Coding Companion for General Surgery/ Gastroenterology. A comprehensive illustrated guide to coding and reimbursement

Transcription

1 Coding Companion for Gnral Surgry/ Gastrontrology A comprhnsiv illustratd guid to coding and rimbursmnt

2 Contnts Gtting Startd with Coding Companion... i Skin...1 Pilonidal Cyst...21 Introduction...22 Rpair...26 Dstruction...59 Brast...62 Gnral Musculoskltal...83 Nck...91 Back...95 Spin...98 Abdomn/Musculoskltal...99 Humrus Forarm/Wrist Hands/Fingrs Plvis/Hip Fmur/Kn Lg/Ankl Foot/Tos Endoscopy Rspiratory Artris and Vins Spln Lymph Nods Diaphragm Esophagus Stomach Intstins Mckl s Divrticulum Appndix Rctum Anus Livr Biliary Tract Pancras Abdomn/Digstiv Tstis Tunica Vaginalis Vas Dfrns Sprmatic Cord/Sminal Vsicls Rproductiv Vagina Thyroid Parathyroid Extracranial Nrvs Mdicin Appndix Evaluation and Managmnt Indx Coding Companion for Gnral Surgry/Gastrontrology Contnts

3 Fmur/Kn [27337, 27339] Excision, tumor, soft tissu of thigh or kn ara, subcutanous; lss than 3 cm cm or gratr Excision, tumor, soft tissu of thigh or kn ara, subfascial (g, intramuscular); lss than 5 cm cm or gratr Explanation Th physician rmovs a tumor from th soft tissu of th thigh or kn ara that is locatd in th subcutanous tissu in and and in th dp soft tissu, blow th fascial plan, or within th muscl in and With th propr ansthsia administrd, th physician maks an incision in th skin ovrlying th mass and disscts to th tumor. Th xtnt of th tumor is idntifid and a dissction is undrtakn all th way around th tumor. A portion of nighboring soft tissu may also b rmovd to nsur adquat rmoval of all tumor tissu. A drain may b insrtd and th incision is rpaird with layrs of suturs, stapls, or Stri-strips. Rport for xcision of a subcutanous tumor whos rsctd ara is lss than 3 cm, and for xcision of a subcutanous tumor that is 3 cm or gratr. Rport for xcision of a subfascial or intramuscular tumor whos rsctd ara is lss than 5 cm, and for xcision of a subfascial or intramuscular tumor that is 5 cm or gratr. Coding Tips Cods hav bn rvisd for 2010 in th official CPT dscription. Cods ar nw for Thy ar rsquncd cods and will not display in numric ordr. An xcisional biopsy is not rportd sparatly whn a thraputic xcision is prformd during th sam surgical sssion. Radical rsction of soft tissu tumor, thigh or kn ara, is rportd with rsquncd cods ; fmur or kn tumor, s ICD-9-CM Procdural Excision of lsion of tndon shath Excision of lsion of muscl Excision of lsion of othr soft tissu Othr xcision of soft tissu Othr local xcision or dstruction of lsion or tissu of skin and subcutanous tissu Radical xcision of skin lsion Ansthsia ICD-9-CM Diagnostic Malignant noplasm of connctiv and othr soft tissu of lowr limb, including hip Malignant mlanoma of skin of lowr limb, including hip Othr malignant noplasm of skin of lowr limb, including hip Malignant noplasm of lowr limb Scondary malignant noplasm of othr spcifid sits Mrkl cll carcinoma of th lowr limb Scondary Mrkl cll carcinoma Lipoma of othr skin and subcutanous tissu Lipoma of othr spcifid sits Othr bnign noplasm of connctiv and othr soft tissu of lowr limb, including hip Lymphangioma, any sit Noplasm of uncrtain bhavior of connctiv and othr soft tissu Noplasms of unspcifid natur of bon, soft tissu, and skin Localizd suprficial swlling, mass, or lump Trms To Know dp fascia. Sht of dns, fibrous tissu lying bnath th subcutanous fat layr that lins xtrmitis and th trunk and holds groups of muscls togthr. intramuscular. Within a muscl. ligamnt. Band or sht of fibrous tissu that conncts th articular surfacs of bons or supports viscral organs. radical rsction. Rmoval of an ntir tumor (.g., malignant noplasm) along with a larg ara of surrounding tissu, including adjacnt lymph nods that may hav bn infiltratd. subfascial. Bnath th band of fibrous tissu that lis dp to th skin, ncloss muscls, and sparats thir layrs. CCI Vrsion , 01320, 10060, 10140, 10160, 20610, , v, 29445, , 29871, 29874, , , 36000, , , 36440, 36600, 36640, 37202, 43752, , , , , 64470, 64475, 64479, 64483, , 69990, , , 93318, 94002, 94200, 94250, , 94770, , 95819, 95822, 95829, 95955, 96360, 96365, 96372, , , Also not with 27327: v, , , , , , 38500, J2001 Also not with 27328: 11012v, 11401, 11404, , , , 20680, 27325, 27327, , 27372, Not: Ths CCI dits ar usd for Mdicar. Othr payrs may rimburs on cods listd abov. Mdicar Edits Fac Non-Fac RVU RVU FUD Assist N/A N/A d d Mdicar Rfrncs: 100-2,15,260; 100-4,12,30; 100-4,12,90.3; 100-4,14, Fmur/Kn CPT only 2009 Amrican Mdical Association. All Rights Rsrvd. Coding Companion for Gnral Surgry/Gastrontrology

