Coding Companion for OB/GYN. A comprehensive illustrated guide to coding and reimbursement

Transcription

1 Coing Companion for OB/GYN A comprehensive illustrate guie to coing an reimbursement 2009

2 Contents Getting Starte with Coing Companion... i Skin...1 Pilonial Cyst...11 Implant...12 Repair...14 Destruction...22 Breast...23 Arteries an Veins...35 Lymph Noes Hemi/Lymphatic...39 Intestines...44 Anus...45 Abomen...57 Ureter...72 Blaer...73 Urethra...86 Reprouctive...94 Vulva Vagina Cervix Uteri Corpus Uteri Oviuct Ovary In Vitro Maternity Care Nervous Operating Microscope Raiology Meicine Appenix Evaluation an Management Inex Coing Companion for OB/GYN Contents

3 Abomen Laparoscopy, surgical; with insertion of intraperitoneal cannula or catheter, permanent with revision of previously place intraperitoneal cannula or catheter, with removal of intraluminal obstructive material if performe Coing Tips Surgical laparoscopy always inclues iagnostic laparoscopy. To report a iagnostic laparoscopy (peritoneoscopy), see Subcutaneous extension of intraperitoneal catheter with remote chest exit site is reporte separately, see For open insertion of permanent intraperitoneal cannula or catheter, see ICD-9-CM Proceural Other operations of abominal region catheter. Flexible tube inserte into an area of the boy for introucing or withrawing flui. intraperitoneal. Within the cavity or space create by the ouble-layere sac that lines the abominopelvic walls an forms a covering for the internal organs. laparoscopy. Direct visualization of the peritoneal cavity, outer fallopian tubes, uterus, an ovaries utilizing a laparoscope, a thin, flexible fiberoptic tube. Explanation A permanent intraperitoneal catheter is inserte laparoscopically for continuous rug infusion, such as insulin, morphine, or chemotherapeutic agents. The physician makes a 1 cm incision in the umbilicus through which the abomen is inflate an a fiberoptic laparoscope is inserte. Other incisions are also mae through which trocars can be passe into the abominal cavity to eliver aitional instruments. The physician manipulates the tools so that the pelvic organs, peritoneum, abomen, an omentum can be viewe through the laparoscope an/or vieo monitor. If the physician is inserting a totally implantable, intraperitoneal rug elivery system, the pump reservoir is secure into a surgically prepare pocket in the subcutaneous fat of the lower or mi-left abomen. The infusion line catheter from the pump is place insie the peritoneal cavity with the tip free moving. If the physician is revising an intraperitoneal catheter, the catheter is inspecte an free of occlusion or blockage. When either proceure is complete, the laparoscope an other instruments are remove an the incisions are close with sutures. Report for insertion of an intraperitoneal cannula or catheter an for its revision. Anesthesia 00790, ICD-9-CM Diagnostic Malignant neoplasm of retroperitoneum Malignant neoplasm of specifie parts of peritoneum Malignant neoplasm of ill-efine sites of igestive organs an peritoneum Malignant neoplasm of corpus uteri, except isthmus Malignant neoplasm of isthmus Malignant neoplasm of other specifie sites of boy of uterus Malignant neoplasm of ovary (Use aitional coe to ientify any functional activity) Malignant neoplasm of fallopian tube Malignant neoplasm of roun ligament of uterus Malignant neoplasm of other specifie sites of uterine anexa Malignant neoplasm of other specifie sites of female genital organs Seconary malignant neoplasm of retroperitoneum an peritoneum Seconary malignant neoplasm of ovary Abominal pain, unspecifie site Abominal pain, right upper quarant Abominal pain, left upper quarant Abominal pain, right lower quarant Abominal pain, left lower quarant Abominal pain, periumbilic Abominal pain, epigastric Abominal pain, generalize Abominal pain, other specifie site Other postoperative infection (Use aitional coe to ientify infection) Terms To Know cannula. Tube inserte into a bloo vessel, uct, or boy cavity to facilitate passage. CCI Version , 36410, 37202, 43653, 43752, 44005, 44180, 49000, 49320, 49400, v, 50715, , 58660, , , 64450, 64470, 64475, 69990, 90760, 90765, 90772, 90774, Also not with 49324: Also not with 49325: 49324v Note: These CCI eits are use for Meicare. Other payers may reimburse on coes liste above. Meicare Eits Fac Non-Fac RVU RVU FUD Meicare References: None Assist 66 Abomen CPT only 2008 American Meical Association. All Rights Reserve. Coing Companion for Ob/Gyn

