2017 Coding and Reimbursement Survival Guide

Transcription

1 2017 Coding and Reimbursement Survival Guide Chapter 8: General Surgery Integumentary Procedures: 4 Questions Focus Your Skin Substitute Graft Coding Hint: Graft size doesn t matter. If your surgeon treats burn victims, trauma patients, or others suffering from serious skin conditions, you need to know how to code skin substitute grafts. With so many facts wound size, graft size, site prep, attachment method, and more you need to master a lot of details to make sure you choose the correct code and capture the pay your surgeon deserves. Do this: Use the following four questions and answers to hone your skin substitute graft coding know-how. Question 1: To select a CPT code for skin substitute grafting, should I use the wound size or the size of the actual graft? Answer 1: You should report grafts according to wound location and size, which the surgeon should record at the time of the procedure, experts say. Surgeons need to be specific in their op notes about both the size of the wound and the size of the graft. Experts recommend that surgeons use a flexible ruler to measure the size of the wound, because wounds are not flat and the extra size for the depth can make a difference in coding and in reimbursement. Here s why: If the patient has a large wound but the surgeon covers only part of the wound with skin substitute, you should still select the skin substitute code based on the larger wound size. The opposite is also true, which you can see in the following example. Example: The surgeon excises a 1-cm melanoma with a 2-cm margin from a patient s left arm, then applies a 30-sq.-cm skin substitute graft with sutures and dresses the area. In the current example, the surgeon documents a 5-cm diameter excision (19.6 sq cm), but a 30-sq. cm skin substitute graft. That means you should code the skin substitute graft as (Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area). Watch out: The size of the graft has nothing to do with the code selection,. Wound surface area is all that matters. Therefore, if you erroneously based the code on the graft size rather than the wound size, you would report and one unit of ( each additional 25 sq cm wound surface area, or part thereof [List separately in addition to code for primary procedure]). Question 2: When should I code for site prep with a skin substitute graft? Answer 2: Be careful not to automatically report surgical preparation when your surgeon performs a skin substitute graft. If the surgeon applies the skin substitute graft immediately following a surgical excision, you should not additionally report a surgical preparation code ( , Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar [including subcutaneous tissues], or incisional release of scar contracture ). Instead, according to CPT instruction, When a primary procedure requires a skin substitute for definitive skin closure (eg, deep tumor removal), you should report the appropriate graft code in the range in addition to the primary procedure, and skip the surgical preparation codes. Learn limitations: You should report a surgical preparation code with the skin-substitute graft only when the surgeon fulfils at least one of these conditions, according to CPT instruction: Appreciable nonviable tissue is removed to treat a burn, traumatic wound, or a necrotizing infection or the clean wound bed may also be created by incisional release of a scar contracture resulting in a surface defect from separation of tissues

2 The intent is to heal the wound by primary intention such as autograft or skin substitute graft. Question 3: How do I code for a skin substitute graft of more than 25 sq cm, of the forehead, for instance? Answer 3: You have a CPT code to cover the first 25 sq cm: (Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area). For anything beyond that, you should report (...each additional 25 sq cm wound surface area, or part thereof [List separately in addition to code for primary procedure]) for each additional 25 sq cm. Example: The surgeon placed a skin substitute graft on a patient s forehead, totalling 36 sq cm. In this case, you select for the first 25 cm and for the remaining 11 sq cm. To report your skin graft procedures correctly, you must be sure that your surgeon documents the size, location, and depth of every graft. Otherwise, you run the risk of receiving payment for a lower-paying graft code. The same pattern holds for most other graft codes, in which your report one code for the initial area, and a second code for each additional specific area for large grafts. Question 4: How do I code if the surgeon simply applies skin substitute to the wound, stabilizing it with dressing, but does not fixate it? Answer 4: When the surgeon applies a skin-substitute graft, you should select the proper code(s) from the range sometimes. Attachment required: Don t code a skin substitute graft if the surgeon simply applies skin substitute to the wound, even if he stabilizes it with dressing. CPT instruction: Instead, use these codes only when the graft is anchored using the provider s choice of fixation. The surgeon s fixation might involve adhesives, sutures, or staples, for instance. Make sure the op note documents fixation before you use skin replacement graft codes. HIPAA Compliance: Get Ahead of Notification Curve for PHI Breach Avoid stiff penalties that could hurt your practice. With fines ranging from $100 to $1,500,000, you can t afford to make mistakes with notifications for protected health information (PHI) breaches under the Health Insurance Portability and Accountability Act (HIPAA). Help is here: Spot potential HIPAA violations with this expert advice. We ll help you stay out in front of any penalties your practice could face for compromising an individual s PHI. Look For Compromised PHI to ID Breaches HHS presumes all impermissible uses or disclosure of PHI to be breaches unless the covered entity or business associate, as applicable, demonstrates that there is a low probability that the PHI has been compromised based on a risk assessment. Example: You are sending a fax to a patient s primary care provider containing PHI about your surgical treatment. You mistakenly misdial the fax number, sending the patient s PHI to the wrong fax number. Other common HIPAA breaches include, but are not limited to: Mailing the wrong PHI to a patient or business entity