4 Elctronic analysis of implantd nurostimulator puls gnrator systm (g, rat, puls amplitud and duration, configuration of wav form, battry status, lctrod slctability, output modulation, cycling, impdanc and patint masurmnts) gastric nurostimulator puls gnrator/transmittr; intraoprativ, with programming subsqunt, without rprogramming subsqunt, with rprogramming Esophagus Nurostimulator Stomach Elctrods Rport for lctronic analysis prformd intraoprativly, rport for subsqunt studis without rprogramming, and for subsqunt studis with rprogramming Explanation Th physician tsts a gastric nurostimulator puls gnrator to vrify that it is functioning proprly. Functions that may b tstd includ rat, puls amplitud and duration, configuration of wavform, battry status, lctrod slctability, output modulation, cycling, impdanc, and patint masurmnt. This cod rports intraoprativ tsting with programming of th dvic. Rport for subsqunt tsting without rprogramming of dvic; with rprogramming, s Coding Tips For laparoscopic implantation, rvision, or rmoval of gastric nurostimulator lctrods, lssr curvatur (morbid obsity), s 0155T 0156T. For insrtion of gastric nurostimulator puls gnrator, s 64590; rvision or rmoval, s ICD-9-CM Procdural Othr nonoprativ masurmnts and xaminations Ansthsia N/A ICD-9-CM Diagnostic Morbid obsity (Us additional cod to idntify Body Mass Indx (BMI), if known: V85.0-V Us additional cod to idntify any associatd mntal rtardation) Gastroparsis (Cod first undrlying disas, as: 249.6, 250.6) Othr complications du to othr intrnal prosthtic dvic, implant, and graft (Us additional cod to idntify complication: , ) V53.99 Fitting and adjustmnt, Othr dvic Trms To Know analysis. Study of body fluid, tissu, sction, or parts. body mass indx. Tool for calculating wight appropriatnss in adults. Th Cntrs for Disas Control and Prvntion placs adult BMIs in th following catgoris: blow 18.5, undrwight; , normal; ovrwight; 30.0 and abov, obs. BMI may b a factor in dtrmining mdical ncssity for bariatric procdurs. Synonym(s): BMI. gastroparsis. Dlay in th mptying of food from th stomach into th small bowl du to a dgr of paralysis in th muscls lining th stomach wall. puls gnrator. Circuit usd to gnrat pulss. Puls gnrators contain th battry, th lctronic circuit, and th connctor in a hrmtically sald ncasmnt. Puls gnrators may b tmporary transcutanous or placd in a subcutanous pockt. CCI Vrsion 15.3 Also not with 95980: v Also not with 95982: 95981v Not: Ths CCI dits ar usd for Mdicar. Othr payrs may rimburs on cods listd abov. Mdicar Edits Fac Non-Fac RVU RVU FUD N/A N/A N/A Mdicar Rfrncs: Non Assist Mdicin CPT only 2009 Amrican Mdical Association. All Rights Rsrvd. Coding Companion for Gnral Surgry/Gastrontrology Mdicin 699

