Overview: Coding and Billing in an OB Hospitalist Practice

February 19, 2017, 11:30 pm

≪ Previous: Connecting the dots: Diagnosis, Procedures, Documentation

Coding and Billing in an OB Hospitalist Practice

In an OB Hospitalist practice, currently there are many different medical and billing scenarios each and every day that bring challenges. Coding and billing for these scenario’s, and how they are documented, submitted to 3^rd party payers, and the reimbursement back to the practice is integral to keeping an OB hospitalist practice solvent and thriving.

At this time in the OB hospitalist specialty there are many different practice and billing models to choose from, and determining which one is right for your business can be confusing. In addition, OB hospitalists encounter patients who don’t have access to, or have not chosen to see a traditional OB or health care provider to oversee their care. Many patients also rely on the OB hospitalists to respond to their emergencies and care for them around the clock.

In many instances, we are now the go-to for traditional OB/GYN providers to augment and provide specialty hospital based services for high risk and trauma ob and GYN patients. The OB hospitalist program concept is fairly new to the American hospital system, and coding and billing for this subspecialty poses a bigger challenge for the providers, as well as the hospital and coding/billing staff. OB hospitalists are bearing the weight of maintaining above standard specialty patient care, in addition to being fiscally solvent.

The OB-GYN hospitalist program has a positive impact on at-risk OB patients’ health care because these programs enable the patients to have emergent care for any type of OB or GYN emergency when their own physician is unavailable on a 24/7/365 basis.

Of course, we provide many other functions such as, supporting local obstetricians as back-up for deliveries and emergency C-sections; providing ancillary testing services for walk-in or emergent trauma situations, and also step in as an assistant surgeon for many operative procedures at a moment’s notice. (that may or may not be OB related)

The fiscal mainstay for the OB Hospitalist practice is evaluation and management (E/M) services, which include all areas of inpatient hospital, outpatient hospital, emergency department, critical care, complex care management, and office-quick/urgent care coding. In addition to the evaluation and management codes, procedure based CPT codes provide an enormous source of revenue, which can include surgery, interventional, diagnostic and therapeutic medicine, radiology/ultrasound services. Not only does and OB hospitalist team provide these services, but are instrumental in also providing “down-stream” services that can impact a facility in a positive way, such as laboratory, radiology, NICU, pharmacy, nutritional services, social work services, and other areas within the facility that would not have had these financial opportunities had the OB hospitalist team not been in place.

Each OB hospitalist program functions under many different licenses within the hospital setting. Some practices are embedded with the Emergency Room, some are an integral part of the Labor & Delivery floor, while others operate as a “emergent outpatient” area of the hospital similar to a “quick-care, urgent-care” walk in clinic. The most common is the OB hospitalist physician team is a “stand alone” practice comprised of OB hospitalist (specialty) physicians that function as a separately identifiable group practice that bills as a physician based practice team utilizing and coding and billing with their own practice management software and/or coding/billing team.

Coding and billing in an OB hospitalist practice is a specialty concept within itself. The OB hospitalists practice specialty has to provide superior care not only for the pregnant patient, but for the fetus too. During routine coding and billing audits, many times the “hish risk” factor is overlooked or undervalued during the “scoring” when determining the evaluation, plan of care, clinical documentation, risk factors, proposed procedures and ancillary services options when coding and billing is performed.

The nuts and bolts of traditional CPT evaluation/management and procedure codes are utilized in addition to the current ICD-10cm diagnosis codeset. Clinical documentation by the OB hospitalist is integral to success when the coder/biller has to combine all these pieces together for the evaluation and management code, the procedures performed, diagnosis, ancillary circumstances (eg pt fell, etcc) are relevant to report for reimbursement for services provided.

The coding and billing for the OB hospitalist team should be one of your primary areas of concern as this will be the key to a successful practice. Education in coding, billing and clinical documentation for the entire OB hospitalist practice should be one of the important areas to review and consider, as you implement a new practice, or work to renew or revitalize a practice that is struggling with a financial issue.

Commonly coded/billed CPT Procedures

ObHospitalist Procedures:

· 59050/51 Fetal monitoring (IUPC)

· 59150/51 Laparoscopic treatment of ectopic pregnancy

· 59120/21 Surgical treatment of ectopic pregnancy

· 58605 Ligation or transection of fallopian tube(s), during same hospitalization

· 58611 Tubal Ligation (Add on w/c-section)

· 59025-26 Fetal NST interpretation

· 59160 Curettage - Post Partum

· 59200 Insertion of cervical dilator

· 59300 Episiotomy or vaginal repair, by other than attending physician

· 59320 Cerclage of cervix

· 59409 Vag Deli Only

· 59412 External cephalic version, with or without tocolysis

· 59414 Placenta only delivery

· 59514-80 Assist to a surgeon for cesarean delivery

· 59514 Cesarean delivery only;

· 59525 Hysterectomy (post cesarean delivery)

· 59612 V-back delivery

· 59618 Cesarean post failed attempted vback delivery

· 59899 CPT “unlisted” services such as Bakri Balloon hemorrhage care

· 76815 Bedside quick-peek Ultrasound

· 76818/19 Fetal Bio-physical profile(s)

· 76998 Intraoperative ultrasound

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

↧

Article 0

February 20, 2017, 12:00 am

≫ Next: Webinar on 04.11.2017 Free CEU's

≪ Previous: Overview: Coding and Billing in an OB Hospitalist Practice

New Code 2017: 58674- Laparoscopic ablation of Uterine Fibroid Tumors

February 4, 2017

CPT has granted coders a new code for the laparoscopic ablation of uterine fibroid tumors. As of January 1, 2017 the code is officially denoted as 58674 Laparoscopy, surgical, ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency. The addition of this new code by CPT marks another successful transition of a code from the Category III code 0336T Laparoscopy, surgical, ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency. Category III codes are the temporary codes set forth by CPT for emerging technology, services and procedures. The usage of this code as a Category III code, allowed for the collection of specific data and its usage of code O336T code for ablation of fibroid tumors has allowed for CPT to create a permanent CPT code for this new technology.

The usage and transition of a Category III code to a permanent CPT code is a very good thing. This allows for a solid RVU value allocation to the code, and insurance payers will also put this into their payment code base for standardized payment. However, some insurance payers may still consider this to be an “experimental” code, so it is advisable to call the carrier prior to the procedure being performed to inquire about payment of this procedure with the new CPT code.

The new CPT code 58674 is primarily targeted for usage with the procedure known as Laparoscopic Radiofrequency Volumetric Thermal Ablation (RFVTA). RFVTA is used to destroy uterine fibroids, yet preserve the uterus. This is revolutionary for some women who still may want to pursue pregnancy, or simply to avoid major surgery such as hysterectomy, to definitively remove fibroid tumors from the uterus.

Clinical indications and documentation

Uterine fibroids are benign, muscular tumors in a woman's uterus that can cause heavy bleeding, painful periods, pressure, and abdominal pressure, pain and distention. According to the National Institute of Health (NIH) at least 70% of women in the US will develop fibroid tumors. Fibroids are a significant women’s health issue, and symptoms can be very mild, to very extreme. The American Congress of Obstetricians and Gynecologists (ACOG) has stated that 39% of all hysterectomies are due to fibroid tumors and the issues related to those tumors. Hysterectomy has been one of the more “traditional” methods for relief of fibroid uterine tumors. The usage of a less invasive procedure that is performed laparoscopically is becoming more popular with surgeons and patients alike.

In women who have symptoms, the most common symptoms of uterine fibroids include:

· Heavy menstrual bleeding.

· Menstrual periods lasting more than a week.

· Pelvic pressure or pain.

· Frequent urination.

· Difficulty emptying the bladder.

· Constipation.

· Backache or leg pains

The ablation of these fibroid tumors via a laparoscopically delivered system of direct ablation to the uterine fibroid allows the patient to alleviate the tumor, and preserve the uterus, thereby avoiding the effects of a hysterectomy or major surgery for elimination of these tumors.

Clinically, this procedure is considered “minimally invasive” and is performed as an outpatient procedure, and the patient can return to a normal lifestyle within 2-3 days post procedure.

The procedure allows the surgeon to ablate targeted fibroids within the uterine cavity. The surgeon the utilizes the laparoscopic tools to specifically targe and deliver thermal radiofrequency energy to the specific fibroid tumor with precise tip inserted into the fibroid itself. With this needle/tip the surgeon can then control the amount of thermal energy need to destroy the fibroid tumor. Ultrasound guidance allows the surgeon to visualize each tumor and the precise location of where the needle/tip of the tools are to be placed for successful ablation of the tumors.

RVU’s and Payment Considerations

With any new CPT code, pricing and payment is something to be considered if the physician has decided to include this into their practice. Below is the table from CMS that outlines the National RVU’s allocated to code 58674. This information can be accessed through the CMS link

https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=0&HT=0&CT=0&H1=58674&M=1.

As you can see from the above table this represents the National Payment indicators from CMS, and therefore may not represent what is the actual RVU values for your particular CMS locality. CMS does allow for payment of this procedure, however many private insurers may still consider this an “experimental” procedure and now allow for payment of this procedure under their specific policies and contracts.

If the patient and physician have decided to pursue this method of surgical intervention, it is advisable to do a thorough pre-authorization with the patients’ insurance carrier to determine if they will pay for this new technology. If the patient’s carries does not pay for this procedure, then you should collect up-front and/or make payment arrangements with the patient. However, this does not preclude you, as the coder/biller from requesting a pre-authorization request for consideration of payment for this code based upon the patients’ medical necessity and the adoption of this procedure by CPT as a permanent code into the codeset, and CMS’s adoption of RVU’s. In addition, a coder/biller can still file a claim with the patients’ insurance post procedure and submitting the operative notes and a formal request for payment.

Case Example

History: L.W. is a 44-year-old woman (G2P2) with a 2-year history of menorrhagia and severe dysmenorrhea but no intermenstrual spotting or bleeding. We reviewed the failure of controlling her symptoms using hormonal methods, without success.

Examination: Palpation reveals that patient has an irregular, nontender uterus 8 weeks in size. Ultrasound reports for the Transvaginal ultrasonography shows two deep, prominent, intramural fibroids. The first is 2 cm by 3 cm in size in the left lateral uterus, adjacent to the endometrial stripe. The second fibroid is 3 cm by 4 cm in the fundal region. Sonohysterography reveals no intracavitary fibroids, although the left lateral myoma has distorted the endometrial cavity.

Medical Decision Making: The patient is seeking removal of her fibroids but would like to preserve her uterus, if at all possible. We have decided to pursue uterine-sparing fibroid treatment, performed laparoscopically instead of a hysterectomy. Patient has signed all appropriate consents and we will contact her insurance carrier for pre-authorization and confirmation.

Operative Session/report:

Utilizing the RFVTA technique we begin with a standard 5-mm laparoscopic infraumbilical port for the camera and video laparoscope. Placee a 12-mm port in the midline, suprapubically at the level of the uterus, and inserted the laparoscopic ultrasound probe. With the laparoscope in place I began the mapping of the uterus and outlined plan with the surgical team with the approach to destroy the fibroids.

