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AMA Coding Guidance



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New Year- New Opportunities to clean out the clutter

   By Maria Bounos, RN, MPM, CPC-H

When the New Year arrives, most of us make resolutions. The most common resolutions include losing a few pounds and becoming more organized. But now that we are in 2013, ICD-10 implementation seems closer and procrastination is not an option! It comes highly recommended that your New Year’s resolution list includes the opportunity to address “coding clutter.” Interesting terminology, but what exactly does “coding clutter” mean? The textbook definition of clutter states “disorderly state or collection.” Therefore, I ask you, is your facility coding and collecting data that is not meaningful? If you are unsure or believe the answer is yes, continue reading to further delve into this notion.

Excessive Coding

Excessive coding may be costing your facility time and money. A documentation review will reveal potential areas that could be strengthened by policies and procedures on what to code and what not to code. Many years ago, official coding guidelines addressed the reporting of additional diagnoses. Is your facility following these guidelines? If not, do they have a legitimate reason for collecting data above and beyond what is required? The guidelines state, for reporting purposes the definition of “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:

  • Clinical evaluation;
  • Therapeutic treatment;
  • Diagnostic procedures;
  • Extended length of hospital stay; or
  • Increased nursing care and/or monitoring.

In addition to the coding guidelines, the UHDDS (Uniform Hospital Discharge Data Set) further clarifies the use of secondary codes by stating not to include diagnoses that relate to an earlier episode, which has no bearing on the current hospital stay. UHDDS definitions apply to inpatients in acute care, short-term, long-term care and psychiatric hospitals as well as home-health agencies, rehab facilities, nursing facilities, etc.

Beyond reporting for reimbursement, facilities collect data to support quality measures and risk and severity adjustments as well as their own internal data needs. So it is time to ask yourself, “When was the last time a review of policies and procedures as well as an analysis of coding was completed by your organization?”

One of the most common examples of “coding clutter” is assigning codes for signs and symptoms that are an integral part of a disease process. The following case study is a “real world” example from an inpatient bill:

410.71 Acute myocardial infarction
682.6 Cellulitis of leg
681.10 Cellulitis of toe
703.0 Ingrowing nail
403.90 Hypertensive Chronic Kidney Disease
585.9 Chronic Kidney Disease, Unspecified
790.5 Abnormal Serum Enzyme Level
729.5 Pain in Limb
729.81 Swelling of Limb

Before reviewing the documentation in the health record, one would question the coding of pain and swelling of limb in a patient with cellulitis. It is possible that the pain is in a different limb than the cellulitis, but worth investigating. As a side note, this generic “pain in limb” ICD-9-CM code will change in ICD-10-CM where you can identify if it was the right forearm, left leg, etc. What about assigning a code for abnormal serum enzyme level? What are your policies for coding abnormal test results? New and inexperienced coders have a tendency to code everything they read. In this case, I would be surprised if the physician really documented ingrown nail, it seems that the patient has more critical issues than an ingrown toenail! This practice can clog the databases with useless codes, not to mention the time it takes to assign the codes.

History of Codes

In another inpatient case study, there were a total of 32 codes for diagnoses, of which 9 were for “history of “ codes. There is no doubt that “history of” codes such as history of cancer or coronary artery bypass surgery could impact the care of a patient and would provide value when profiling the patient’s illness. However, assigning V43.64 (hip joint replacement) on a patient who is admitted for failed hip prosthesis doesn’t make sense. Is there a reason to assign numerous “history of” codes documented for an 89-year-old patient who has sepsis? Is it necessary to assign four “family history” codes, abstracted from the prenatal record of a healthy 24-year-old patient? Answers to these questions will help to eliminate excessive coding.

Procedure Codes

When reviewing the policies for coded data, don’t forget about procedure codes. Are you assigning 99.04 for blood transfusions? If so, there needs to be readily accessible documentation that describes the approach (e.g. percutaneous or open) and route of administration (e.g. peripheral vein, central vein). ICD-10-PCS requires this additional documentation before assigning the code. Currently, some facilities do not assign 99.04, but collect the data from other internal data sources. Use of unspecified codes should be analyzed for proper use. Is there any reason to assign 99.99 (other miscellaneous procedures) on an inpatient stay?