5 Evaluation and Managmnt This sction provids an ovrviw of valuation and managmnt (E/M) srvics, tabls that idntify th documntation lmnts associatd with ach cod, and th fdral documntation guidlins with mphasis on th 1997 xam guidlins. This st of guidlins rprsnt th most complt discussion of th lmnts of th currntly accptd vrsions. Th 1997 vrsion idntifis both gnral multi-systm physical xaminations and singl-systm xaminations, but providrs may also us th original 1995 vrsion of th E/M guidlins; both ar currntly supportd by th Cntrs for Mdicar and Mdicaid Srvics (CMS) for audit purposs. Although som of th most commonly usd cods by physicians of all spcialtis, th E/M srvic cods ar among th last undrstood. Ths cods, introducd in th 1992 CPT manual, wr dsignd to incras accuracy and consistncy of us in th rporting of lvls of non-procdural ncountrs. This was accomplishd by dfining th E/M cods basd on th dgr that crtain common lmnts ar addrssd or prformd and rflctd in th mdical documntation. Th Offic of th Inspctor Gnral (OIG) Work Plan for physicians consistntly lists ths cods as an ara of continud invstigativ rviw. This is primarily bcaus Mdicar paymnts for ths srvics total approximatly $29 billion pr yar and ar rsponsibl for clos to half of Mdicar paymnts for physician srvics. Th lvls of E/M srvics dfin th wid variations in skill, ffort, and tim and ar rquird for prvnting and/or diagnosing and trating illnss or injury, and promoting optimal halth. Ths cods ar intndd to rprsnt physician work, and bcaus much of this work involvs th amount of training, xprinc, xprtis, and knowldg that a providr may bring to bar on a givn patint prsntation, th tru indications of th lvl of this work may b difficult to rcogniz without som xplanation. At first glanc, slcting an E/M cod may appar to b difficult, but th systm of coding clinical visits may b mastrd onc th rquirmnts for cod slction ar larnd and usd. Typs of E/M Srvics Whn approaching E/M, th first choic that a providr must mak is what typ of cod to us. Th following tabls outlin th E/M cods for diffrnt lvls of car for: Offic or othr outpatint srvics nw patint Offic or othr outpatint srvics stablishd patint Hospital obsrvation srvics Hospital inpatint srvics initial car Hospital inpatint srvics subsqunt car Obsrvation or inpatint car (including admission and discharg srvics) Consultations offic or othr outpatint Consultations inpatint Th spcifics of th cod componnts that dtrmin cod slction ar listd in th tabl and discussd in th nxt sction. Bfor a lvl of srvic is dcidd upon, th corrct typ of srvic is idntifid. Offic or othr outpatint srvics ar E/M srvics providd in th physician s offic, th outpatint ara, or othr ambulatory facility. Until th patint is admittd to a halth car facility, h/sh is considrd to b an outpatint. A nw patint is a patint who has not rcivd any fac-to-fac profssional srvics from th physician within th past thr yars. An stablishd patint is a patint who has rcivd fac-to-fac profssional srvics from th physician within th past thr yars. In th cas of group practics, if a physician of th sam spcialty has sn th patint within thr yars, th patint is considrd stablishd. If a physician is on call or covring for anothr physician, th patint s ncountr is classifid as it would hav bn by th physician who is not availabl. Thus, a locum tnns physician who ss a patint on bhalf of th patint s attnding physician may not bill a nw patint cod unlss th attnding physician has not sn th patint for any problm within thr yars. Hospital obsrvation srvics ar E/M srvics providd to patints who ar dsignatd or admittd as obsrvation status in a hospital. Cods ar usd to indicat initial obsrvation car. Ths cods includ th initiation of th obsrvation status, suprvision of patint car including writing ordrs, and th prformanc of priodic rassssmnts. Ths cods ar usd only by th physician admitting th patint for obsrvation. Cods ar usd to indicat valuation and managmnt srvics to a patint who is admittd to and dischargd from obsrvation status or hospital inpatint on th sam day. If th patint is admittd as an inpatint from obsrvation on th sam day, us th appropriat lvl of Initial Hospital Car ( ). Cod indicats discharg from obsrvation status. It includs th final physical xamination of th patint, instructions, and Evaluation and Managmnt CPT only 2009 Amrican Mdical Association. All Rights Rsrvd. Coding Companion for Gnral Surgry/Gastrontrology Evaluation and Managmnt 731