I then inserted the handpiece containing the radiofrequency needle through the abdominal wall under laparoscopic visualization and placed the needle into the targeted fibroid using both laparoscopic and ultrasound guidance. I then accessed the first fibroid, in the left lateral uterus and deployed the needle array to the maximum diameter necessary to begin the destruction. I then engaged the radiofrequency generator and set it for optimal destruction of the 2 x 3 cm fibroid, The fibroid was then ablated and destroyed without damage to the surrounding healthy myometrium. I then performed this same procedure upon the second fibroid in the fundal region. This fibroid measured 3 x 4 cm with optimal destruction. Treatment is complete, and confirmed I retracted the needle array. I then coagulated the needle track during withdrawal of the probe, and confirmed hemostasis of all surgical areas within the uterine cavity. All sponge and instruments counts were correct and accounted for. The patient was then taken to recovery area in good condition. Patient to be discharged the same day. I will see the patient back in-office on day 3 for a postoperative check.

Wrapping it up

As a coder, remember to code what you know, and do not assume. If in doubt, or the documentation does not appear to be clear or is confusing, query the provider. Good patient care requires the provider to accurately reflect the patient care via their documentation in the medical record. Our job, as a coder, is to correlate the coding and billing to reflect the medical that was documented and provided by the physician. If you are unsure about the coding guidelines utilize your resources such as CPT, ICD-10cm, ICD-10pcs and HCPCS.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CDIP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

↧

Webinar on 04.11.2017 Free CEU's

March 16, 2017, 11:03 am

≫ Next: I have a webinar for HCPRO coming up!

≪ Previous: Article 0

Good Morning!!! Below is info for a Webinar from our friends at Navicure...

Live Webinar: Patient Payments Check-Up™: Survey of Patient & Provider Attitudes & Behaviors
Tuesday, April 11 | 1 pm EDT / 10 am PDT

Good for 1.0 CEU (and it's free)

Click link below to get registered. -

https://www.navicure.com/events.html

↧

I have a webinar for HCPRO coming up!

March 31, 2017, 10:44 pm

≫ Next: The Medical Necessity Hot Button

≪ Previous: Webinar on 04.11.2017 Free CEU's

Are you struggling with Medical Necessity - I have a webinar coming up on Coding and Medical Necessity... HCPRO!!! https://hcmarketplace.com/coding-reporting-medical-necessity

I have a LOT of great info that I'll be presenting. I would love to have you join me! :)

↧

The Medical Necessity Hot Button

April 27, 2017, 4:30 pm

≫ Next: A new Webinar for me - July 2017

≪ Previous: I have a webinar for HCPRO coming up!

Clearing up the confusion surrounding Medical Necessity!

by Lori-Lynne A. Webb, CPC, CCS-P, CCP, COBGC, CHDA (originally printed through HCPro March 2017)

Understanding and determining medical necessity can be very complex for physicians, clinicians, coders, and billers.A physician or clinical provider of care may have a completely different understanding, interpretation, and definition of medical necessity than the patient or a patient’s family member. A third-party insurance payer may also have another completely different understanding and application of the term.

Defining medical necessity

So what is medical necessity? Coders or billers struggle to understand and sort out as the term, which leads to misinterpretation and misunderstanding of what needs to be communicated in a variety of areas.

CMS provides a specific definition under the Social Security Act:

… no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

In essence, the diagnosis drives medical necessity. Coders need to understand the diagnosis itself, as well as what services or treatment options are available to the provider.

Third-party payers add more confusion

Medical necessity can also be confusing when it comes to who is going to pay for the procedure or services. Many third-party payers have specific coverage rules regarding what they consider medically necessary or have riders and exclusions for specific procedures. Third-party payers may have a specific exclusion for procedures that they consider experimental, unproven for a specific diagnosis, or cosmetic.

One example is a surgeon using a daVinci robotic surgical device to perform a laparoscopic surgery. Upon pre-authorization for the surgery, the insurance payer states it will not pay for the surgery if the daVinci is used. The insurer’s policy includes a rider that deems the daVinci as an experimental surgical device. However, if the physician uses a traditional laparoscopic or open procedure, the third-party payer would reimburse. In this case, the insurance carrier is not stating that the surgery is not medically necessary, just that it will not reimburse for this surgery if the robotic device is used.

Even if a particular procedure or service is considered medically necessary, some payers impose limits on how many times a provider may render a specific service within a specified time frame. For Medicare and Medicaid, these limitations are known as National Coverage Determinations (NCD) and Local Coverage Determination (LCD). Private payers may simply refer to this type of limitation as a policy guideline or policy exclusion or rider.

Within these guidelines, payers may define where or when they will cover a specific service, but may limit coverage to a specific diagnosis. For example, insurance policies may have a wellness or preventive care benefit, but may only cover one such visit per year. Some payers may only reimburse for a single Prostate-Specific Antigen (PSA) test per year. The payer may require a documented screening diagnosis in coordination with the test.

If the patient underwent a PSA test January 1, 2012, for screening, his insurance may not pay for another test until 365 days (or one calendar year) have elapsed. However, if the patient undergoes a PSA blood test for screening and the test results are abnormal, the clinician may decide another PSA test is needed. The coder must submit that claim as a PSA blood test with the appropriate diagnosis for a sign, symptom, or abnormality, not as a screening.

Documenting medical necessity

Medical necessity continues to be open for interpretation by all parties involved. Many third-party payers have created lists of criteria they use to interpret medical necessity. These lists do not necessarily reflect all options, but payers include this reference in their policy guidelines.

Most providers have not developed a comprehensive listing of medically necessary qualifiers, so coders and clinicians must focus on good documentation and coding accuracy to communicate the medical necessity of services accurately to payers. If third-party payers deny reimbursement for medical services, physicians, clinicians, and coders need to rely on the formal appeal process.

Medical necessity documentation from a physician or provider should include the following:

§ Severity of the “signs and symptoms” or direct diagnosis exhibited by the patient. This is our diagnosis driver, and multiple diagnoses may be involved.

§ Probability of an adverse or a positive outcome for the patient, and how that risk equates to the diagnosis currently being evaluated. This is the medical risk vs. gain.

§ Need and/or availability of diagnostic studies and/or therapeutic intervention(s) to evaluate and investigate the patient’s presenting problem or current acute or chronic medical condition. In other words, does the facility, office, or hospital have what the provider or clinician needs to render care?

These bullet points reflect the basics of evaluation and management (E/M) guidelines that are currently in place from CPT^®: the history, exam, and medical decision making processes. Coders will have an easier time evaluating medical necessity from this aspect. Of course, a good understanding of this integration of medical necessity within the E/M guidelines makes communicating this same principle to the providers much easier. Coders should encourage providers to continually enhance their documentation to improve overall coordination between the medical record, coding accuracy, and third-party payer reimbursement.

The third-party payers employ a wide spectrum of policies defining medical necessity is and should encompass. Physicians, clinical providers, and coders should review what these payers have established within their guidelines. Someone within the physician office, hospital, or medical facility should thoroughly scrutinize these guidelines before establishing a contractual relationship with a particular third party payer. This up-front communication will help avoid claim denials in the future.

Here are some examples of what some third party payers are currently including in their medically necessary verbiage:

§ Treatment is consistent with the symptoms or diagnosis of the illness, injury, or symptoms under review by the provider of care.

§ Treatment is necessary and consistent with generally accepted professional medical standards (i.e., not experimental or investigational).

§ Treatment is not furnished primarily for the convenience of the patient, the attending physician, or another physician or supplier.

§ Treatment is furnished at the most appropriate level that can be provided safely and effectively to the patient, and is neither more or less than what the patient is requiring at that specific point in time.

§ The disbursement of medical care and/or treatment must not be related to the patient’s or the third party payer’s monetary status or benefit.

Documentation of all medical care should accurately reflect the need for and outcome of the treatment.
Treatment or medical services deemed to be medically necessary by the provider of those services,(e.g., physician, therapist, clinician, etc.) does not imply or infer that the service(s) provided will be covered by or deemed a medically necessary service payable by a third-party insurance payer.

Medical Necessity Q&A

Q: Could you give me some guidance on how I can instruct my MD's on avoiding vague and/or subjective clinical documentation?

A:. Ask your providers to adequately describe his/her skilled care providedand give a clear picture of the treatment and/or “next steps” to be taken.

Do not use vague or subjective descriptions like "tolerated treatment well,""improving,""caregiver instructed on med management," or "continue with plan of care." "patient is here for follow up"

examples of more complete and compliant statements:

1. Patient tolerated ROM exercises with a pain level of 6/10.

2. Patient was able to verbalize understanding and importance of checking their blood sugars prior to administering insulin.

3. Plan for next visit: to continue education on importance of daily inspection of feet for diabetic patient, provide wound care, etc.

Q I work in dermatology and need to know what documentation is required for excisions? We are struggling with getting paid

A: The provider should include the actual "size" of the lesion/mass they are going to excise. Then they should document the area of the excision which needs to include the lesion + any margins. (Height, Width, Depth) and if circular/elliptical etc… and denote the "why" it was performed that way. If you have to appeal, the problem with using strictly the sizes from a pathology report, is that tissue "shrinks" once it is excised, and the would "enlarges" once the tissue is excised.

Q. What is the BEST way to document our time spent… the CPT codes state a vague "time" amount but the doctors struggle with this..

A. Notation of Time in/Time out is always very helpful… it is also helpful if the provider "explains" the time. Eg - spent 20 minutes of our 30 minute visit discussing how to properly use their new asthma inhaler. Or I was requested by Dr. Doe for "standby" for a possible cesarean section during vaginal delivery. I entered the delivery room at 0800 and departed at 0915 status post a successful vaginal delivery.

Coders must understand the complex relationships between the physician, the patient, the medical record documentation, the coder, the biller, the insurance payer, and the communication between all of these entities to successfully guide the interpretation of medical necessity.

↧

A new Webinar for me - July 2017

June 15, 2017, 10:30 pm

≫ Next: Are you needing an Ed'Venture???

≪ Previous: The Medical Necessity Hot Button

I will be doing another AudioEducator Webinar in July. I will be doing a webinar regarding Ultrasound Services in the physician office. We'll be discussing both Obstetric Ultrasound and Gyncologic Ultrasound. If you'd like to join me - Here's a $20.00 off "coupon code" ... and as always... I'll be Packing in a LOT of info in a short amount of time!!! You always get your $'s worth of info!

Become Competent in Billing Ultrasound Services in OB/Gyn Physician Offices
Get $20 Off On Registering NOW!
(Use Codé "Webb20" at Checkóut )

↧

Are you needing an Ed'Venture???

July 14, 2017, 9:47 am

≫ Next: Medical Necessity Toolkit! Available NOW!!!+

≪ Previous: A new Webinar for me - July 2017

Hey - did you know??? Idaho State University is a CAHIIM accredited school in the State of Idaho?? AND you can get your education 100% on-line???