Leading to a Smoother Transition to ICD-10-CM

Eliminating the coding clutter will refocus your attention on the importance of coding. Consistent policies for data collection of secondary diagnoses will help pave the way for a smoother transition to ICD-10. So, if you haven’t already added the opportunity for a policy and documentation review, it’s not too late to add this to your New Year’s resolution! Taking the time to be well prepared for the onset of ICD-10 sounds like a smart resolution to me.

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Complete Overhaul of Coronary Angioplasties in CPT 2013

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

The percutaneous transluminal coronary angioplasty (PTCA) codes underwent a complete overhaul in CPT 2103, even changing the terminology to Percutaneous Coronary Intervention (PCI). These codes have been rearranged to describe the complexity of the intervention(s) and they now resemble the endovascular revascularization codes for the lower extremities that were implemented in 2011.

These new codes are designed to have higher intensity services be inclusive of all services of a lower intensity performed at the same site. The highest intensity of PCI service is to place a stent into a vessel. The next lower intensity of service is to perform an atherectomy of the vessel and the lowest intensity of service is to perform a balloon angioplasty of the vessel.

This new series also includes codes for three specialized types of interventions. The first specialized type of intervention involves interventions done through a graft, establishing the intensity as equal to that of the placement of a stent. The second specialized type of intervention is the treatment of a chronic total occlusion of a vessel, establishing that as the highest intensity of service, along with the combination of atherectomy with stent placement. The third specialized type of intervention is the treatment of an acute total or subtotal occlusion of a vessel during a myocardial infarction, also establishing that as the highest intensity of service.

In addition, each intervention code includes:

  • Accessing and selectively catheterizing the vessel,
  • Transversing the lesion,
  • Radiological supervision and interpretation directly related to the intervention(s),
  • Closure of arteriotomy when performed through the access sheath, and
  • Imaging performed to document completion of the intervention.

Code assignment in this section is designed to use base codes and add-on codes. A base code is assigned for an intervention in a major coronary artery with add-on codes for interventions in up to two additional branches of a major coronary artery. Major coronary arteries and their recognized branches are defined in CPT 2013 as:

  • Left main (LCA or LMCA) – no branches
  • Left anterior descending (LAD) – two diagonal branches
  • Left circumflex (LC or LCX) – Two obtuse marginal branches
  • Right (RCA) – Posterior descending branch and the posterolateral branch
  • Ramus Intermedius (alternate anatomy not found in all patients) – no branches

A base code is assigned to each intervention in a major coronary artery or one of its recognized branches. Add-on codes are assigned to an intervention in a recognized branch of the same major coronary artery that is performed at the same session. Additional interventions in other major coronary arteries, or one of the recognized branches, are coded with base codes.

Examples might help. Example 1: The left anterior descending and the left circumflex are both treated with stents. They are both major coronary arteries and therefore, base codes are assigned to both procedures and the codes are 92928 and 92928. The same base code is used twice because two major coronary arteries are treated using the same method.

Example 2: The same two vessels are treated as in Example1. An additional intervention is required in the obtuse marginal, a recognized branch of the left circumflex coronary artery. This is treated with balloon angioplasty. Both base codes of 92928 and 92928 are assigned, as well as 92921, an add-on code for the intervention in a recognized branch of a treated major coronary, performed at the same session.

Example 3: The left anterior descending is treated with a stent and the obtuse marginal of the left circumflex is treated with balloon angioplasty. The base code of 92928 is assigned for the stent in a major coronary artery. An additional base code of 92920 is assigned for the treatment of a lesion in a major coronary artery or its recognized branch. A base code is assigned to this treatment of the obtuse marginal because no treatment was performed in the left circumflex during this session.

Knowledge of the hierarchy of interventions, the anatomy of the major coronary arteries and the anatomy of the recognized branches of those major coronary arteries are all vitally important to correct code assignment for percutaneous coronary interventions.

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Changes to CPT Coding for Transcatheter Thrombolysis

   By Beth Bontemps, MSN, RN, CCS

Thrombolysis, also known as thrombolytic therapy, is a treatment to dissolve clots (thrombi) in blood vessels, thereby preventing damage to tissue. Thrombolysis may involve the delivery of drugs via a peripheral intravenous line or via a catheter that delivers drugs directly to the site of the thrombus (this is referred to as “transcatheter therapy”). There have been significant changes to transcatheter thrombolysis codes for 2013.

