2017 Physician Coding Survival Guide

Transcription

1 2017 Physician Coding Survival Guide Chapter 3: Dermatology Melanoma: Stop Melanoma Coding Errors Before They Spread If the dermatologist gets down to the fascia, would you still stick with an integumentary code? Those answers and more below. Skin cancer is the most common form of cancer, according to the American Cancer Society. The rates of melanoma have been rising over the last 30 years, and the ACS estimates that 76,380 new cases will be diagnosed in Some of those will surely be in your practice. Are you ready for the challenges of melanoma coding? Or do you still frequently ask one of the questions below? Read on for our expert answers. Question: Should we bill melanoma treatments using the skin or musculoskeletal codes? Answer: Even if the dermatologist removes tissue down to but not including the fascia, you should only report the procedures with a code from the integumentary CPT series. Example: The dermatologist re-excises a melanoma of 11 cm by 3.3 cm (excised diameter) on the patient s left upper arm. The surgeon removed tissue down to, but not including, the fascia. The defect required an intermediate repair. You should code this using the appropriate codes from the CPT Integumentary Section, such as (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm) for the excision, and (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 7.6 to 12.5 cm) for the repair. Even though the dermatologist went below the integumentary layer, you would not report a CPT code from the musculoskeletal section, such as (Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous, less than 3 cm). Here s why: Because the case is for a melanoma, you re dealing with a skin lesion, not a soft tissue tumor, so you should use the skin codes. Melanoma can spread unlike basal cell carcinoma, or be so large as to require an excision that does require going through the fascia and possibly removing soft tissue. Melanoma does spread to lymph nodes and other organs. Basal cell carcinoma is never deeper than skin. Important: The fascia is a boundary between the integumentary codes and the soft-tissue ones. One may only use the soft tissue codes if tissue below the fascia has been removed. Question: Can we bill repair separately after a melanoma excision? Answer: Sometimes. Malignant lesion excision codes include simple repair, but you can additionally code for an intermediate or complex repair if the surgeon documents that type of closure. What s the difference? A simple repair generally includes a single-layer closure. But when you see the term intermediate repair, it means your physician performed one of two things: Layered closure of one or more deeper layers (subcutaneous and superficial fascia/non-muscle) in addition to skin; or

2 Single-layer closure of heavily contaminated wounds requiring extensive cleaning. Complex repair procedures are more than multilayered closure and include a wide range of possibilities such as scar revision or involved debridement. Complex repair generally includes extensive undermining, stenting, or retention sutures. Complex repair is very time-consuming. Tissue transfers such as Z-plasty and W plasty include the excision, since tissue must be removed to obtain the repair. Some coders may find this challenging what they consider a complex repair may turn out to be a tissue transfer. Do this: What you need to know to bill the closure is the longest dimension of the wound. This is likely to be quite a bit longer than the excision itself, because surgeons often create an elliptical excision, which is needed for a clean closure. You will identify the total length of the repair and choose the intermediate repair code that matches that length. For instance: The dermatologist creates an elliptical excision 6 cm long surrounding a 2.5 x 1.5 x 1.0 cm lesion excision with 1 cm margins on the scalp. You should report the intermediate repair with CPT code (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm) in addition to the excision code (11604, Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 3.1 to 4.0 cm). On average nationally, CPT code alone brings $ in a non-facility, according to the Medicare Physician Fee Schedule. Reporting separately brings in an additional $ These rules for closure coding apply for excision of benign and malignant lesions of both the integumentary system (114xx-116xx) and the musculoskeletal system for lesions such as lipomas (e.g., 21011, Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm). The only difference is that you can only separately report complex repair with muscle/soft tissue lesions, while you can separately report intermediate and complex repair with integumentary lesions. Question: Is the diagnosis coding different for in situ melanoma vs. malignant melanoma? Answer: Once upon a time, it wasn t but that time is past. The ICD-9 diagnosis codes for malignant melanoma of skin (172.x) did include melanoma in situ But effective Oct. 1, 2015, the code set for malignant melanoma of skin expanded considerably. In addition to more specificity in body location (for example, different ICD-10 codes for melanoma on right and left eyelids), the new diagnosis codes will distinguish between malignant melanoma and melanoma in situ. Example: Under ICD-10, you have these expanded options for a malignant melanoma of the eyelid: C43.10 Malignant melanoma of unspecified eyelid, including canthus C43.11 right eyelid, including canthus C43.12 left eyelid, including canthus D03.10 Melanoma in situ of unspecified eyelid, including canthus D03.11 right eyelid, including canthus D03.12 left eyelid, including canthus. Tip: Just as in ICD-9, your first stop when coding for a neoplasm in ICD-10 is the Neoplasm Table. You ll find the table just after the end of the Alphabetic Index in your coding manual, rather than under N in the Alphabetic Index. Question: Can we report adjacent tissue transfer separately from melanoma repair? Answer: No. In cases involving adjacent tissue transfer to close a repair after a melanoma excision, you can only report one CPT code: the tissue transfer itself. That code includes the excision, so you cannot report it separately. Example: The dermatologist excises a melanoma of the face and closes using adjacent tissue transfer. You may be tempted to code both (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; defect 10 sq cm or less) and (Excision, malignant lesion including margins, face, ears,