See the info below and get your ED'Venture started.... You get the opportunity to be taught by some of the most amazing faculty - These folks are GREAT!!!

******************************************************************************************************************

Greetings Fellow HIM Professionals:

The Idaho State University, College of Technology, Health Information Technology (HIT) program is pleased to announce that we are expanding our program to continue to meet your businesses needs and the entire health care industry’s needs.

Our statistics show that the demand for Health Information Technicians and Medical Coders is vastly increasing each year. To compensate for this high demand, we have recently expanded our class sizes to train even more students for these health care positions. The HIT program offers both traditional seated and wholly online options, with the exception of the final hands on practicum, that prepares students to pass the Registered Health Information Technician exam once graduated.

Graduates that you hire will still have the same superior educational skills and training. The only difference in the HIT program is that it can now enroll and accept a larger number of students, and a Medical Coding Certificate option is available. Our program has proudly prepared highly qualified health information technicians and/or medical coders who have been hired by companies all over the world. We know this expansion will be a benefit to multiple health care trades including your own.

We encourage you to take advantage of this exciting opportunity and reach out to colleagues, associates, family members, and friends who may be interested in pursuing a rewarding, profitable career in health information technology and/or medical coding. The program is particularly well suited to individuals who are already working in HIM and wish to pursue their RHIT credential.

The program can also work with individuals who wish to retrain into the HIM field. Full and part-time student status is available. We are always available to meet with future students and help them start their successful careers!

The HIT program is now enrolling for the Fall 2017 semester, beginning in August!

For more information on the Health Information Technology program, please contact any of the following faculty:

Glenna Young, RHIA, CCS at younglen@isu.edu or 208-282-4524
Wade Lowry, RHIT at lowrwade@isu.edu or 208-282-3738
Rhonda Ward, RHIT at wardrhon@isu.edu or 208-282-2388

We are also pleased to announce the addition of full-time faculty in the Boise area, housed at the ISU Meridian Center! The faculty member can be reached at:

Mona Doan, RHIT, CCS-P at doanmona@isu.edu or 208-242-8119

↧

Medical Necessity Toolkit! Available NOW!!!+

July 14, 2017, 2:06 pm

≫ Next: Communication - The bridge between providers and coders

≪ Previous: Are you needing an Ed'Venture???

Guess what??? My Medical Necessity Toolkit that I developed for HC-Pro is available now... so please take advantage of some GREAT info at an extremely good price!!! .... Just click on the link above! ... and again. HAPPY CODING!

↧

Communication - The bridge between providers and coders

July 20, 2017, 7:40 am

≫ Next: IdHIMA Coding Roundtable - On-line Access

≪ Previous: Medical Necessity Toolkit! Available NOW!!!+

This originally published in March of 2014... yet still has some GREAT information for all to use

******************************************************************************

Communication - The bridge between providers and coders

March 11, 2014 (Revised and Updated 07 20 2017)

We have all heard the adage “if it wasn’t documented, it wasn’t done”. However, in the role of the medical provider, the fast pace of the job can get in the way of the accuracy of documentation. Unfortunately, in our current healthcare state, our practices have to be fiscally solvent. This is accomplished by accurate coding/billing, AND providing good patient care. Clinical Documentation is a fundamental piece of our total job function coupled with the challenge of providing good communication to our coders for accurate coding a billing.

The importance of good clinical documentation cannot be underestimated. Medical documentation is essential to ensure high quality medical care for your patient throughout the continuum of care. Good clinical documentation both to and from all medical providers (physicians, nurses, PT/OT, etc) benefit not only the patient, but also your revenue stream. If your coder/biller is able to quickly decipher and bill the claim it means the reimbursement will be back to your practice that much faster. Good documentation supports medical necessity for payment and clarification of services provided to your patients, especially if they have an emergent visit, or unexpected clinical finding upon testing.

Documentation will always be a “necessary evil” in the role of healthcare and reimbursement. The conversion to ICD-10 cm (Took place on 10.01.2015) will take place October 1, 2014, and providers will be tasked with providing better documentation with this new diagnostic/diagnosis system. Your willingness to improve your clinical documentation now, will only make it easier for you to adapt and continue to provide excellent patient care in the future.

Communication is the bridge between the provider of care, and the coder/biller. According to the Merriam-Webster dictionary a “wordsmith” is one who is an expert in the use of words; a person who works with words, or is an especially skillful writer. As a providers and coders, think about this….. both fall into this category of expertise! The primary function of a coder is to apply that which is written by the provider, into a numeric format; such as ICD-9cm (ICD-10cm). However, once ICD-10cm is implemented, coders will need an excellent understanding of not only medical terminology, but anatomy, physiology, disease process, the numeric codes, and a little bit of “wordsmithing” to correctly apply the written diagnoses per the documentation into the new alpha-numeric ICD-10cm format.

ICD-10 includes many new terms, and certain codes will now require documentation to be more precise and complete to give coders the best “picture” of the care received by the patient via a numeric format. Our challenge as good providers is to document and communicate this new criteria more effectively so we can all share the same understanding of the words needed to continue being fiscally solvent, but to also document the clinical course of care provided.

Unfortunately, most physician and clinical providers don’t have the "inside track" as to what criteria or “words” are needed to clearly document in ICD-9, much less for ICD-10. Both the coder and the providers are challenged even more by the specificity needed in ICD-10. A coder and the clinical documentation specialist are going to be looked up to as the expert. The ‘experts’ will now be looked to help educate and inform providers how to document more clearly and to get to the desired goal of clear, concise, correct documentation, which can be interpreted correctly, and most closely to ICD-10cm definitions. If we succeed in this endeavor, everyone benefits.

The coding query process can help. The query process is a very useful tool, but real 1-1, face to face communication, combined with good ICD-10cm training for the coder, clinical staff, physicians and mid-level providers will be a critical point for ICD-10cm and pcs coding success. Currently none of us are “good” or “expert” at ICD-10, so we all are struggling to become proficient at what we need.

As the transition to ICD-10 marches forward, the documentation and support for ‘medical necessity’ remains. The clinical documentation is always the first thing requested for a payment audit or review. Not only as providers are we having to make the leap to ICD-10, but the healthcare payers are also challenged to be proficient at this new documentation system also. We have substantial challenges for payment at this point in time. Concern is are the payers going to be ready also, and how will they respond, if there is a question regarding documentation, payment for your services.

Outlined below are a few quick clinical documentation tips and hints to help clarify your clinical record documentation.

A) The medical record should be complete and legible

Documentation for each encounter should include:

§Reason for the encounter and relevant history, physical exam findings and prior diagnostic test results;

§Assessment, clinical impression or diagnosis

§Plan of care

§Time spent (eg face to face/counseling-coordination of care)

o Documented time in

o Documented time out

o Documented total time spent (eg at bedside, on monitor(s), etc)

§Date and Signature

§The rationale for ordering diagnostic and other ancillary services

§Past and present diagnoses (If pertinent to the encounter)

§Appropriate health risk factors should be identified (if pertinent to the encounter)

§Patient’s progress, response to and changes in treatment and/or revision of diagnosis

B) Avoid Ambiguous Language

Eg.. “Non-contributory” : The term “non-contributory” is good example of ambiguous documentation. In some instances, a provider intends the term to mean the body system was not relevant, therefore was not reviewed... while another provider may intend that verbiage to mean that the body system was reviewed, but had no pertinent findings to be reported. Be clear, concise and relevant by avoiding using the term “non-contributory”.

Another term that can be misconstrued is “abnormal” be sure to clarify, qualify, or quantify what is “abnormal”.

C) Clarify your diagnosis

“For a presenting problem with an established diagnosis the documentation should reflect whether the problem is:

a) improved, well controlled, resolving or resolved;

b) inadequately controlled, worsening, or failing to respond/or change as expected

“For a presenting problem without an established diagnosis, the assessment or clinical impression can be stated a) as a “possible”, “probable”, or “rule out” (R/O) diagnosis,(such as rule out kidney stone)

c) and should also denote any signs and/or associated symptoms in your findings (such as pelvic pain, sinus pressure etc)

D) Ordering of Tests and Procedures

Clinical documentation guidelines state that the rationale for tests/procedures should be ‘easily inferred’, but suggest clearly documenting the reason(s) for any testing or procedures

§document ‘what’ test/procedure is being ordered. (i.e. Fetal NST, fetal fibronectin)

§document ‘why’ the test/procedure is being ordered (i.e. decreased fetal movement)

E) Omitted Information

In the event information is inadvertently forgotten, delayed, or omitted from the medical record, it is acceptable to amend the record. “Late entries” are also acceptable however, should be used infrequently.

Acceptable methods for recording “amendments”, “addendum” and “late entries” follow:

•Create a new entry for the additional information

•Do not annotate in the margins to add information

•Keep all entries chronological and in record sequence

•Title or head the entry or note as “Addendum”, “Amendment” or “Late Entry”

•Use the actual date of the addendum, amendment or late entry

•Reference the original entry or document by indicating the date of the service

•Always sign the additional entry or document

The need for good communication and documentation brings us back to the term “wordsmith”. Again, both the coder and the physician/provider will need to add this to their job proficiencies. Getting the conversation started is the first step. A quick way to begin is to conduct a mini review of the current physician/provider documentation. The coder can develop, or may have a feel, as to how best to ascertain the top 5 or top 10 commonly mis-coded or difficult to code diagnoses in the practice. If the coders’ are currently struggling with appending these “difficult” diagnoses now utilizing ICD-9, this challenge now is amplified by dual coding/cross coding with ICD-10cm codes which will be mandatory in October of 2014. Have the coder document and analyze what they've found. This quick analysis will help define where better communication and documentation is needed for both the coder and provider.

Here's a quick process to help enhance communication processes for both the coder and the physician/provider of care.

Ask the coder(s) and provider(s) for the top 5 mis-coded or difficult to code diagnoses
Pull the operative/procedure notes that were associated with these diagnoses
Cross-code the documentation with both ICD-9 and ICD-10 codes
Identify areas that need to be clarified for the coder with the physician or provider
Schedule a meeting (face to face) with the coder and the provider and include

The actual provider notes
The ICD-9 codes (using the code -book)
The ICD-10 codes (using the code-book)

Then, once this is all in place, you then have a terrific “learning opportunity” to share and commit to learning from each other how best to document or “wordsmith” so all get what they need.

Amazingly, the communication process is not only an informative session, but the opportunity to get to know and understand what each area needs for a successful transition and implementation to ICD-10.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

↧

IdHIMA Coding Roundtable - On-line Access

August 1, 2017, 12:58 pm

≫ Next: 2018 OB-GYN Coding Bootcamp!!! Join me!!! (and save some $'s)

≪ Previous: Communication - The bridge between providers and coders

For those of you that need a quick/easy and inexpensive way to get your CEU's (for AHIMA or AAPC) ... the IdHIMA Coding Roundtable is now live and easily accessible from our IdHIMA website! Check it out!

