Friday, October 10, 2014

V42.2 Vs. V43.3

Status Codes V42.2 Vs.V43.3 Confusion:
  V42.2 – Heart valve replaced by transplant
  V43.3 – Heart valve replaced by Other means
  If the patient has a tissue valve (porcine, bovine, etc),  it’s a v42.2.
  Artificial valve is V43.3. An artificial valve requires the Coumadin, tissue valves   typically do not.

Tissue Heart Valve:
 Tissue valves are harvested from pig heart valves (porcine) or cow heart sac (bovine).     These tissues are treated and neutralized so that the body will not reject them. Some are mounted on a frame or stent; others are used directly (stentless).
The lifetime of a tissue valve is typically 10 to 15 years, often less in younger patients. Over this time the valve will likely be degenerating to the point of requiring replacement. Because valve replacement surgery carries a significant risk of death, patient life expectancy is a major criterion in considering a tissue valve.

Mechanical Heart Valve:
The most widely used mechanical valves are made from pyrolytic carbon, which has been used for over 30 years. Most are bileaflet designs, meaning that they employ two carbon “leaflets” to regulate flow to a single direction.

The primary advantage of mechanical valves is that they will last a patient’s lifetime. Mechanical valves are preferred for patients with life expectancies beyond 10-15 years because they eliminate the mortality risk inherent in the replacement of a worn out tissue valve.
Ref: Onxlti.com

Saturday, November 30, 2013

Query Samples



Medical Coding Query format/Sample Coding query forms
 

 After a patient is discharged, coders often desire additional clarification or information from the attending physician before they feel they can code from the medical record. A common method for coders to obtain additional information is to submit a "query form" to the attending physician. The query form provides an opportunity for the physician to state more clearly or confirm the diagnosis of a patient as reflected in the medical record. Often these forms are used when other pieces of documentation, such as a discharge summary, are not yet available to the coder.

Physician queries have also been used to confirm certain diagnosis codes that have been scrutinized by the government. For example, in some situations a coder might query a physician to determine whether a patient should be diagnosed with the higher-paying gram negative pneumonia (instead of the lower-paying unspecified bacterial pneumonia) or to determine whether the physician’s usage of the vague term "sepsis" should be understood to refer to (higher-paying) septicemia or (lower-paying) urinary tract infection.

 
1. Example Open-Ended Query
 
A patient is admitted with pneumonia. The admitting H&P examination reveals WBC of 14,000; a respiratory rate of 24; a temperature of 102 degrees; heart rate of 120; hypotension; and altered mental status. The patient is administered an IV antibiotic and IV fluid resuscitation.

Leading: The patient has elevated WBCs, tachycardia, and is given an IV antibiotic for Pseudomonas cultured from the blood. Are you treating for sepsis?

Nonleading: Based on your clinical judgment, can you provide a diagnosis that represents the below-listed clinical indicators?

In this patient admitted with pneumonia, the admitting history and physical examination reveals the following:

·  WBC 14,000

·  Respiratory rate 24

·  Temperature 102° F

·  Heart rate 120

·  Hypotension

·  Altered mental status

·  IV antibiotic administration

·  IV fluid resuscitation

Please document the condition and the causative organism (if known) in the medical record.

Source: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010): expanded web version.


2.Example Multiple Choice Query
A patient is admitted for a right hip fracture. The H&P notes that the patient has a history of chronic congestive heart failure. A recent echocardiogram showed left ventricular ejection fraction (EF) of 25 percent. The patient’s home medications include metoprolol XL, lisinopril, and Lasix.

Leading: Please document if you agree the patient has chronic diastolic heart failure.

Nonleading: It is noted in the impression of the H&P that the patient has chronic congestive heart failure and a recent echocardiogram noted under the cardiac review of systems reveals an EF of 25 percent. Can the chronic heart failure be further specified as:

·  Chronic systolic heart failure____________________

·  Chronic diastolic heart failure___________________

·  Chronic systolic and diastolic heart failure_________

·  Some other type of heart failure _________________

·  Undetermined________________________________

Source: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010): expanded web version.

