelines include definitions of the terms included in the sleep testing codes, new parentheticals pointing out codes that cannot be reported together, and required durations for certain sleep testing services. Additionally, this article addresses questions posed to the CPT Editorial Board regarding reporting of sleep test reporting.

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Clarification: Perinatal Period Definition


According to the official ICD-9-CM Guidelines for Coding and Reporting, perinatal is defined as, before birth through the 28th day following birth. To better understand what this means, the following may be useful: the perinatal period ends on the 29th calendar day following birth, and the day of birth is considered day zero. CPT codes impacted by these guidelines include 99468, 99469, 99471, 99472, and 99477.

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Coding Brief: Computed Tomography of Abdomen and Pelvis (Codes 74176-74178)


The Relativity Assessment Group uses a screening process to identify procedures performed together more than 90% of the time. This helps to identify areas where separate payment for procedures often performed together is resulting in overpayments. This screening identified computer tomography (CT) services for the abdomen and pelvis as a place where procedures were performed together more than 90% of the time. This ruling led to the creation of three new Category I codes in 2011 for CT studies that combine the abdomen and the pelvis. The new Category I codes are: 74176, 74177, and 74178.

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CPT Assistant THEN and NOW Updated Reporting Instruction: Percutaneous Insertion and Removal of Intra-aortic Balloon Assist Devices


A then and now look at percutaneous intra-aortic balloon (IAB) assist device codes 33967 and 33968. This reviews a CPT Assistant article published in 2002 and how it compares to an updated article for 2011 that now includes codes (33967, 33968, 33970, 33971, 33973, and 33974) for the insertion and removal of the IAB at the same setting.

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Coding Brief: Lower Extremity Thrombectomy/Atherectomy (Codes 37186, 37225, 37227, 37229, 37231, 37233, 37235)


This includes information on when it is and is not appropriate to report thrombectomy with lower extremity femoral and tibial/peroneal atherectomy procedures described by codes 37225, 37227, 37229, 37231, 37233, and 37235. The CPT codes discussed, in addition to those already listed, are: 37184 - 37188, 75898, 76000, and 76001.

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Coding Consultation: Questions and Answers


An article by the CPT Editorial Panel answers questions posed to the panel regarding the subjects of surgery/musculoskeletal and cardiovascular systems, medicine/neurology, radiology/diagnostic ultrasound, pathology and laboratory/microbiology, and Category III Codes. The responses answer multiple questions including: does code 76817, Ultrasound, pregnant uterus, real time with image documentation, transvaginal, include the valuation of both twin fetuses and may both code 63056, Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disk), single segment; lumbar, and code 22630, Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar, be reported for the same interspace/segment?

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To view these articles via CCH Coding Comply, search from the Search Code Sets tab in Coding Comply for any of the codes listed above, view the Related Documents by clicking on the paper icon next to the code, then select the article. To view these articles in The Coding Suite, go to the CPT Assistant Archives folder and in the Search field within this folder and enter “November 2011.”

Code Set Updates

2012 annual update to HCPCS code set


The 2012 HCPCS annual update has been released and is now reflected in Coding Comply. The update, effective January 1, 2012, includes new, modified and deleted codes. Over 275 new codes were added, including E2626-E2633, G0442-G0451, and Q4122-Q4130. Over 70 codes were modified, including G0425-G0427 and G8574-G8578, and over 70 codes were deleted, including C9270-C9284.

To view the updated Code Set go to the Search Code Sets tab in CCH Coding Comply, select the appropriate code set, select added, modified, and/or deleted in the Filter Actions and in the Start Date field enter 1/01/2012. Via the search results, you will be able to export all or some codes in Excel format by checking the box next to individual codes or the “Select All” box; and then clicking on the “Export” icon in the upper right corner of the screen. To view the updated Code Sets in the Coding Suite there is a link on the Coding tab for each code set and users should choose the appropriate code set and then view the download page for the most recent changes.

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NOTE: To follow the MediRegs links above, you will need to be a subscriber to the Coding Suite of products and if prompted, enter your username and password. If you cannot remember your user name or password go to: http://wk.mediregs.com/login_fs.html and the system will let you request a reminder. For the Internet Research Network or IntelliConnect links, you will need to be a subscriber to the CCH Coding Comply.

Requests for information about article submission and comments from readers are welcome and should be directed to at Nicole Stone at Nicole.Stone@wolterskluwer.com, Fax 847-267-2514. Customer service inquiries should be directed to 800-449-9525. CCH Coding Compliance Advisor is published monthly by CCH, a Wolters Kluwer business.

©2012 CCH. All rights reserved. No claim is made to original government works; however, the gathering, compilation, and arrangement of such materials, the historical, statutory and other notes and references, as well as commentary and materials in this Publication are subject to CCH copyright. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the publisher is not engaged in rendering legal, accounting or other professional service. If legal advice or other expert assistance is required, the services of a competent professional should be sought. For more information about the The Coding Suite or CCH Health Care Portfolio, please visit our online store at http://mediregs.com or http://health.cch.com.

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About the Authors

Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA, is a health care consultant with more than 25 years of experience working in the health care profession. She is the founder of Kuehn Consulting, LLC. Prior to her own business, she held a number of leadership positions in large physician organizations, both privately owned and hospital-based. Her experience includes operational assessment, physician service coding and reimbursement systems, data quality, compliance training, and information systems management for physician offices, surgery centers and ancillary diagnostic service providers. Lynn is a board member of the 2012 CCH & MediRegs Coding Compliance Advisory Board.

Jana Gill, MA, CPC, has over 12 years of experience in healthcare and currently serves as the Coding and Compliance Director for Medical Management, Inc., a medical practice management firm based out of Boise, ID. Jana is a member of the 2012 CCH and MediRegs Coding Advisory Board.

Jennifer Ridell, CPC, is the Data Application Coordinator for CCH Coding comply, CCH Reimbursement Toolkit, CCH Health Reform Toolkit and creates all value-add content in the CCH and MediRegs Coding Suite product line. She is the lead editor for the weekly Coding Comply newsletter and also writes for the CCH Medicare and Medicaid Guide weekly report letter where she serves as a coding and billing expert contributor.

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