We have Great pricing for amazing education... and you don't have to be a member, we allow both members and non-members access!

https://www.idhima.org/physician-based-obgyn-edventure-online-education/

↧

2018 OB-GYN Coding Bootcamp!!! Join me!!! (and save some $'s)

October 18, 2017, 8:24 am

≫ Next: Article 4

≪ Previous: IdHIMA Coding Roundtable - On-line Access

2018 Coding Updates Virtual Bootcamp

Preparing Coders for a Successful 2018

Attend the Year’s Biggest Virtual Ob-Gyn Coding Event

Dec. 07 & Dec. 08, 2017

Presented by: Lori-Lynne A. Webb

You’ll start 2018 off right if you’ve got a clear understanding of the codè adjustments you’ll need to make for your ob-gyn claims. Having someone clear out the clutter and focus on what’s most important is like feng shui for the brain, and we have an expert to do this for you.

Lori-Lynne A. Webb will update you on the CPT^©, ICD-10, and Medìcare changes you need to know and will advise you on how to accurately report your E/M services in the coming year. Listen as she unravels the mysteries of the Ob global package and hear what auditors will be looking for in the coming year so you can prepare. Join us!

Get 6 AAPC-APPROVED CEUs

Sessions

2018 CPT, ICD-10 & HCPCS updates for Ob-Gyn
Coding in the Ob ‘global package’ and coding for the Gyn ‘surgical package’
Clinical and coding audits for 2018: What’s on the radar for the OIG, CMS and pay for performance
How-to for auditing: A hands-on review of clinical documentation, queries, audits, appeals and reimbursement

Training Highlights

In-depth strategies and the most up-to-date concepts for global and unbundled OB services billed in the physìcian office
What’s on the radar screens of the big players and government payers, and how it will affect Ob-Gyn physìcians in particular, as well as the hospitals, and public health services that they and their patients currently accèss, including outside labs, health departments and others
Strategies for parsing the OIG’s plans for Ob-Gyn services in 2018
A solid understanding of the federal programs and services that will be effecting change in the healthcare fìeld next year and beyond
In-depth strategies and timely concepts for how to conduct audits within your practice for clinical documentation
How to query and write appeals for denìed claims
How to deal effectively with reimbursement issues

Get the knowledge and skills to combat common problems and find answers to complex ob-gyn coding questions in these comprehensive training sessions. Prepare for a successful 2018!

CLICK HERE TO REGISTER

✆ Call now at 1-866-251-3060 and mention S99NVTEM

Get $50 Off On Registering NOW!
(Use Codé "Webb50" at Checkóut )

↧

Article 4

July 26, 2018, 9:30 pm

≫ Next: Article 3

≪ Previous: 2018 OB-GYN Coding Bootcamp!!! Join me!!! (and save some $'s)

Usage of Time Based Billing for CPT Evaluation and Management

Lori-Lynne A. Webb

07.21. 2018

Within the guidelines of the CPT code book, CPT has stated; “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record.”

What this means to our physicians and providers, is that time alone can be used to select a level of care, and bill for our services regardless of the clinical documentation of history, exam and medical decision making that is noted or documented in the in the medical record for the current encounter or visit.

The lack of complete documentation from busy providers is an area of concern that many coders see and take note of when performing coding audits in their role as a coder/clinical documentation specialist. Physicians are not consistently documenting the “nuts and bolts” of the core CPT criteria needed in regard to meet the CPT’s criteria especially when admitting their patients to the hospital.

The CPT codes 99221 – 99223 are set aside for inpatient admission, and the lowest level admission code, 99221(level 1 admit) requires a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making of straightforward or low complexity; the 99222 (level II admit) requires a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity, the 99223 (level III admit) requires a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Also within meeting these criteria, all three key components are to be met. The only difference between a 99222 and a 99223 code is the medical decision making of moderate complexity vs/ high complexity.

As a case in point, In order to bill a 99222 “level II” admission, CPT guidelines require a comprehensive exam to be noted in the clinical documentation of the medical record.

It is common to see the clinical documentation noted in the record denoting a comprehensive history, and moderate to high level medical decision making, but the “exam” portion can be very skimpy.

As per the 1995 exam guidelines to code/bill a 99222 or a 99223 admission, the clinical documentation must state that greater than 8 body systems or body areas were examined to meet the comprehensive exam requirement (on a multisystem exam).

As per the 1997 exam guidelines the clinical documentation must state that for the Comprehensive Examination (single specialty) – should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected.

Unfortunately, the reality is that these examinations are more than likely being performed by the providers, however, coders are finding that clinicians are doing a poor job of documenting that these exams were performed, even with the many EMR documentation tools at their disposal.

However, if these physicians and providers utilize the option of documentation of “Time” in the clinical notes, they still have to document the care given, but it can be noted that they spent “XX amount of time” at the bedside and/or on the unit in care of the patient and of that 50% of this time was spent in counseling, and coordination of care of “XXX diagnosis, testing, etc”

From a revenue and denial standpoint, it is frustrating to have an auditor or insurance carrier review the clinical chart and downcode the admission from a 99222/223 to a low level admission 99221 due to skimpy history, exam, or medical decision notations.

So the “pearl” of wisdom is to be cognizant of the clinical documentation habits, for the physician providers, which can include macro’s, shortcuts and additional EMR/EHR data based tools. As coders/billers/managers, we need to be diligent and educate providers on the usage of time based billing for admissions and other pertinent E&M services.

Not all CPT E&M services have a time based component that can be utilized to represent the care provided. Within the CPT codes outlined for usage in an Emergency Department, “Time” is NOT a descriptive component, and all three key components for each CPT code 99281 - 99285 must be denoted within the emergency department patient visit. The rationale that CPT gives us for this caveat is that emergency services that are typically provided can be hugely variable due to acuity and presenting diagnosis factors.

The usage of time should not be a totally foreign concept to most providers, as this has been in place in one form or another since1992. The usage of time as a billing/coding component for providers to use, can get overlooked, or forgotten when in the heat of the moment, or in the day to day busy patient load or high complexity patient demand on the provider.

Time based clinical documentation does need to be very specific, The face-to-face time spent in an outpatient or office type setting includes not only the time the provider spent counseling and coordination of the patients care but has to be rendered face to face with the patient. Any pre or post time spent ( when patient and provider are not face to face) cannot be included in the time component described in the CPT E&M codes.

If the provider is providing care for a patient that is on a hospital unit or floor, the intraservice time for these codes is noted or defined as “unit/floor time” which includes the time present on the patient’s hospital unit and at the patient’s bedside providing services for that patient. In this setting, this includes time to establish and review the patient’s chart, examine the patient, write clinical notes, documentations, orders and to communicate with other providers and the patient’s family. In this hospital setting the pre and post time including time spent off that patient’s floor are NOT to be included in the time component noted in the CPT code descriptors.

In the descriptors below it outlines the criteria for the 99221, 99222 and 99223 hospital admission codes and how the dime designations are presented. These times noted in the CPT descriptions are considered a “typical” amount of time spent, however, actual time may vary.

CPT® 99221 is defined by the AMA as:

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making of straightforward or low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit.

CPT® 99222 is defined by the AMA as:

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit.

CPT® 99222 is defined by the AMA as

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit.

Clinical documentation of time can be denoted as a cumulative amount, or as a time in/time out notation within the record. In a best practice, the provider would document both.

Appropriate time statement examples

· Time in was 1400, time out at 1506, I spent 40 minutes of the 66 minutes in the encounter counseling the patient on their diagnosis of “xxxxx” and the remainder of the time was spent obtaining the HPI and examination of the patient.

· I spent greater than 50% of my 30 minute visit with the patient discussing the options of surgery versus watchful waiting regarding their diagnosis of “xxxxxx”

Inappropriate Time Statement Examples:

· I had a lengthy discussion with the patient.

· I spent 20 minutes in supportive counseling.

· I spent 15 minutes talking about the treatment options.

· I spent 30 minutes with the patient

↧

Article 3

July 26, 2018, 10:00 pm

≫ Next: Understanding Coding of Hypertension in Pregnancy

≪ Previous: Article 4

Pelvic Congestion Syndrome: Pelvic Varices

5/13/2018

Pelvic congestion syndrome is denoted as chronic pelvic pain in women who have varicose veins in or near their ovaries within the pelvic cavity. Pelvic congestion syndrome is a common cause of chronic pelvic pain, but many times is overlooked as a cause for the pelvic pain. In women that have pelvic varicose veins and venous insufficiency pelvic pain is a complaint, however, may not have any symptoms at all. It remains a medical mystery as to why some women develop pain and other symptoms, yet others have no complaint at all. The majority of women diagnosed with pelvic congestion syndrome normally fall within the 20-45 year age demographic and have had multiple pregnancies.

Physician have noted that chronic and acute pelvic pain from these enlarged veins, primarily develops after pregnancy, and the pain level from this trends upward and seems to worsen with each subsequent pregnancy. Typically, this type of pelvic pain is a dull ache, however, it may be reported by the patient as an acute, sharp, stabbing, or throbbing type of pain. Some patients have stated that it seems to worsen at the end of the day, or after sitting/ standing for long periods of time. Pelvic pain from pelvic varices can also occur during or after sexual intercourse, and may be accompanied by low back pain, aches in the legs, and abnormal menstrual bleeding. In addition, some women may also have varicose veins in the vulva, vagina, perineal area, buttocks, thighs, and lower legs. And as if these symptoms weren’t enough, some women experience a clear or watery discharge from the vagina, fatigue, mood swings, headaches, abdominal bloating, painful ovaries and cervical pain with motion tenderness.

Diagnosing Pelvic Congestion Syndrome

In the clinical diagnosis and documentation of pelvic congestion syndrome, a diagnosis can be made using non-invasive ultrasound testing, or by a diagnostic pelvic laparoscopy. Ultrasound is the diagnostic tool most commonly used and many OB physicians perform both an abdominal and a transvaginal duplex ultrasound in the office as the first-line testing . These ultrasounds may be enough to enable the provider to see if there is a pelvic varicosity within the pelvic area, and if venous enlargement and/or venous reflux is causing the patients’ pelvic pain. Unfortunately ultrasound may not show pelvic varices, or pelvic veins well, especially when the patient is lying down, or is obese. Ultrasound does not produce good images in patients that are obese as the sound waves do not travel through adipose tissue as well as they do in non-obese patients.

If ultrasound does not diagnose or confirm the pelvic congestion syndrome, additional testing such as venography, CT, MRI, magnetic resonance venography may be necessary to confirm the pelvic varicosities diagnosis. If venography is performed, contrast dye tests may be utilized for better imaging and real time viewing. If non-invasive procedures do not give the provider a good confirmed diagnosis of pelvic congestion syndrome, then the option of a diagnostic surgical pelvic laparoscopy may be the next choice for diagnosis confirmation.