3.Example Yes/No Queries
Compliant Example 1

Clinical Scenario: A patient is admitted with cellulitis around a recent operative wound site, and only cellulitis is documented without any relationship to the recent surgical procedure.

Query: Is the cellulitis due to or the result of the surgical procedure? Please document your response in the health record or below.

Yes _____________

No ______________

Other ___________

Clinically Undetermined ______________

Name: ___________________ Date:__________

Rationale: This is an example of a yes/no query involving a documented condition potentially resulting from a procedure.

Compliant Example 2
Clinical scenario: Congestive heart failure is documented in the final discharge statement in a patient who is noted to have an echocardiographic interpretation of systolic dysfunction and is maintained on lisinopril, Lasix, and Lanoxin.

Query: Based on the echocardiographic interpretation of systolic dysfunction in this patient maintained on lisinopril, Lasix, and Lanoxin can your documentation of “congestive heart failure” be further specified as systolic congestive heart failure? Please document your response in the health record or below.

Yes _____________

No ______________

Other ___________

Clinically Undetermined____________

Name: ___________________ Date:__________

Rationale: This yes/no query provides an example of determining the specificity of a condition that is documented as an interpretation of an echocardiogram.

Compliant Example 3
Clinical scenario: During the removal of an abdominal mass, the surgeon documents, in the description of the operative procedure, a “serosal injury to the stomach was repaired with interrupted sutures.”

Query: In the description of the operative procedure a serosal injury to the stomach was noted and repaired with interrupted sutures. Was this serosal injury and repair:

A complication of the procedure _____________

Integral to the above procedure _____________

Not clinically significant ____________________

Other ___________

Clinically Undetermined____________

Please document your response in the health record or below accompanied by clinical substantiation.

Name: ___________________ Date:__________

Rationale: This is an example of a query necessary to determine the clinical significance of a condition resulting from a procedure.

Non-Compliant Example 1
Clinical scenario: On admission bilateral lower extremity edema is noted, however, there are no other clinical indicators to support malnutrition.

Query: Do you agree that the patient’s bilateral lower extremity edema is diagnostic of malnutrition? Please document your response in the health record or below.

Yes______________

No ______________

Other ___________

Clinically Undetermined ______________

Name: ___________________ Date:__________

Rationale: Malnutrition is not a further specification of the isolated finding of a bilateral lower extremity edema. An open-ended or multiple choice query should be used under this circumstance to ascertain the underlying cause of the patient’s edema.

Non-Compliant Example 2
Clinical scenario: A patient is admitted with an acute gastrointestinal bleed, and the hemoglobin drops from 12 g/dL to 7.5 g/dL and two units of packed red blood cells are transfused. The physician documents anemia in the final discharge statement.

Query: In this patient admitted with a gastrointestinal bleed and who underwent a blood transfusion after a drop in the hemoglobin from 12 g/DL on admission to 7.5 g /dL, can your documentation of anemia be further specified as an acute blood loss anemia? Please document your response in the health record or below accompanied by clinical substantiation.

Yes ______________

No ______________

Other ____________

Clinically Undetermined ____________

Name: ___________________ Date:__________

Rationale: In this example, a yes/no query is not appropriate for specifying the type of anemia. A multiple-choice or open-ended query is a better option.

Non-Compliant Example 3
Clinical Scenario: In the ED, a foley catheter was inserted for the patient with dysuria and elevated WBCs that was removed two days after admission. The cultures were positive for E.coli and the progress note reflect a catheter associated urinary tract infection (CAUTI) and this was coded. Quality has requested review of the HAC condition to ensure it should be coded as it does not meet the CDC definition for CAUTI.

Query: The quality department has indicated that your documented diagnosis of CAUTI does not meet the CDC definition which impacts the Hospital Acquired condition statistics for your profile as well as the hospital. Does your patient have a catheter associated urinary tract infection?