3 eyelids, nose, lips; excised diameter 2.1 to 3.0 cm). You should report only for the closure using existing tissue transfer. Evaluation & Management: Think a Patient Must Be "Established" Forever? Think Again These myths could be holding back your dermatology practice s E/M claims. Whenever a patient sees your dermatologist for an E/M encounter in the office, a first step to determining the appropriate E/M code to report for the visit is knowing if the patient is new or established. But these common myths that will help you overcome coding hurdles and help you better understand the rules for when to report a new patient E/M code and when to use an established patient E/M code. Myth 1: Patient Once Seen Is Always Established Reality: This is not true. According to CPT s definition, an established patient is one who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. So, if the patient has not visited your clinician or any other physician in your specialty or subspecialty in the same group in the past three years, then you can report the E/M encounter that the patient has with an appropriate new patient E/M code. Reimbursement: Apart from raising red flags for coding wrong between new patient E/M codes and established patient E/M codes, you also stand to lose out on deserved pay if you are reporting an established patient code when you should have reported a new patient E/M code. For instance, you would be foregoing about $63 in reimbursement under Medicare if you report instead of The 2016 non-facility total relative value units (RVUs) for are 5.82 RVUs while carries 4.07 total RVUs in the non-facility setting. This translates to a Medicare reimbursement of $ for while you will only receive $ for So, you will lose out on deserved pay if you mistakenly report an established patient E/M code when you actually could have reported a new patient code. Hence, whenever your clinician performs an E/M service for a patient that he or anyone in the same specialty within the group has seen before, don t be in a hurry and report an established patient code. Check when your clinician or the other physician has last seen the patient and if the time gap has been more than 3 years, report the encounter with a new patient E/M code. Myth 2: Patient Seen by Any Physician Is Established Reality: If your practice is a multispecialty practice and the patient has been seen by a physician from a different specialty within the practice before seeing your dermatologist, you should not necessarily consider that patient as an established patient. If the patient has seen a physician from another specialty in the past three years but has not received services from your dermatologist or any other dermatologist in the group in the past three years, then the patient should be considered new and not established when they see the dermatologist. The definition of established patient includes the phrase exact same specialty and subspecialty who belongs to the same group practice. That means that if the patient is seeing physicians from different specialties within the group in a three year span, then the patient may be a new patient for one physician in a given specialty even though he has seen a physician from another specialty in the group. This is another area in which a patient s lack of knowledge of the CPT definitions may necessitate deviating from what is technically permissible to code for the sake of patient relations. Explaining to a patient that they are new because they saw a dermatologist today and a cardiologist in the same practice two years ago will be difficult, bordering on impossible. To avoid patient disgruntlement and potential bad word of mouth about the practice, it may be preferable to code the encounter with the dermatologist as established, even though that is technically incorrect and results in lost income to

4 the practice for that encounter. Laceration Repair: 5 Tips to Stitch Up Your Laceration Repair Coding Errors Information particularly location, length, and type of repair provides the power to get to the right CPT code. CPT includes several rules with numerous variables to guide coding for wound repair or closure. You must consider wound severity and location to determine the appropriate code from the repair section. And variables such as depth of the wound, method of closure, and degree of contamination of the site can complicate your choice further. However, you can greatly simplify even the most confusing scenarios by using these five tips from our experts. Tip 1: Determine the Location Within each level of repair, CPT further classifies wounds according to anatomic location. Note that these categories are not identical for each repair level. Example: For simple repairs, CPT groups the scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet) together as covered by For intermediate repairs, describe layered closure of wounds of scalp, axillae, trunk and/or extremities excluding hands and feet, while apply for repair of wounds to neck, hands, feet and/or external genitalia. For complex repairs, the subclassifications are still more precise, with separate sections for trunk; scalp, arms and/or legs; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet, etc. Tip 2: Consider Wound Severity After you have determined that the repair or closure codes apply and the location of the wound, you must assess the severity of the wound itself. CPT classifies repairs as simple, intermediate or complex, according to wound depth, with each category receiving its own complement of codes. Simple repairs are superficial wounds that involve primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, according to CPT. Additionally, CPT stresses only simple, one layer, primary suturing is required. Physicians will refer to these as single-layer closures. CPT code range covers such repairs, which include local anesthesia and chemical or electro-cauterization of wounds left unclosed. Intermediate repairs are more extensive and involve one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure, according to CPT. If the physician mentions layered closure, you probably have an intermediate repair. A single-layer closure may qualify as an intermediate repair if the wound is heavily contaminated and requires extensive cleaning or removal of particulate matter. A common example of this is repair of road rash wounds that result from falling on gravel, blacktop or concrete surfaces. CPT code range describes intermediate closures. Complex repairs involve more than layered closure, such as extensive undermining, stents or retention sutures. If the physician mentions repair to the depth of muscle or deeper, it s probably a complex repair. Complex repairs are often reconstructive procedures and include creation of a defect to be repaired (for instance, excision of the scar and subsequent closure). Such repairs do not, however, include excision of lesions.