When Pelvic Congestion Syndrome occurs pelvic pain is one of the first symptoms, however, clinically, the same effect happen to the pelvic veins , similar to development of varicose veins that develop in other areas of the body, such as in the perineal, vulvar and groin area, and the upper and/or lower extremities. The physiology behind this, is the vein valves in the veins no longer function normally, causing blood to back up within the vein, therefore becoming enlarged, engorged or “congested”. This “congestion” is what causes the pain.

Treatment for pelvic congestion syndrome

OB providers may treat pelvic congestion syndrome with oral drug therapy, such as NSAIDS (nonsteroidal anti-inflammatory drugs) which can reduce pain, decrease fever, prevent blood clots and, reduce inflammation. At this time, aspirin, ibuprofen, and naproxen sodium, can be purchased over the counter, but many NSAIDs, such as ketorolac tromethamine, celecoxib, meloxicam and many others still requires a prescription from the provider. Usually the first line treatment is nonsteroidal anti-inflammatory drugs, as nonsteroidal anti-inflammatory drugs (NSAIDs) usually relieve the pain. If NSAIDs are ineffective, the provider may prescribe a suppression of ovarian function and prescribe oral or injected hormone therapy. It is also becoming more and more common for providers to refer patients out for non-traditional medical therapies for pain relief such as acupuncture therapy, physical therapy, bio-feedback training, and yoga meditative therapy in addition to traditional medical therapy.

If the above treatments fail, the next option is a minimally invasive surgical option which involves stopping blood flow to the varicose veins using a procedure called known as venous embolization. The procedure requires an overnight stay in hospital, and is done using a local anesthetic or conscious sedation, and has a fairly high success rate.

Currently there are two procedures are available:

· Embolization of a vein: After using an anesthetic to numb a small area of the thigh, doctors make a small incision there. Then, they insert a thin, flexible tube (catheter) through the incision into a vein and thread it to the varicose veins. They insert tiny coils, sponges, or glue-like liquids through the catheter into the veins to block them.

· Sclerotherapy: Similar to embolization, a catheter is inserted into the vein, and the provider injects a sclerosing solution through it and into the varicose veins. The solution blocks the vein(s). It is assumed that when blood can no longer flow into the varicose vein(s) in the pelvis, the pain usually lessens.

Coding Considerations:

Scenario 1 - For pelvic congestion syndrome

A diagnostic venogram is obtained from a right common femoral venous puncture, with selective catheterization and diagnostic venography of the left renal vein, left ovarian vein, bilateral hypogastric veins, and bilateral external iliac veins. A large, varicose left ovarian vein is shown with reflux into enlarged uterine veins. The left ovarian vein is embolized with coils and sotradecyl.

CPT Codes:

· 37241: Venous embolization

· 36012X3: Selection of left renal/ovarian, left hypogastric, left external iliac veins

· 36011: Selection of right hypogastric vein

· 75822-59: Bilateral extremity venogram

· 75831-59: Left renal/ovarian venogram

ICD-10cm Codes

· N94.89 Other specified conditions associated with female genital organs and menstrual cycle

· I86.2 Pelvic varices

· R10.2 Pelvic and perineal pain

Scenario 2 - Pelvic congestion syndrome, persistent unimproved pelvic pain despite bilateral gonadal vein embolizations

Moderate sedation was employed using Versed and Fentanyl titrated for patient comfort by a trained independent observer. Continuous physiologic monitoring vital signs was performed for approximately 105 minutes.

Lidocaine was administered locally. A small dermatotomy was made and a micropuncture needle was placed into the right internal jugular vein. Ultrasound guidance was used. A hardcopy image was saved. An 0.018" wire was easily passed. A micropuncture sheath assembly was advanced and a Benson guidewire was then advanced into the IVC.

A 6 French sidearm sheath was then placed into the IVC.

Using AP venous catheter, the right internal iliac vein was catheterized contrast was injected to confirm position. The catheter was then advanced over a wire into the main trunk draining pelvic varicosities. A 1 cc Foley catheter was then advanced over an exchange length Bentson guidewire and the balloon was insufflated proximally 0.3 cc of dilute contrast to include flow. Approximately 5 cc of contrast was then gently injected to fill numerous large pelvic varicosities. Access was then gained into the left internal iliac vein and contrast was injected. A 1 cc Fogarty catheter was then placed into the left internal iliac vein and contrast was injected following insufflation of the balloon. Access was regained into the right internal iliac vein varicosity. The portable gland was insufflated to occlude flow and 3 cc of 3% Sotradecol was then administered as a sclerosing agent. This was allowed to dwell for 5 minutes. Repeat venogram was performed which demonstrated decreased size of varicosities. The catheter was removed and manual compression was used to achieve hemostasis.

FINDINGS:

1. Initial right internal iliac vein venogram demonstrates numerous large varicosities in the pelvis. The majority of these are present inferiorly. Treatment was performed only of the more inferior varicosities. Post sclerotherapy venogram demonstrates significant decrease in size of varicosities.

2. Left internal iliac vein venogram demonstrates several mildly enlarged pelvic veins. These are much less impressive than noted on the right.

CPT Codes:

· 36470 Injection of sclerosing solution; single vein

· 75822 Venography, extremity, bilateral, radiological supervision and interpretation

· 36012 (rt int iliac) Selective catheter placement, venous system; second order, or more selective, branch (e.g., left adrenal vein, petrosal sinus)

· 36012 (lt int iliac) Selective catheter placement, venous system; second order, or more selective, branch (e.g., left adrenal vein, petrosal sinus)

ICD-10cm Codes

· N94.89 Other specified conditions associated with female genital organs and menstrual cycle

· I86.2 Pelvic varices

· R10.2 Pelvic and perineal pain

Billing/Reimbursement Issues

Some 3^rdparty payers may consider venous embolization or pelvic venous sclerotherapy of the ovarian or internal iliac veins as experimental, unproven or not medically necessary. If the provider and patient wish to have this procedure performed, a pre-authorization and patient/insurance policy review should be performed before the procedure is scheduled. If the insurance carrier does not consider these procedures as medically valid, or necessary be sure to have the patient sign an advanced beneficiary notice and collect payment as appropriate for your practice.

↧

Understanding Coding of Hypertension in Pregnancy

July 26, 2018, 10:30 pm

≫ Next: Modifier 22 - A new perspective on a misunderstood modifier

≪ Previous: Article 3

Understanding Coding of Hypertension in Pregnancy

Saturday, June 23, 2018

Hypertension in pregnancy still remains as one of the most misunderstood complications of pregnancy, in addition to the incorrect usage of the ICD-10 diagnosis codes that go with it. ICD-10cm has a specific block of codes allocated to Pregnancy and hypertension, that should be used with all pregnancy coding. These codes denote a pre-existing hypertention and then the gestational or pregnancy-induced hypertension.

ICD-10cm Code block Group

· O10 Pre-existing hypertension complicating pregnancy, childbirth and the puerperium

· O11 Pre-existing hypertension with pre-eclampsia

· O12 Gestational [pregnancy-induced] edema and proteinuria without hypertension

· O13 Gestational [pregnancy-induced] hypertension without significant proteinuria

· O14 Pre-eclampsia

· O15 Eclampsia

· O16 Unspecified maternal hypertension

As you can see from the list above, there are numerous codes to choose from. As coders, we rely on our physicians to give us good clinical documentation within the pregnancy record, so we can code and bill appropriately for their services. As in the case of a pregnancy that the OB is supervising, the added diagnosis of Hypertension in pregnancy brings added risk factors to that pregnancy oversight. We also need to add ICD-10cm code for a high risk pregnancy due to hypertension. The pregnancy supervision code for high risk pregnancy will be coded as the primary code based upon the ICD-10cm guidelines. ICD-10cm coding guidelines for high-risk pregnancy changed in 2017. The current rule from the 2018 ICD-10-CM Official Guidelines for Coding and Reporting (effective Oct 1, 2017 – Sept 30, 2018) is below:

Supervision of High-Risk Pregnancy (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018Page 58 of 117) Codes from category O09, Supervision of high-risk pregnancy, are intended for use only during the prenatal period. For complications during the labor or delivery episode as a result of a high-risk pregnancy, assign the applicable complication codes from Chapter 15. If there are no complications during the labor or delivery episode, assign code O80, Encounter for full-term uncomplicated delivery.

For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category O09, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis..

The high risk supervision codes noted below, do not have a category specifically for oversight of hypertension in pregnancy, however this is something that we need to have coded for our diagnoses. If we are going to add a high risk pregnancy diagnosis to our record, the code choice of O09.89 would the best choice, as the hypertension in pregnancy is in the “other high risk” category and our provided has specified it as such.

O09 Supervision of high risk pregnancy

· O09.0 Supervision of pregnancy with history of infertility

· O09.1 Supervision of pregnancy with history of ectopic pregnancy

· O09.A Supervision of pregnancy with history of molar pregnancy

· O09.2 Supervision of pregnancy with other poor reproductive or obstetric history

o O09.21 Supervision of pregnancy with history of pre-term labor

o O09.29 Supervision of pregnancy with other poor reproductive or obstetric history

· O09.3 Supervision of pregnancy with insufficient antenatal care

· O09.4 Supervision of pregnancy with grand multiparity

· O09.5 Supervision of elderly primigravida and multigravida

o O09.51 Supervision of elderly primigravida

o O09.52 Supervision of elderly multigravida

· O09.6 Supervision of young primigravida and multigravida

o O09.61 Supervision of young primigravida

o O09.62 Supervision of young multigravida

· O09.7 Supervision of high risk pregnancy due to social problems

· O09.8 Supervision of other high risk pregnancies

o O09.81 Supervision of pregnancy resulting from assisted reproductive technology

o O09.82 Supervision of pregnancy with history of in utero procedure during previous pregnancy

o O09.89 Supervision of other high risk pregnancies

· O09.9 Supervision of high risk pregnancy, unspecified

In some cases, the high blood pressure diagnosis is present prior to the pregnancy, however, the patient can develop high blood pressure during pregnancy, which would then be noted as gestational hypertension.

Ø Chronic hypertension is high blood pressure that was present before pregnancy or that occurs before 20 weeks of pregnancy. But because high blood pressure usually doesn't have symptoms, the provider may be reluctant to state this as a chronic condition, as this may or may not have been noted as a diagnosis for the patient by a previous provider or prior to the pregnancy.

Ø Chronic hypertension with superimposed preeclampsia is condition that can also occur in women with chronic hypertension before pregnancy who develop worsening high blood pressure and protein in the urine or other blood pressure related complications during pregnancy.

Ø Gestational hypertension is the patient noted in the record to have high blood pressure that develops after 20 weeks of pregnancy. Normally there is no excess protein noted in the urine or other signs of organ damage however, some women with gestational hypertension may develop preeclampsia.

Ø Preeclampsia occurs when hypertension develops after 20 weeks of pregnancy, and is associated with signs of damage to other organ systems, including the kidneys, liver, blood and/or brain. Untreated preeclampsia can lead to serious complications for mother and baby, including development of seizures which then the diagnosis becomes eclampsia.

o Previously, preeclampsia was clinically diagnosed only if a pregnant woman had high blood pressure and protein in her urine. However, it has been noted that it's possible for the patient to have preeclampsia without having protein in the urine.