CPT Code 37201, Transcatheter therapy, infusion for thrombolysis other than coronary, has been deleted for 2013. CPT codes 37211 through 37214 were implemented effective January 1, 2013. The new codes differentiate between arterial and venous thrombolysis. They also allow the provider to capture the initial treatment day vs. subsequent treatment days of thrombolysis.

CPT Description
37211 Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including RS&I, initial treatment day
37212 Transcatheter therapy, venous infusion for thrombolysis, any method, including RS&I, initial treatment day
37213 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including RS&I, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed;
37214 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including RS&I, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up

The appropriate choice of a thrombolysis code is based on the day of therapy (i.e., initial vs. subsequent day):

  • Code 37211 or 37212 are used to report the initial day of transcatheter thrombolytic infusion, including follow-up arteriography/venography and catheter position change or exchange, when performed.
  • Code 37213 is used to report continued transcatheter thrombolytic infusions on subsequent days, other than the initial day and final day of treatment.
  • 37214 is used to report the final day of transcatheter thrombolytic infusion. This code also captures the removal of the catheter used to deliver the thrombolytic agent.
  • When initiation and completion occur on the same day, report only CPT 37211 or 37212. The removal of the catheter is not separately reported.

Procedures that may be reported in addition to thrombolysis codes include the following. Refer to the CPT coding manual for specific coding guidance.

  • Codes for catheter placement (selective and non-selective)
  • Ultrasound guidance (76937) for vascular access, when performed.
  • Peripheral interventions such as stent or angioplasty done during thombolysis infusion, when performed. If thrombolysis is done at the same time as other endovascular interventions, catheter placement codes are not separately reportable.

The following codes for intravenous thrombolysis have been retained for 2013:

CPT Description
37195 Thrombolysis, cerebral, by intravenous infusion
92977 Thrombolysis, coronary; by intravenous infusion

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AMA Coding Guidance

CPT® Assistant Bulletin 2, 2012   

 By Jennifer Ridell, CPC

Preventive Services and Use of Modifier 33

  

This article provides background for preventive services as impacted by the Affordable Care Act, and includes discussion of cost-sharing rules. Modifier 33, Preventive Services, was created to identify services as preventive and allow payer processing systems to waive the deductible associated with the co-payment and co-insurance cost and has been in effect since January 1, 2011. An example of when modifier 33 is helpful is when it is appended to the code for a diagnostic or surgical procedure performed for preventive purposes. When a test becomes a diagnostic or surgical service on the date of a screening service, modifier 33 may be used to indicate that the patient encounter was initiated as a preventive service, but it was converted to a therapeutic service that is not considered to be a covered preventive service. The most common example of this is screening colonoscopy (code 45378), which was initiated as a preventive service, but resulted in a polypectomy (code 45383) instead.

For some services, Medicare has created parallel Healthcare Common Procedure Coding System (HCPCS) Level II modifiers that may be appended to services that need to be identified as having resulted from preventive services. Modifier 33 is used when the primary purpose of the service is the delivery of an evidence-based preventive medicine service in accordance with a U.S. Preventive Services Task Force (USPSTF) "A" or "B" rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory). For separately reported services that are specifically identified as preventive, modifier 33 should not be used. A complete list of the USPSTF–rated service categories and grades is listed in Table 1 of this article. The article concludes with some clinical examples of preventive services, using codes 99381, 99383, 99387, and 99395.

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December 2012 CPT® Assistant   

 By Jennifer Ridell, CPC

Thyroidectomy and Parathyroidectomy


This article discusses the diseases, procedures and reporting of codes for Thyroidectomy (60210-60271) and Parathyroidectomy (60500-60505), including a review of lymph node regions, which is excerpted from the August 2010 issue of CPT® Assistant. Also included is a list of definition of terms. Codes 60240-60271 are generally reported for excision of thyroid tissue because of more complex, benign conditions (e.g., very large goiter) or malignancy. These conditions may also require neck dissection, a surgical procedure for the evaluation and control of neck lymph node metastasis.

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Island Pedicle Flaps


Confusion in determining when to code an island pedicle flap has led to the inappropriate reporting of code 15740 for flaps other than island pedicle flaps. To correct this ambiguity, code 15740 and the guidelines for its use have been revised for 2013. This article provides clarification on the appropriate reporting of an island pedicle flap, and includes a definition of terms list and a set of frequently asked questions related to the reporting of various types of flap procedures that do not represent an island pedicle flap.