5 Coding for complex repairs differs slightly from coding for other wound repairs. With complex repairs, CPT assigns add-on codes for each additional 5 cm beyond 7.5 cm. You may bill multiple units of these add-on codes when necessary. Report complex repairs using code range To determine the level of repair, pay close attention to the operative report. Single-layer closures are generally simple unless the physician has noted extensive cleansing of the wound, in which case they may be intermediate. Duallayer closures are considered as intermediate. Extensive revision or repair of traumatic lacerations or avulsions are considered complex. Tip 3: How Was It Closed? Before you can code for wound closure, you must determine if the wound repair or closure codes apply. If the doctor determines that the severity of the laceration does not warrant stitches, staples, or tissue adhesive, and instead closes the wound using Steri-strips or butterfly bandages, however, you may report only the appropriate E/M service code, as supported by the chart documentation. According to CPT, codes designate closure utilizing sutures, staples, or tissue adhesive (such as 2- cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips. Although CPT does not differentiate among stitches, staples and tissue adhesive, and the coding does not change regardless of the physician s method of closure, Medicare has different rules. Effective January 1, 2000, a new HCPCS code, G0168 (Wound closure utilizing tissue adhesive[s] only), was established for Dermabond or other tissue adhesive applications. G0168 is defined as wound closure utilizing tissue adhesive(s) only. The rationale for this code and its RVU assignment is based on FDA data that show wounds closed with tissue adhesives take, on average, one-quarter of the time needed to close a wound with traditional method of treatment, including use of wound closure tapes. As a result, the payment for repair using adhesives is less than one using sutures. For 2016, the Medicare facility payment for code (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) is $45.47 while the payment for G0168 is $ Caution: Adhesive strips alone don t qualify for wound repair. If the physician closes the wound using adhesive strips only, you may not report the repair or closure codes. Instead, you would report wound closure using adhesive strips as the sole repair material as a part of any E/M service the physician provides. This creates a divergence between CMS policy and CPT rules as well as a difference in code choice for simple versus intermediate or complex repairs. For non-medicare patients, you ll code for a simple laceration repair with adhesives with the applicable 12xxx CPT code. If it is an intermediate or complex closure code for it with the appropriate CPT code, regardless of whether adhesives was used or not. But for Medicare patients, you ll code for a simple laceration repair with adhesives with G0168, and an intermediate or complex closure with the appropriate CPT code regardless of whether adhesive was used or not, since sutures would be used for the deeper layers. Tip 4: Measure It and Add It Up In addition to severity (depth) and anatomic location, CPT groups repair and closure procedures according to the size (length) of the wound. Example: Code describes simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less, whereas (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 7.6 cm to 12.5 cm) describes repair of the same severity and location, but of 7.6 cm to 12.5 cm length.