Ø Eclampsia is the onset of seizures (convulsions) in a woman with pre-eclampsia. The onset may be before, during, or after delivery, but it can be diagnosed and treated during the second trimester in the pregnancy.

o The seizures are usually the tonic–clonic type and typically last between 30 and 60 seconds. Complications of eclampsia include aspiration pneumonia, cerebral hemorrhage, kidney failure, and cardiac arrest

Ø HELLP Syndrome is another variant of pre-eclampsia and/or eclampsia as a known pregnancy complication. HELLP syndrome is characterized as hemolysis, elevated liver enzymes, and low platelet count. HELLP syndrome can be fatal to both the mother and the fetus.

The clinical documentation of consistent pregnancy blood pressure is an important part of the patients’ prenatal care. The list below designates the levels at which the blood pressures should be noted. As a coder, if you are not seeing these designations, you will want to query the provider and ensure if the patient has a true “hypertension” or simply an elevated blood pressure. This will make a difference in your code choice. This will also determine if the ob visit should be considered part of the prenatal care/OB package, or if it should be billed as a separately identifiable visit outside of the prenatal care/OB package.

o Elevated blood pressure: Elevated blood pressure is a systolic pressure ranging from 120 to 129 millimeters of mercury (mm Hg) and a diastolic pressure below 80 mm Hg. Elevated blood pressure tends to get worse over time unless steps are taken to control blood pressure.

o Stage 1 hypertension: Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.

o Stage 2 hypertension: More severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.

NOTE: After 20 weeks of pregnancy, blood pressures that exceeds 140/90 mm HG — documented on two or more occasions within the prenatal record, that are at least four hours apart, without any other organ damage — is considered to be gestational hypertension.

As we look to the ICD-10cm coding guidelines, the pre-existing condition (such as hypertension) should be considered carefully.

Pre-existing conditions versus conditions due to the pregnancy (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 59 of 117)

Certain categories in Chapter 15 distinguish between conditions of the mother that existed prior to pregnancy (pre-existing) and those that are a direct result of pregnancy. When assigning codes from Chapter 15, it is important to assess if a condition was pre-existing prior to pregnancy or developed during or due to the pregnancy in order to assign the correct code.

Categories that do not distinguish between pre-existing and pregnancy-related conditions may be used for either. It is acceptable to use codes specifically for the puerperium with codes complicating pregnancy and childbirth if a condition arises postpartum during the delivery encounter.

The ICD-10cm guidelines also go on to say that the “O” codes that have been set forth for hypertension in pregnancy also include the codes for hypertensive chronic kidney disease. If this is the case we are then to assign not only the appropriate O10 code, but also add an additional code from the appropriate hypertension category from ICD_10cm Chapter 9: Diseases of the Circulatory System (I00-I99) and specify the type of heart failure or CKD.

Pre-existing hypertension in pregnancy (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 60 of 117)

Category O10, Pre-existing hypertension complicating pregnancy, childbirth and the puerperium, includes codes for hypertensive heart and hypertensive chronic kidney disease. When assigning one of the O10 codes that includes hypertensive heart disease or hypertensive chronic kidney disease, it is necessary to add a secondary code from the appropriate hypertension category to specify the type of heart failure or chronic kidney disease. See Section I.C.9. Hypertension

Office Coding Scenario – Admission to L&D:

Patient is a 32 year old who has come in at the request of our Triage RN status post patient call 1 hr ago. Pt is G2 and P1 at 35 and 3/7 weeks with gestational hypertension stable on labeletol. Pt arrived 20 minutes ago and is now complaining of a severe headache, leg swelling, blurred vision, abdominal pains, and a BP of 170/102. She notes baby is moving well, but is having contractions. Her husband is present with her and is very supportive, but concerned. Sarah has a history of mild pre-eclampsia with her first child who delivered vaginally 2 years ago. She is allergic to PCN with a bad rash noted 4 years ago. Her Blood pressure in the clinic 2 days ago was 140/85.. She was not started on any new medications, nor any changes to her current Labeletal dose, but was put on bedrest. She continues to complain of a severe headache. She is oriented x3, but somewhat sleepy. She has pitting edema bilaterally at a 3+ She has also complained of some mild nausea with no vomiting at this point. No complaints of shortness of breath. Lungs are still clear. She continues to complain of upper abdominal pain. Her urine dip indicated some mild 2+ proteinuria. Her most recent vital signs are BP158/98, P98 R14, T98.6 . She has current symptoms of severe pre-eclampsia, with pre-term labor and trending toward eclampsia. At this time, I will send orders for direct admission to L&D Observation for continued surveillance of severe pre-eclampsia. Patient directed to L&D. I will follow with patient at evening rounds.

Coding Considerations:

ICD-10 cm Diagnosis:

O09.89 Supervision of other high risk pregnancies

O14.13 Severe pre-eclampsia third trimester
O60.03 Preterm labor without delivery
Z3A.37 37 weeks gestation of pregnancy

According to the CPT Maternity Care and Delivery guidelines that are noted at the beginning of the maternity care section within the CPT book it clearly states

“Medical complications of pregnancy; (eg cardiac problems, neurological problems, diabetes, hypertension, toxemia, hyperemesis, preterm labor, premature rupture of membranes,trauma) and medical problems complicating labor and delivery management may require additional resources and may be reported separately.”

Billing/Reimbursement Issues

Some 3^rdparty payers may consider the above scenario of care as part of the OB package of care, and not reimburse for the admission to observation as a separately identifiable service outside of the OB package. If that is the case, CPT does allow for this and you should code, bill and subsequently appeal for your appropriate payment of such.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

↧

Modifier 22 - A new perspective on a misunderstood modifier

July 26, 2018, 10:45 pm

≫ Next: Stress Urinary Incontinence – Surgical Intervention Coding for Urinary Sling

≪ Previous: Understanding Coding of Hypertension in Pregnancy

Modifier 22 - A new perspective on a misunderstood modifier

01/28/2018 - Lori-Lynne A. Webb

Modifier 22 Increased Procedural Services modifier, as explained in CPT® Appendix A:

“ When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).”

Neither CPT, the Centers for Medicare & Medicaid Services (CMS), or even AMA guidelines precisely define the term “substantially greater” than typically required. Nor does CPT address the issue that modifier 22 allows a physician to receive a larger reimbursement (usually an extra 20-25%) for an especially difficult or time-consuming procedure. Unfortunately, 3^rd party payers won’t automatically increase reimbursement for a modifier 22 claim. It is common for physicians to increase their fee by 20-25% when submitting a claim with the modifier 22 attached to compensate the provider for the “over and above” work that was performed on the case. CPT does not specify “financial compensation” in the modifier definition.

However, in getting modifier 22 claims paid ; overall the case will require more than just extra work in the operating room; it also means clear and concise clinical documentation to support the “additional work performed” to be noted by the provider. As the coder, you have a responsibility to ensure the claim submission went through correctly; and you have followed the claim through to ensure it was paid by the carrier with the additional revenue. If your claim was not paid correctly, it will be up to you to formulate an appeal back to the carrier for the additional reimbursement you have asked for .

When to use Modifier 22

Modifier 22 Increased Procedural Services; is to be used only for services/procedures which are greater than usual and which requires increased physician work above and beyond normal. When it comes to a “normal” procedure, the definition of “above and beyond” normal is very vague and can be interpreted in a multitude of ways by the 3^rd party payers.

Specific circumstances that may support modifier 22 include:

· Excessive/unexpected blood loss or hemorrhage relative to the procedure

· Presence of an excessively large surgical specimen(especially in abdominal surgery)

· Trauma that is extensive enough to complicate the particular procedure. (and that cannot be billed with additional procedure codes or with an unlisted procedure code)

· Abnormal and/or other pathology, tumors, malformations that interfere directly with the surgery

· Procedures that are significantly more complex than described in CPT 9and cannot be billed with additional procedure codes and/or an unlisted procedure code)

· Morbid obesity and

· Altered anatomy such as severe scarring or adhesions from previous trauma.

· Patient complications during complex surgery such as converting a laparoscopic procedure to an open approach; patient hemorrhage during surgery; or unexpected operative complications during surgery.

· Complex delivery/birth (eg twins, excessive hemorrhage, fetal or maternal distress)

Modifier 22 usage with global maternity care, or maternal services may be appropriate if:

Management of pregnancy related complications (pre-eclampsia, preterm labor, bleeding, etc…) has required greater than 15 antepartum visits.
For cesarean delivery of multiple gestations.
The cesarean delivery requires substantial additional work.

However, with usage in obstetric services, the 3^rd party payers may have restrictions or specified criteria to be followed when submitting obstetric service claims with a modifier 22. CMS/Medicare/Medicaid have not specifically addressed usage of this modifier with claims. American Congress of Obstetricians and Gynecologists have noted that modifier 22 can be used for 3^rd and 4^th degree lacerations that occur at the time of delivery.

In Appendix A of the CPT book, the definition also includes a “note” that informs us that modifier -22 should not be appended to an E/M service. This information implies that modifier 22 should only be used along with valid procedure/surgery CPT codes. According to the Medicare Physician Fee Schedule Database, modifier 22 can be appended to procedures having a global surgery indicator of 000, 010, or 090 post operative days. Modifier -22 is not valid for “XXX” global period indicators, which includes E/M, radiology, laboratory, pathology, and most medicine codes. With some 3^rd party payers, procedure codes with global day indicator of ZZZ, or MMM in addition of modifier 22 upon those claims may be considered upon review.

Clinical Documentation

The clinical documentation provided in the patients’ operative record is crucial to substantiate usage of modifier 22. A clear and concise description of the unusual circumstance(s) that outline why this particular encounter required greater effort, than the normal services, should be well documented by the provider.

When documenting in the operative/procedural record avoid using a generalized statement. Comments like "patient was obese" or "surgery took longer than usual" or "multiple adhesions" lack specificity to truly detail why the procedure was beyond the normal or routine type difficulties that are encountered with the procedure on a day to day basis. The surgeon should explain and identify any additional acute or chronic illnesses, and/or preexisting conditions, or complications that were encountered within the surgery that contributed to warrant extra time effort and the usage of modifier 22.

Communicate with the provider to use “comparative” verbiage to show how this procedure was significantly different from the typical and or average procedure. For example, a statement such as “The patient lost 850 cc’s of blood during the delivery with extensive clotting, hemorrhage and uterine atony. Normal blood loss is approximately 200 cc’s”. The provider should also denote any and all additional procedures that were performed to control the hemorrhage during the delivery. ( eg. postpartum curettage, application of a Bakri-Balloon or hemabate) If the original clinical documentation does not support the usage of the modifier 22 prior to the claim being submitted, ask the provider to amend or re-document the surgery to accurately reflect the complexity of the surgery that necessitates the usage of the modifier 22.