Yes ____________

No ______________

Other ___________

Clinically Undetermined _________________

Name: ___________________ Date:__________

Rationale: This query is inappropriate as it explains the impact of the addition or removal of the diagnosis for the physician and hospital profiles. This query questions the physician’s clinical judgment which may be more appropriate in an escalation policy and/or physician education regarding the CDC definition of CAUTI.


 

Saturday, November 16, 2013

Pain Management CPT Coding



Pain Management CPT Coding

Joints and Bursa – Injection or Aspiration

  • Major joint/bursa: 20610 (knee, hip, shoulder, trochanteric bursa, subacromial bursa, pes anserine bursa)
  • Intermediate joint/bursa: 20605 (temporomandibular, acromioclavicular, wrist, elbow, ankle, olecranon bursa)
  • Minor joint/bursa: 20600 (fingers [PIP, DIP], toes)
  • Sacroiliac joint (SIJ) with fluoroscopy: 27096
  • Sacroiliac joint (SIJ) without fluoroscopy: 20552 (billed as a trigger point injection)
  • Fluoroscopic needle guidance (non-spinal): 77002

Tendons, Ligaments, and Muscle Injections

  • Tendon sheath or Ligament: 20550 (iliolumbar ligament, trigger finger, De Quervain’s tenosynovitis, plantar fascia)
  • Tendon origin/insertion: 20551
  • Trigger point injection (1 or 2 muscles): 20552
  • Trigger point injection (3 or more muscles): 20553
  • Sacroiliac joint (SIJ) without fluoroscopy: 20552 (billed as a trigger point injection)
  • Intramuscular injections: 96372
  • Fluoroscopic needle guidance (non-spinal): 77002

Nerve Blocks

  • Greater occipital nerve block: 64405
  • Lesser occipital nerve block: 64450
  • Other peripheral nerve: 64450 (I use this for third occipital nerve blocks [TON block] and superior cluneal nerve blocks)
  • Other peripheral nerve: 64640 (used for S1, S2, S3 lateral branches during RFA)
  • Suprascapular nerve: 64418
  • Intercostal nerve (single): 64420
  • Intercostal nerve (multiple): 64421
  • Ilioinguinal and Iliohypogastric nerve: 64425
  • Trigeminal nerve (any branch): 64400
  • Sphenopalatine ganglion: 64505
  • Stellate ganglion (cervical sympathetic): 64510
  • Superior hypogastric plexus: 64517
  • Thoracic or lumbar paravertebral sympathetic: 64520
  • Celiac plexus: 64530
  • Plantar common digital nerve (Morton’s neuroma): 64455
  • Unlisted procedure: 64999

Epidural Steroid Injections (ESI)

  • Interlaminar
    • Interlaminar – cervical or thoracic: 62310
    • Interlaminar – lumbar or sacral: 62311
    • Fluoroscopic needle guidance (Spinal): 77003
  • Transforaminal
    • Transforaminal – cervical or thoracic (first level): 64479
    • Transforaminal – cervical or thoracic (each additional level): 64480
    • Transforaminal – lumbar or sacral (first level): 64483
    • Transforaminal – lumbar or sacral (each additional level): 64484
    • Remember: Fluoro can NOT be billed separately for these.
    • Ex: A bilateral L5 TF ESI would be billed as 64483 -50.

Facet Joint Procedures

  • Intraarticular Joint or Medial Branch Block
    • Intraarticular joint or medial branch block (MBB) – cervical or thoracic (1st level or site): 64490
    • Intraarticular joint or medial branch block (MBB) – cervical or thoracic (2nd level or site): 64491
    • Intraarticular joint or medial branch block (MBB) – cervical or thoracic (3rd level or site): 64492
    • Intraarticular joint or medial branch block (MBB) – lumbar or sacral (1st level or site): 64493
    • Intraarticular joint or medial branch block (MBB) – lumbar or sacral (2nd level or site): 64494
    • Intraarticular joint or medial branch block (MBB) – lumbar or sacral (3rd level or site): 64495
    • Note: You can bill for bilateral facets or MBB at the same levels (with the -50 modifier), but you will NOT typically get reimbursed for over 3 facet joints or medial branches on the same side.
    • Ex: Bilateral L3, L4, L5 MBBs would be billed as 64493 -50, 64494 -50, and 64495 -50.
    • Note: Many use 64450 (other peripheral nerve) for third occipital nerve (TON) blocks.
    • Remember: Fluoro can NOT be billed separately for these.