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Abdominal Paracentesis (49082, 49083)/Peritoneal Lavage (49084)


To more accurately reflect the work required to properly perform an abdominal paracentesis, codes 49080 and 49081 were deleted, and codes 49082 and 49083 were established in 2012 to describe this procedure performed without or with imaging guidance. If the physician or other qualified health care professional performs abdominal paracentesis without imaging guidance, code 49082 is reported. If abdominal paracentesis is performed with imaging guidance (regardless of the method used), code 49083 is reported. For circumstances when paracentesis is requested and the ultrasound localization images demonstrate no fluid, it is appropriate to code for the localization images—and only the localization images—that resulted in the decision to discontinue the requested procedure. When the ultrasound is used only for fluid localization, there is no reason to image all elements required for a full and complete abdominal study and, thus, the limited imaging service is reported.

CPT® code 49084 is reported for diagnostic or therapeutic peritoneal lavage. A diagnostic peritoneal lavage is usually performed to confirm or reject suspected intra-abdominal bleeding (e.g., in the setting of trauma). A therapeutic peritoneal lavage may be performed as a definitive treatment for inflammation or infection. In this procedure, a needle or catheter is inserted in the abdominal cavity, fluid is infused (eg, warm saline, antibiotic solution), which is then removed and submitted for analysis.

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THEN and NOW: Temporalis Fascial Graft


The March 2007 and August 2008 editions of the CPT® Assistant discussed the reporting of code 69631, Tympano-plasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction, with harvesting of a temporalis fascial graft through the same or separate incision. The March 2007 CPT® Assistant indicated that code 69631 includes the work of harvesting the graft material. Therefore, code 69631 should be reported regardless of whether the graft was harvested through the same incision or a separate incision, and that it would not be appropriate to report a separate code for the fascial graft.

The August 2008 CPT® Assistant discussed the repair of a tympanic membrane perforation, wherein a graft is harvested from either the temporalis fascia or other locations (i.e., vein, periosteum, or conchal cartilage perichondrium). Occasionally, a graft is used from material other than autogenous tissue. If the temporalis fascia graft is harvested through a separate donor incision, the harvesting should be reported separately from the tympanoplasty. The August 2008 coding guidance supersedes the March 2007 CPT® Assistant instruction, as it agrees with the general CPT® convention that graft harvest is reported separately under these conditions: (1) when obtained through a different incision; and (2) when the descriptor language does not specify graft harvest as integral to a service.

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CPT® Assistant Bonus Feature: Special Edition Q&As


An article by the CPT® Editorial Panel answers questions posed to the panel regarding the subjects of Anesthesia; Surgery: Musculoskeletal System/Nervous System/Eye and Ocular Adnexa; and Medicine: Active Wound Care Management. The responses answer multiple questions, including: Is the application of a bone-filler product in a nonspine orthopaedic procedure, such as an open tibia fracture repair, considered inherent in the open fracture treatment; What is the correct way to code for the repair of an intervertebral disc, such as with sutures or mesh, immediately following a discectomy, and is this repair considered to be included in the discectomy procedure; and May CPT® codes 66170 and 66172 trabeculectomy ab externo be reported in addition to 0191T and 0192T for insertion of anterior segment aqueous drainage device without extraocular reservoir?

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 “December 2012.”

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NOTE: To follow any 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 any 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 Health Care Compliance Advisor is published monthly by CCH, a Wolters Kluwer business.

©2013 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

Maria Bounos, RN, MPM, CPC-H, joined Wolters Kluwer in the fall of 2007 and is currently the Business Development Manager for Regulatory and Reimbursement software solutions. She began her career at WK as Product Manager responsible for product development, maintenance, enhancements and business development and now solely focuses on business development. She has more than twenty years of experience in healthcare including nursing, coding, health care consulting, and software solutions.

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 2013 CCH & MediRegs Coding Compliance Advisory Board.

Beth Bontemps, RN, MSN, NP, CCS, is a Clinical and Reimbursement Consultant at JR Associates, Inc. JR Associates is a medical reimbursement consultancy that provides comprehensive coding, coverage and payment solutions and strategies for device manufacturers, venture capital firms and healthcare practitioners, worldwide. Beth is a board member of the 2013 CCH & MediRegs Coding Compliance 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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