When using time as a modifier 22 criteria, comparative verbiage is also helpful, such as stating “I spent 2 hours of abdominal adhesiolysis due to the patient’s morbid obesity before gaining access to the operative field. Normal time for adhesiolysis for this surgery is usually 20-30 minutes. Other good clinical examples are “Due to the altered anatomical issues and scarring from previous abdominal surgeries; upon entrance to the abdominal cavity, we had to delicately lyse colonic adhesions from the abdominal and peritoneal area for over an hour to obtain access into the surgical field, whereas, this normally takes 5-10 minutes.” Or “We had to make four attempts to place the guide wire due to extensive plaque buildup prior to the start of the catheterization.”

Claims Submission

Unfortunately, many 3^rd party payers automatically reject or refuse any claims that have a modifier 22 appended to them upon initial electronic claim submission. Once this rejection has been received back to the provider, you will need to submit the procedure/operative report documents to support your claim for payment of additional revenue for modifier 22claims. In addition, be prepared to submit the operative notes and a separate statement or letter indicating how the procedure was significantly more difficult that the normal surgical procedure. You may also want to consider adding a notation within the separate statement asking for the additional 20-25% more reimbursement for the additional work performed. Last but not least, if the 3^rdparty payer refuses to consider your claim upon the submission of the additional information, appeal to the highest level possible, up to and including a peer to peer physician review with physicians that practice within the same specialty.

↧

Stress Urinary Incontinence – Surgical Intervention Coding for Urinary Sling

July 26, 2018, 10:50 pm

≫ Next: New Webinars from me! Come listen in...

≪ Previous: Modifier 22 - A new perspective on a misunderstood modifier

Stress Urinary Incontinence – Surgical Intervention Coding for Urinary Sling

March 2018

Urinary incontinence is the unintentional loss of urine. Stress Urinary Incontinence (SUI) is what occurs when there is stress or movement/ activity put upon your bladder. This activity can be something as minor as laughing, coughing, sneezing, running or lifting. SUI is not a condition related to “stress” in a psychological way, such as a person who is suffering from a mental anxiety or issue, SUI is purely related to a movement/activity that is related to a physical stress upon the body. .

There are four main types of urinary incontinence

· Urge incontinence

· Stress incontinence (SUI)

· Overflow incontinence

· Functional incontinence

Stress urinary incontinence is defined as the unintentional loss of urine caused by the bladder muscle contracting, involuntarily with physical movement. Some patients also experience a sense of urgency. SUI is much more common in women than men, however, the most common cause of SUI is a pelvic floor disorder, damage to, or weakening of the soft tissue that normally supports the urinary organs.

SUI is a direct result of the urinary sphincter muscle that controls the urethra becomes weakened, in addition to the weakening of the soft tissues. When both the muscle and the soft tissue supports become weak, this allows the release of urine to happen during a “stressful, physical event” such as laughing, coughing, sneezing, etc.

Coding interventions

SUI surgery is not exclusive just to the Urology specialty, many gynecologists also perform surgical intervention for SUI in women. CPT has given us many code choices for surgical intervention of SUI. Currently the most commonly used for treatment in both men and women are the surgical procedures for a urinary “sling”.

When a sling procedure is performed, the surgeon uses the patient's own tissue (or other type of supply) to essentially “sling up” or “pex up” the uretha by inserting a strip of additional material/tissue to create an additional support system for the urethra. This support is sewn into the pelvic area to help keep the urethra in the proper physical location.

Slings can be used for both men and women with SUI.

Urinary Sling procedures can be performed as an open procedure or as a laparoscopic procedure. The two most common types of bladder slings are the TOT sling (transobturator tape sling) and the TVT sling (tension-free vaginal tape sling). The TOT sling and the TVT sling are normally performed as a quick 30 minute, outpatient procedures with a high success rate of nearly 90%. The incisions are small (less than one centimeter) and recovery times are quick. However, these procedures can be done in coordination with other surgical procedures.

The CPT codes below are those that are specifically related to SUI.

· 57288 Sling operation for stress incontinence (eg, fascia or synthetic) - Open Approach

· 57287 Removal or revision of sling for stress incontinence (eg, fascia or synthetic) – Open or laparoscopic Approach

· 53440 Sling Operation for correction of male urinary incontinence (eg, fascia or synthetic) – Open Approach

· 53442 Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic) – Open Approach

· 51990 Laparoscopy, surgical; urethral suspension for stress incontinence

· 51992 Laparoscopy, surgical; sling operation for stress incontinence (eg, fascia or synthetic)

· 10120 Incision and removal of foreign body, subcutaneous tissue – simple

· 10121 Incision and removal of foreign body, subcutaneous tissue - complicated

When coding for these procedures, the coder need to carefully review the operative report to double check if the procedure is being performed laparoscopically or as an open procedure. The codes for the open approach include the 57287, 57288, 53440 and 53442. The physician/surgeon may state this is a “mini-laparotomy” however, this still means the surgical approach is “open”. If the physician documents the procedure was performed with a laparoscope, the codes 51990 and 51992 would be the correct codes to choose. If the sling is removed laparoscopically, the 57287 is the correct code to use regardless if the procedure was performed as an open procedure or a laparoscopic procedure.

Codes 53440, 53442, 51990, 51992, 57287 and 57288 all have a 90 day global period. Should a sling revision be surgically necessary during the global period, you will need to add modifier -78, to your code, as this is an unplanned return to the OR for a related procedure.

In addition, revision of an SUI sling procedure code(s) 57287 or 53442 both of these codes include replacement procedure of a sling (codes 57288 or code 53442) when performed on the same date of service. These codes are bundled in the CCI bundling edits from CMS, and do not allow a modifier to over-ride the bundling edit.

The usage of code 10120 and 10121 have become common when physicians have “removed” portions of a mesh erosion that has eroded into the subcutaneous tissues around the abdomen and groin areas. These integumentary codes are very specific if the mesh is only being removed from the subcutaneous tissue, and not a full excision or revision of the sling itself. When reporting CPT code 10120 or 101210 you will need to add either a modifier -58 or modifier -78 if the mesh erosion is treated in the office/procedure room. The verbiage of codes 10120/10121 strictly denotes in the definition as a removal of foreign body“subcutaneous” tissue.

Unfortunately, CPT does not give clear guidance as to what constitutes “simple” versus “complicated” when it comes to codes 10120 and 10121. So if you choose to use CPT Code 10121 (incision and removal of foreign body, subcutaneous tissues; complicated) when an incision is necessary to remove the foreign body you will need to educate the physician to document in the operative note that the removal was “complicated”. In addition, the physician should also document “why” the removal was complicated, with the usage of additional terms such as; embedded, deep, size, location, abnormality. It may necessitate having the physician document the amount of time spent in the removal to support the usage of the “complicated” code 10121, rather than the “simple” code 10120.

Operative Report SPARC suburethal Sling

PROCEDURE: SPARC suburethral sling

PREOPERATIVE DX: Stress urinary incontinence; hypermobility of urethra

POSTOPERATIVE DX: Stress urinary incontinence; hypermobility of urethra.

OPERATIVE PROCEDURE: SPARC suburethral sling.

FINDINGS & INDICATIONS: Outpatient evaluation was consistent with urethral hypermobility, stress urinary incontinence. Intraoperatively, the bladder appeared normal with the exception of some minor trabeculations. The ureteral orifices were normal bilaterally.

DESCRIPTION OF OPERATIVE PROCEDURE: This patient was brought to the operating room, a general anesthetic was administered. She was placed in dorsal lithotomy position. Her vulva, vagina, and perineum were prepped with Betadine scrubbed in solution. She was draped in usual sterile fashion. A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder. Two Allis clamps were placed over the mid urethra. This area was injected with 0.50% lidocaine containing 1:200,000 epinephrine solution. Two areas suprapubically on either side of midline were injected with the same anesthetic solution. The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra. Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus. The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally. The Foley catheter was removed. A cystoscopy was performed using a 70-degree cystoscope. There was noted to be no violation of the bladder. The SPARC mesh was then snapped onto the needles, which were withdrawn through the stab wound incisions. The mesh was snugged up against a Mayo scissor held under the mid urethra. The overlying plastic sheaths were removed. The mesh was cut below the surface of the skin. The skin was closed with 4-0 Plain suture. The vaginal vault was closed with a running 2-0 Vicryl stitch. The blood loss was minimal. The patient was awoken and she was brought to recovery in stable condition.

Cpt Code:

57288 Sling operation for stress incontinence (eg, fascia or synthetic) - Open Approach

ICD-10CM :

N39.3 Stress incontinence (female) (male)

N36.41 Hypermobility of urethra

Operative Report Male Sling

General anesthesia administered and patient positioned in the dorsal lithotomy position. A 16F Foley catheter placed to drain the bladder. Peri-operative antibiotics are administered. A vertical incision is made to the perineum approximately 1-2 cm inferior to the penoscrotal junction and carried 1 cm anterior to the rectum. Dissection is continued through Colles' fascia and the underlying bulbocavernous muscle. Sharp dissection is continued until the spongiosal bulb has been freely dissected. The perineal body is identified and dissection is continued proximally approximately 4 cm.

Attention is then focused on identification and marking of the anatomical and landmarks for placement of the surgical passers. The adductor longus tendon is identified and marked, each of the two trochar insertion sites are then marked, and insertion is performed just lateral to the inferior pubic ramus. The skin sites are incised and surgical passer placement is performed. A surgical finger is placed inside the perineal dissection and to identify the inferior pubic ramus where the passer will exit. Under manual guidance, the passer is advanced through the medial aspect of the obturator foramen, exiting at the level of the perineal body lateral to the spongiosal bulb. Care is taken to maintain a 45º angle during passage, therefore completing the trochar rotation. The passer is then hooked to the respective sling arm, which is then pulled though the obturator foramen to exit via the skin incision bringing the mesh into place. The mesh is then checked to ensure that twisting has not occurred. Subsequently, the opposite passer is placed in an identical fashion and the sling is pulled into place.

The central mesh anchor is sutured into place, with the posterior aspect fixed to the spongiosal tissue at the most proximal aspect of the bulbar dissection. The distal anchor is then sutured to the spongiosal tissue, each performed with 3-0 vicryl suture. Tensioning of the sling is now performed, by pulling the mesh arms so the bulb of the corpus spongiosum is brought cephalad by the sling. Sling tensioning is increased until 3-4 cm of proximal urethral movement is obtained. Bulbar suspension is confirmed by measuring proximal movement from the initial point of fixation to the perineal body. A cystourethroscopy is then performed to rule out any urethral or bladder injury. The arms of the mesh are cut below skin level and skin incisions closed with Dermabond. The perineal dissection is then closed with a standard 3-layer closure with absorbable suture.