4 Resection (tumor ebulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abominal, retroperitoneal tumors), with omentectomy, if performe; with pelvic lymphaenectomy an limite para-aortic lymphaenectomy Explanation These coes report tumor ebulking in recurrent ovarian, uterine, tubal, or peritoneal malignancies. Through a full abominal incision extening from just above the pubic hairline to the rib cage, the physician explores the abomen, pelvis, an viscera. In aition to ebulking recurrent malignancy, the physician releases intestinal ahesions or excises all or portions of the omentum, ovaries, or fallopian tubes. The physician may remove all visible tumors or only reuce their size, epening on the nature of the malignancy an the structures involve. The abominal incision is close with layere sutures. Report when pelvic an para-aortic lymph noes are also remove. Coing Tips If significant aitional time an effort is ocumente, appen moifier 22 an submit a cover letter an operative report. This is a bilateral proceure an as such is reporte once even if the proceure is performe on both sies inclues any lymphaenectomy or omentectomy the physician may perform. For initial malignancy of the ovaries, uterus, tubes, or primary peritoneal structures, see For staging of tubal, ovarian, or primary peritoneal malignancy, see ICD-9-CM Proceural 40.3 Regional lymph noe excision 54.4 Excision or estruction of peritoneal tissue Anesthesia ICD-9-CM Diagnostic Malignant neoplasm of specifie parts of peritoneum Malignant neoplasm of peritoneum, unspecifie Malignant neoplasm of ovary (Use aitional coe to ientify any functional activity) Malignant neoplasm of fallopian tube Malignant neoplasm of other specifie sites of uterine anexa Seconary an unspecifie malignant neoplasm of intra-abominal lymph noes Seconary an unspecifie malignant neoplasm of intrapelvic lymph noes Seconary malignant neoplasm of ovary Seconary malignant neoplasm of genital organs retroperitoneum an peritoneum ovary (Use aitional coe to ientify any functional activity) other an unspecifie female genital organs V84.02 Genetic susceptibility to malignant neoplasm of ovary (Use aitional coe, if applicable, for any associate family history of the isease: V16-V19. Coe first, if applicable, any current malignant neoplasms: , V84.04 Genetic susceptibility to malignant neoplasm of enometrium (Use associate family history of the isease: V16-V19. Coe first, if applicable, any current malignant neoplasms: , V84.09 Genetic susceptibility to other malignant neoplasm (Use associate family history of the isease: V16-V19. Coe first, if applicable, any current malignant neoplasms: , Terms To Know lymphaenectomy. Dissection of lymph noes free from the vessels an removal for examination by frozen section in a separate proceure to etect early-stage metastases. malignant. Any conition tening to progress towar eath, specifically an invasive tumor with a loss of cellular ifferentiation that has the ability to sprea or metastasize to other areas in the boy. omentum. Fol of peritoneal tissue suspene between the stomach an neighboring visceral organs of the abominal cavity. resection. Surgical removal of a part or all of an organ or boy part. CCI Version , 36410, 37202, , 38770, 38780, 43752, 44005, 44180, , 44950, , 49080, 49180, , 49215, 49255, 49320, 49570, 50715, , 57410, , 58548, , , , , 58943, 58960, , , 64450, 64470, 64475, 69990, 90760, 90765, 90772, 90774, Also not with 58957: , Also not with 58958: , Note: These CCI eits are use for Meicare. Other payers may reimburse on coes liste above. Meicare Eits Fac Non-Fac RVU RVU FUD Meicare References: None Assist Ovary CPT only 2008 American Meical Association. All Rights Reserve. Coing Companion for Ob/Gyn Ovary 261