  • Radiofrequency Ablation (RFA) / “Destruction” of Facet Joint
    • Radiofrequency ablation (RFA) – cervical or thoracic (1st joint): 64633
    • Radiofrequency ablation (RFA) – cervical or thoracic (each additional joint): 64634
    • Radiofrequency ablation (RFA) – lumbar or sacral (1st joint): 64635
    • Radiofrequency ablation (RFA) – lumbar or sacral (each additional joint): 64636
    • Remember: Fluoro can NOT be billed separately for these.

Sacroiliac Joint

  • Sacroiliac joint (SIJ) without fluoroscopy: 20552 (billed as a trigger point injection)
  • Sacroiliac joint (SIJ) with fluoroscopy: 27096
  • Sacral lateral branch blocks: 64450
  • Radiofrequency Ablation (RFA) of the Sacroiliac Joint
    • RF of L5 dorsal primary ramus: 64635
    • RF of S1 lateral branches: 64640
    • RF of S2 lateral branches: 64640
    • RF of S3 lateral branches: 64640
    • Fluoroscopic needle guidance (Spinal): 77003 (for the S1-S3 nerve lateral branches, not the L5)
    • Note: Use 724.6 (Disorder of the sacrum) and 721.3 (lumbar spondylosis) as the diagnostic codes

Vertebroplasty / Kyphoplasty

  • Vertebroplasty
    • Vertebroplasty – Thoracic (1st level): 22520
    • Vertebroplasty – Thoracic (each additional level): 22522
    • Vertebroplasty – Lumbar (1st level): 22521
    • Vertebroplasty – Lumbar (each additional level): 22522
    • Note: Same charge whether you perform unilateral or bilateral injection of cement (PMMA).

  • Kyphoplasty
    • Kyphoplasty – Thoracic (1st level): 22523
    • Kyphoplasty – Thoracic (each additional level): 22525
    • Kyphoplasty – Lumbar (1st level): 22524
    • Kyphoplasty – Lumbar (each additional level): 22525
  • Fluoroscopic guidance (radiologic supervision & interpretation) for vertebroplasty or kyphoplasty: 72291
  • Under CT guidance: 72292

Neurostimulation (Spinal Cord Stimulator / Dorsal Column Stimulator)

  • Trial Procedure
    • Percutaneous implant of electrode array: 63650 (includes 10-day global) – bill two units if you implant two trial leads
  • Implantation of Spinal Cord Stimulator Percutaneous Leads and Generator
    • Percutaneous implant of electrode array: 63650 (includes 10-day global)
    • Insertion or replacement of pulse generator: 63685 (includes 10-day global)
  • Implantation of Spinal Cord Stimulator PADDLE Leads and Generator
    • Laminectomy for implant of neurostimulator electrode, paddle: 63655 (includes 90-day global)
    • Insertion or replacement of pulse generator: 63685 (includes 10-day global)
  • Removal of Leads/Generator (Explant)
    • Removal of spinal neurostimulator percutaneous array(s): 63661 (includes 10-day global)
    • Removal of spinal neurostimulator paddle electrode: 63662 (includes 90-day global)
    • Removal of pulse generator: 63688 (includes 10-day global)
  • Important: Also bill for the implanted neurostimulator electrodes (each lead): L8680

Discogram / Discography

  • Discogram / Discography – Cervical/Thoracic (each disc): 62291
  • Supervision & interpretation of fluoroscopy – Cervical/Thoracic (each disc): 72285
  • Discogram / Discography – Lumbar (each disc): 62290
  • Supervision & interpretation of fluoroscopy – Lumbar (each disc): 72295
  • Remember: Fluoroscopy is bundled here and can NOT be billed separately for these.