6 Remember: Reporting should be based on the size of the wound. Under the Repair (Closure) section, the first instruction for coding is to report the size of the repaired wound. It is important to note that depending on the type of repair performed, some wounds will have a final defect size that is greater than the original defect size. Base your CPT code assignment on the documented wound size, which is typically performed after cleaning of the wound and prior to repair. Don t Forget To Combine Similar Repairs When Indicated After you have determined the location, length, classification, and means of closure for all individual repairs or closures, add together the lengths of the various wounds at each identical level of severity and classified anatomic location to arrive at a total length. CPT treats all wounds at the same level of severity and anatomic subcategory as a single wound. Tip 5: Consider the Global Period Medicare rules for simple repairs can differ from those for intermediate and complex codes. Medicare changed the payment policy for simple laceration repairs starting in 2011 by changing the global surgical package from ten days to zero days. Since then, the follow-up visit for a wound check and suture removal is no longer included in the payment for suturing, stapling or using tissue adhesives on superficial wounds primarily involving the epidermis or dermis without deeper damage. This change came about in part because Medicare officials did not believe it was typical for emergency department patients to return to the ED where the sutures were placed to have them removed ten days later. Pressure Ulcers: Ease the Pressure of Pressure Ulcer Claims With the Right Dx and Procedure Codes Tip: Each character of the ICD-10 code makes the diagnosis more specific. Common among patients with limited movement, pressure ulcers (also known as decubitus ulcers) are certainly worrisome for those afflicted with them. But they can also be vexing to dermatology coders, especially now that ICD-10 is in effect. Read on to see if one of your frequently asked questions about pressure ulcer coding is tackled by our experts. Question: What are the diagnosis codes for pressure ulcers? Answer: Start with the L89 (Pressure ulcer) series in ICD-10. You will then have to select three further characters to fully describe the ulcer. Fourth character: After L89 (and the decimal point), the fourth character describes the location of the pressure ulcer. For the different bodily areas, those characters are: 0: Elbow 1: Back 2: Hip 3: Buttock 4: Contiguous site of back, buttock, and hip 5: Ankle 6: Heel 7: Other site 8: Unspecified site

7 Fifth character: The fifth character narrows down the site of the ulcer even further. For example, for a pressure ulcer on the elbow, you have three choices for a fifth character: 0: Unspecified elbow 1: Right elbow 2: Left elbow For a pressure ulcer on the back, you have six options: 0: Unspecified part of back 1: Right upper back 2: Left upper back 3: Right lower back 4: Left lower back 5: Sacral region Sixth character: The sixth and final character describes the stage of the ulcer: 0: Unstageable 1: Stage 1 2: Stage 2 3: Stage 3 4: Stage 4 5: Unspecified Put it together: Once you have all the information about location and staging, you can come up with the correct ICD-10 code. For example, you would code a stage 3 ulcer on the right elbow as L A stage 1 ulcer of the right upper back would be L Question: How do I know what stage an ulcer is? Answer: Always check with the dermatologist to confirm the stage. You can find hints, however, in how ICD-10 describes the different stages: Stage 1: Pressure pre-ulcer skin changes limited to persistent focal edema Stage 2: Pressure ulcer with abrasion, blister, partial thickness skin loss involving epidermis and/or dermis Stage 3: Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue Stage 4: Pressure ulcer with necrosis of soft tissues through to underlying muscle, tendon, or bone Finding those specific terms in your dermatologist s documentation can lead you to the correct diagnosis code. Question: What about procedure codes for treatment? Answer: The CPT code you report for your dermatologist s treatment of pressure ulcers (also known as decubitus ulcers) will depend on the location and the method of treatment. Your coding will also change if the surgeon also removed infected bone under the sore; however, it would be unlikely that a dermatologist would do this. Your dermatologist may just close the ulcer wound using a primary suture. This is usually the case when your surgeon is treating smaller pressure ulcers. In these situations, you confirm the location of the pressure ulcer and report code (Excision, sacral pressure ulcer, with primary suture), (Excision, ischial pressure ulcer, with primary suture), or

8 15950 (Excision, trochanteric pressure ulcer, with primary suture) for ulcers on the sacrum, ischium, or trochanter, respectively. Note: The series of CPT contains specific codes for these anatomic areas: Sacrum (bottom of the spine) Ischium (base of the pelvis) Trochanter (hip area) If the pressure ulcer is somewhere else the elbow, for example you would need to turn to CPT code (Unlisted procedure, excision pressure ulcer). Although CPT provides 20 pressure ulcer codes ( ), those aren t your only choices when your surgeon treats a decubitus ulcer. Find out: Did the dermatologist excise the ulcer and close the wound, or did she debride the ulcer and allow the wound to stay open to heal? A debridement will lead you to CPT codes (Debridement ). Both debridement and excision are ways to remove the ulcer and clear infection, so you ll need to look for documentation regarding the closure to help you choose the proper code. For example, the dermatologist might document an ulcer removal by stating, The skin was cut in an elliptical fashion around the lesion, and the excised lesion was sent to pathology. But the code choice could depend on a statement such as, The wound was packed open to drain and heal by secondary intention, (debridement) versus The surgeon closed the wound with 4-0 sutures in a layered fashion, (excision). According to CPT instruction, you should report debridement codes by depth of tissue that is removed and by surface area of the wound. The codes describe the following three depths: Subcutaneous tissue (includes epidermis and dermis, if performed) and Muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed) and Bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed) and Calculate area: Each of the preceding pairs of codes identifies the first 20 sq. cm. or less for the first code in the pair, and each additional 20 sq. cm. or part thereof for the add-on code from the pair. - Published on