Cpt Code:

53440 Sling Operation for correction of male urinary incontinence (eg, fascia or synthetic) – Open Approach

ICD-10CM :

N39.3 Stress incontinence (female) (male)

Operative Report – Laparoscopic removal

A laparoscopic approach was utilized to remove the polypropylene mesh sling from the retropubic space and , bladder, We entered the peritoneal cavity through the umbilicus and then placed 3 ancillary ports under direct vision . A 10-mm port is placed in the left paramedian region for suturing, and 5-mm ports are placed suprapubically and in the right paramedian region. After the pneumoperitoneum was created, and adhesiolyis was performed, and taken down, the bladder is filled in a retrograde manner with 200 mL to 300 mL of saline, allowing for identification of the superior border of the bladder edge. Entrance into the space of Retzius was accomplished with a transperitoneal approach using a Harmonic scalpel. The incision was made approximately 3 cm above the bladder reflection, beginning along the medial border of the right obliterated umbilical ligament. After entering the space of Retzius the pubic ramus was visualized; the bladder drained to prevent injury during dissection. Separation of the loose areolar and fatty layers using blunt dissection develops the retropubic space, and dissection is continued until the retropubic anatomy is clearly visualized. Identification of the sling mesh was made where it touches the pubic rami, approximately 3 cm lateral from midline. Once identified, the mesh was grasped and excised from the anterior abdominal wall and then peeled free of the pubic rami periosteum. Dissection was then continued down along the mesh toward the bladder and pubocervical fascia. Extensive scarring was encountered, and the mesh was cut out with the scarred tissue. In addition, the mesh was eroded into the bladder, and the dissection was continued down to where the mesh appeared to be eroded into the bladder. The mesh was removed but erosion was not found to be in the bladder. Dissection was continued down to and through the pubocervical fascia on both sides. An incision was then made suburethrally, and the remaining mesh below the urethra identified, cut in the midline, and freed up allowing removal of the entire portion of the mesh sling. All laparoscopic surgical devices were removed and accurate sponge and surgical devices accounted for. Patient then taken to the recovery area, and will be discharged when stable.

Cpt Code:

57287 Removal or revision of sling for stress incontinence (eg, fascia or synthetic) – Open or laparoscopic Approach

ICD-10CM :

T83.711D Erosion of implanted vaginal mesh to surrounding organ or tissue; subsequent encounter

Wrap up

The biggest challenge of coding for SUI is ensuring that the correct codes were chosen for either open or laparoscopic approach. In addition to ensuring that your codes for CPT are correct, but double check your ICD-10cm diagnoses for accuracy. And with all claims, follow them to ensure that they were submitted in a timely manner, but were also reimbursed correctly. If not, then file an appeal for readjudication or peer review as necessary.

↧

New Webinars from me! Come listen in...

August 24, 2018, 10:34 am

≫ Next: 2019 Coding Updates Virtual Boot Camp

≪ Previous: Stress Urinary Incontinence – Surgical Intervention Coding for Urinary Sling

HELLO!!! I have a couple of new webinar's coming out in September and October in conjunction with AudioEducator.com. I will be doing one on the ICD-10cm & PCS Updates targeted for OB/GYN or areas of interest for those of us currently working in OB/GYN, URO. then in October I will do a special Webinar on how to use the NCCI edits correctly to ensure that your claims go thru and to lessen denials.

Please join me! and if you would like a "discount code". Hit me up on Facebook or e-mail and I'll be happy to send you my discount codes....

↧

2019 Coding Updates Virtual Boot Camp

October 12, 2018, 11:00 pm

≫ Next: UPDATE TO THE 2020 ICD-10 coding Guidelines E-Cig/Vaping

≪ Previous: New Webinars from me! Come listen in...

2019 Coding Updates Virtual Boot Camp

Preparing Coders for a Successful 2019

Attend the Year’s Biggest Virtual Ob-Gyn Coding Event

Presented by: Lori-Lynne A. Webb | November 29 & 30, 2018

Register Now

Are you sure you coded that last Ob-Gyn claim correctly? Second-guessing your Ob-Gyn coding accuracy is a daily reality for many Ob-Gyn coders. But it’s an uncomfortable mindset to live with. Silence the nagging inner voice, and get up to speed on the 2019 codè changes. Find out the latest on CPT^®, ICD-10-CM, and HCPCS updates for obstetrics-gynecology in 2019.

Join Ob-Gyn coding expert Lori-Lynne Webb for an instructive session on the most important coding changes, strategies for correct modìfìer use, and instructions on improving documentation. Get expert insights on coding and billing for breast procedures, ultrasound services, E&M issues, and so much more! Isn’t your peace of mind worth it?

Get 6 AAPC-APPROVED CEUs

Sessions

ICD-10-CM/PCS and CPT^®/HCPCS Updates in OB-GYN
Auditing for OB-GYN
A Look at the GOOD, the BAD, and the UNREALISTIC Expectations of EMR/EHR
A Look to the Future – Blending Medical Necessity and Clinical Documentation

Session Agenda

How to clearly document CPT^® procedures and ICD-10 diagnoses
Key strategies and coding concepts for correct billing
How to perform internal reviews of coding accuracy
How to demonstrate medical necessity
Finding an EMR solution that works best with your existing system
Addressing prìvacy/securìty and sharing EMR information to an outside provider
How to document medical necessity for Ob-Gyn services and procedures
How to rectify documentation issues
And more

Register Now for AudioEducator’s 2019 Coding Updates Virtual Boot Camp and get in shape for a great 2019!

CLICK HERE TO REGISTER

✆ Call now at 1-866-251-3060 and mention S99NVTEM

Get $50 Off On Registering NOW!
(Use Codé "Webb50" at Checkóut )

↧

UPDATE TO THE 2020 ICD-10 coding Guidelines E-Cig/Vaping

October 22, 2019, 10:58 pm

≪ Previous: 2019 Coding Updates Virtual Boot Camp

ICD-10-CM Official Coding Guidelines - Supplement

Coding encounters related to E-cigarette, or Vaping, Product Use
Post Date: October 17, 2019

Introduction
The purpose of this document is to provide official diagnosis coding guidance for healthcare encounters related to the 2019 health care encounters and deaths related to e-cigarette, or vaping, product use associated lung injury (EVALI). This guidance is consistent with current clinical knowledge about e-cigarette, or vaping, related disorders.
As necessary, this guidance will be updated as new clinical information becomes available. The clinical scenarios described below are not exhaustive and may not represent all possible reasons for health care encounters that may be related to e-cigarette, or vaping, product use. Proposals for new codes that are intended to address additional detail regarding use of e-cigarette, or vaping, products will be presented at the March 2020 ICD-10 Coordination and Maintenance Committee Meeting.
This guidance is intended to be used in conjunction with current ICD-10-CM classification and the ICD-10-CM Official Guidelines for Coding and Reporting (effective October 1, 2019). https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf. The ICD-10-CM codes provided in the clinical scenarios below are intended to provide e-cigarette, or vaping, product use coding guidance only. Other codes for conditions unrelated to e-cigarette, or vaping products may be required to fully code these scenarios in accordance with the ICD-10-CM Official Guidelines for Coding and Reporting. A hyphen is used at the end of a code to indicate that additional characters are required.
General Guidance
Lung-related complications
For patients documented with electronic cigarette (e-cigarette), or vaping, product use associated lung injury (EVALI), assign the code for the specific condition, such as:
• J68.0, Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors; includes chemical pneumonitis
• J69.1, Pneumonitis due to inhalation of oils and essences; includes lipoid pneumonia
• J80, Acute respiratory distress syndrome
• J82, Pulmonary eosinophilia, not elsewhere classified
• J84.114, Acute interstitial pneumonitis
• J84.89, Other specified interstitial pulmonary disease
For patients with acute lung injury but without further documentation identifying a specific condition (pneumonitis, bronchitis), assign code:
• J68.9, Unspecified respiratory condition due to chemicals, gases, fumes, and vapors
ICD-10-CM Coding Guidance
Vaping related disorders (October 17, 2019)
2
Poisoning and toxicity
Acute nicotine exposure can be toxic. Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes. For these patients assign code:
• T65.291-, Toxic effect of other nicotine and tobacco, accidental (unintentional); includes Toxic effect of other tobacco and nicotine NOS.
For a patient with acute tetrahydrocannabinol (THC) toxicity, assign code:
• T40.7X1- Poisoning by cannabis (derivatives), accidental (unintentional).
Substance use, abuse, and dependence
For patients with documented substance use/abuse/dependence, additional codes identifying the substance(s) used should be assigned.
When the provider documentation refers to use, abuse and dependence of the same substance (e.g. nicotine, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:
• If both use and abuse are documented, assign only the code for abuse
• If both abuse and dependence are documented, assign only the code for dependence
• If use, abuse and dependence are all documented, assign only the code for dependence
• If both use and dependence are documented, assign only the code for dependence.
Assign as many codes, as appropriate. Examples:
Cannabis related disorders: F12.---
Nicotine related disorders: F17.----
Specifically, for vaping of nicotine, assign code:
 F17.29-, Nicotine dependence, other tobacco products. Electronic nicotine delivery systems (ENDS) are non-combustible tobacco products.
Signs and symptoms
For patients presenting with any signs/symptoms (such as fever, etc.) and where a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms such as:
• M79.10 Myalgia, unspecified site
• R06.00 Dyspnea, unspecified
• R06.02 Shortness of breath
• R06.2 Wheezing
• R06.82 Tachypnea, not elsewhere classified
• R07.9 Chest pain, unspecified
ICD-10-CM Coding Guidance
Vaping related disorders (October 17, 2019)
3
• R09.02 Hypoxemia
• R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems (includes chest congestion)
• R10.84 Generalized abdominal pain
• R10.9 Unspecified abdominal pain
• R11.10 Vomiting, unspecified
• R11.11 Vomiting without nausea
• R11.2 Nausea with vomiting, unspecified
• R19.7 Diarrhea, unspecified
• R50.- Fever of other and unknown origin
• R53.83 Other fatigue
• R61 Generalized hyperhidrosis (night sweats)
• R63.4 Abnormal weight loss
• R68.83 Chills (without fever)
This coding guidance has been approved by the four organizations that make up the Cooperating Parties: the National Center for Health Statistics, the American Health Information Management Association, the American Hospital Association, and the Centers for Medicare & Medicaid Services.
References:
Ghinai I, Pray IW, Navon L, et al. E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury — Illinois and Wisconsin, April–September 2019. MMWR Morb Mortal Wkly Rep 2019;68:865–869. DOI: http://dx.doi.org/10.15585/mmwr.mm6839e2
National Academies of Sciences, Engineering, and Medicine. 2018. Public Health Consequences of E-Cigarettes. Washington, DC: The National Academies Press. https://doi.org/10.17226/24952.
Perrine CG, Pickens CM, Boehmer TK, et al. Characteristics of a Multistate Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping — United States, 2019. MMWR Morb Mortal Wkly Rep 2019;68:860–864. DOI: http://dx.doi.org/10.15585/mmwr.mm6839e1
Schier JG, Meiman JG, Layden J, et al. Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance. MMWR Morb Mortal Wkly Rep 2019;68:787–790. DOI: http://dx.doi.org/10.15585/mmwr.mm6836e2
Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019. MMWR Morb Mortal Wkly Rep. ePub: 11 October 2019. DOI: http://dx.doi.org/10.15585/mmwr.mm6841e3

↧