Botulinum Toxin Injections

  • Botulinum toxin type A – Botox, Dysport (per unit): J0585
  • Botulinum toxin type B – Myobloc (per 100 units): J0587
  • Needle electromyography in conjunction with chemodenervation: 95874
  • Chemodenervation of muscles in the neck (spasmodic torticollis): 64613
  • Chemodenervation of muscles of the trunk and/or extremity (cerebral palsy, dystonia, multiple sclerosis): 64614
  • Chemodenervation of muscles innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (chronic migraine): 64615

Other

  • Carpal tunnel injection: 20526
  • Epidural blood patch: 62273
  • Moderate sedation (first 30 minutes): 99144 (requires presence of another trained person to monitor the patient’s consciousness and vitals)
  • Moderate sedation (each additional 15 minutes): 99145
  • Fluoroscopic needle guidance (spinal): 77003
  • Fluoroscopic needle guidance (non-spinal): 77002
  • CT needle guidance: 77012

Modifiers

  • -50: Bilateral
  • -52: Incomplete procedure (reduced service) [I have used this for hip or epidural injections that the patient didn't tolerate and so it wasn't completed]
  • -26: Professional component only

Injectables (J-codes)

  • Omnipaque 300 (per ml): Q9967
  • Dexamethasone sodium phosphate (per mg): J1100
  • Celestone (per 3 mg): J0702
  • Celestone (per 4 mg): J0704
  • Depo-Medrol (40mg): J1030
  • Depo-Medrol (80mg): J1040
  • Kenalog/Triamcinolone (per 10 mg): J3301
  • Toradol/Ketorolac (per 15mg): J1885 (don’t forget the 96372 code if injected intramuscular)
  • Methocarbamol – Robaxin (up to 10 ml): J2800 (don’t forget the 96372 code if injected intramuscular)
  • Synvisc 3 dose (per 2 ml syringe): J7325
  • Synvisc One (per 6 ml syringe): J7325S
  • Versed (per mg): J2250
  • Fentanyl (0.1 mg): J3010
  • Diphenhydramine – Benadryl (injection up to 50-mg): J1200
  • Botulinum toxin type A – Botox, Dysport (per unit): J0585
  • Botulinum toxin type B – Myobloc (per 100 units): J0587

Electromyography (EMG) & Nerve Conduction Studies (NCS)

  • Sensory NCS (each nerve): 95904
  • Motor NCS w/o F-wave (each): 95900
  • Motor NCS with F-wave (each): 95903
  • H-reflex (gastrocnemius/soleus): 95934
  • H-reflex (other than gastroc/soleus): 95936
  • Blink reflex (orbicularis oculi): 95933 (only once per study)
  • EMG guidance during botulinum toxin injections: 95874
    • Add modifier -26 if you don’t own the EMG machine you’re using
  • EMG w/NCS, each extremity, “limited” (4 or fewer muscles): 95885
  • EMG w/NCS, each extremity, “complete” (5+ muscles, innervated by 3+ nerves or 4+ spinal levels): 95886
  • EMG w/o NCS on same day: one extremity = 95860, two extremities = 95861, three = 95863, four = 95864
  • Cranial nerves
    • EMG (unilateral): 95867
    • EMG (bilateral ): 95868
  • Note: EMG needles can not be billed separately, as they are included in the EMG codes
  • Muscle testing before the study
    • Extremity w/o hand (must include a report of this): 95831
    • Hand: 95832
 
  • 2013 CPT Coding Changes for Nerve Conduction Studies – Effective January 1, 2013
    • Each conduction study is counted as one for sensory, motor with or without F-wave, or H-reflex. Orthodromic and antidromic tests on the same nerve count only once.
    • Example: Bilateral sensory and motor median and ulnar NCS is performed. This is eight (8) separate tests, so the proper code now is 95910. Adding a radial sensory on one side would then make it a 95911.
    • 1-2 NCS = 95907
    • 3-4 NCS = 95908
    • 5-6 NCS = 95909
    • 7-8 NCS = 95910
    • 9-10 NCS = 95911
    • 11-12 NCS = 95912
    • 13+ NCS = 95913

Source: http://thepainsource.com/