5 Evaluation an Management This section provies an overview of evaluation an management (E/M) services, tables that ientify the ocumentation elements associate with each coe, an the feeral ocumentation guielines with emphasis on the 1997 exam guielines. This set of guielines represent the most complete iscussion of the elements of the currently accepte versions. The 1997 version ientifies both general multi-system physical examinations an single-system examinations, but proviers may also use the original 1995 version of the E/M guielines; both are currently supporte by the Centers for Meicare an Meicai Services (CMS) for auit purposes. Although some of the most commonly use coes by physicians of all specialties, the E/M service coes are among the least unerstoo. These coes, introuce in the 1992 CPT manual, were esigne to increase accuracy an consistency of use in the reporting of levels of non-proceural encounters. This was accomplishe by efining the E/M coes base on the egree that certain common elements are aresse or performe an reflecte in the meical ocumentation. The Office of the Inspector General (OIG) Work Plan for physicians consistently lists these coes as an area of continue investigative review. This is primarily because Meicare payments for these services total approximately $29 billion per year an are responsible for close to half of Meicare payments for physician services. The levels of E/M services efine the wie variations in skill, effort, an time an are require for preventing an/or iagnosing an treating illness or injury, an promoting optimal health. These coes are intene to represent physician work, an because much of this work involves the amount of training, experience, expertise, an knowlege that a provier may bring to bear on a given patient presentation, the true inications of the level of this work may be ifficult to recognize without some explanation. At first glance, selecting an E/M coe may appear to be ifficult, but the system of coing clinical visits may be mastere once the requirements for coe selection are learne an use. Types of E/M Services When approaching E/M, the first choice that a provier must make is what type of coe to use. The following tables outline the E/M coes for ifferent levels of care for: Office or other outpatient services new patient Office or other outpatient services establishe patient Hospital observation services Hospital inpatient services initial care Hospital inpatient services subsequent care Observation or inpatient care (incluing amission an ischarge services) Consultations office or other outpatient Consultations inpatient The specifics of the coe components that etermine coe selection are liste in the table an iscusse in the next section. Before a level of service is ecie upon, the correct type of service is ientifie. Office or other outpatient services are E/M services provie in the physician s office, the outpatient area, or other ambulatory facility. Until the patient is amitte to a health care facility, he/she is consiere to be an outpatient. A new patient is a patient who has not receive any face-to-face professional services from the physician within the past three years. An establishe patient is a patient who has receive face-to-face professional services from the physician within the past three years. In the case of group practices, if a physician of the same specialty has seen the patient within three years, the patient is consiere establishe. If a physician is on call for or covering for another physician, the patient s encounter is classifie as it woul have been by the physician who is not available. Thus, a locum tenens physician who sees a patient on behalf of the patient s attening physician may not bill a new patient coe unless the attening physician has not seen the patient for any problem within three years. Hospital observation services are E/M services provie to patients who are esignate or amitte as observation status in a hospital. Coes are use to inicate initial observation care. These coes inclue the initiation of the observation status, supervision of patient care incluing writing orers, an the performance of perioic reassessments. These coes are use only by the physician amitting the patient for observation. Coes are use to inicate evaluation an management services to a patient who is amitte to an ischarge from observation status or hospital inpatient on the same ay. If the patient is amitte as an inpatient from observation on the same ay, use the appropriate level of Initial Hospital Care ( ). Coe inicates ischarge from observation status. It inclues the final physical examination of the patient an instructions an Evaluation an Management CPT only 2008 American Meical Association. All Rights Reserve. Coing Companion for OB/GYN Evaluation an Management 391