3 Losing an unencrypted laptop or memory stick containing PHI Using unsecure digital communications for professional purposes involving PHI over the Internet. Bad news: In addition to these typical HIPAA violations, hackers are starting to assault medical practice s records in an effort to obtain PHI and other personal information, Sheldon-Dean warns. HIPAA Breaches Aren t All Business-Related Though most breaches occur within the realm of a medical practice s business operations, some PHI violations bleed into providers personal, and in some cases political, worlds. According to Weston, when a physician discusses a patient s medical history with a friend or family member that the patient has not authorized to access his medical records or information, it might be a breach. This will depend entirely on the situation, but everyone in the practice should mind what they say about patients PHI outside of the office just to be safe. Weston has also been on the receiving end of a HIPAA violation, which shows just how prevalent and unexpected these breaches can be. Notify Individuals, Secretary of Breaches When your practice commits a HIPAA breach, HHS wants you to provide notifications to three entities: any affected individuals; the HHS Secretary; and, in certain circumstances, the media. Here s what HHS expects you to do for each of these populations should a breach occur: Individuals: You must immediately notify any patient, business associate, employee, etc., that the breach affects. Secretary: You must notify the HHS Secretary of any breaches by completing a breach report form, which you can find online at Media: If you experience a breach that affects more than 500 residents of a state or jurisdiction, you must notify the affected individuals and provide notice to prominent media outlets serving the state or jurisdiction, HHS reports. CPT 2017: Overhaul Laryngoplasty and Flexible Laryngoscopy Coding Add lesion ablation and other specific procedure choices. When your surgeon performs a flexible laryngoscopy with therapeutic injection next year, you ll finally have a specific code to report the service (31573). The new code is part of an update of the flexible laryngoscopy family that revises the four existing codes and adds three new ones. That s not all: CPT 2017 also updates the Laryngoplasty codes with revisions, deletions, and additions that you need to know. Read on to let our experts guide you in how to report these procedures beginning January 1. Don t Look for Fiberoptic Restriction The common part of the flexible laryngoscopy procedure descriptor changes in 2017 to drop the term fiberoptic from the definition, as follows: Laryngoscopy, flexible fiberoptic; diagnostic That means all of the codes in this family share the laryngoscopy, flexible description without confining the codes to fiberoptic methodology. Although most procedures using a flexible laryngoscope continue to use fiberoptic technology, that s not always the case, so the revised codes will now apply even if the laryngoscope uses other visualization techniques. CPT 2017 also revises the existing flexible laryngoscopy codes to account for multiple specimens, as follows (strike through means the text is deleted, underline means the text is new in 2017):

4 31576 with biopsy (ies) with removal of foreign body(s) with removal of lesion(s), non-laser You ll also find the following three new codes to describe other specific therapeutic procedures that your surgeon might perform as part of a flexible laryngoscopy: with ablation or destruction of lesion(s) with laser, unilateral with therapeutic injection(s) (eg, chemodenervation agent or corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral with injection(s) for augmentation (eg, percutaneous, transoral), unilateral. Distinguish codes: Flexible laryngoscopy is different from direct laryngoscopy procedures that you should report with codes in the range (Laryngoscopy, direct ). Surgeons typically perform the latter procedures in the operating room under anesthesia, while they generally perform flexible laryngoscopy in the office using topical anesthetics rather than sedation or general anesthesia. Also, you may see the flexible laryngoscope identified as nasal pharyngeal laryngoscopy (NPL) if the approach is through the nose rather than the mouth. In those cases, you ll need to further distinguish from (Nasal endoscopy ) by ensuring that the surgeon documents examination and procedure(s) involving the larynx, not just the nasal passages and sinuses. Beware E/M: If your surgeon performs a flexible laryngoscopy in the office, you may be tempted to bill a separate E/M. But you should not separately report the small E/M performed as part of a scheduled scope procedure. However, if the physician performs a scheduled office-visit E/M, then decides to perform a medically-necessary flexible laryngoscopy at the same session based on the findings, you can code both procedures by using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Documentation needs to show that the scope was not planned and a decision to perform it was made based on the manual exam of the specific anatomy that applies. That helps justify appending modifier 25 to the E/M code. Re-Work Laryngoplasty Coding If your surgeon performs any open larynx repair procedures, you ll need to know about revisions, deletions, and additions to codes in the range for CPT Replace with new codes: For laryngeal stenosis repair, you ll no longer report (Laryngoplasty; for laryngeal stenosis, with graft or core mold, including tracheotomy) in 2017, because CPT deletes the code. In its place, you ll find the following four new codes to choose from (listed with # in the CPT book because they re out of numerical sequence): Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, younger than 12 years of age for laryngeal stenosis, with graft, without indwelling stent placement, age 12 years or older for laryngeal stenosis, with graft, with indwelling stent placement, younger than 12 years of age for laryngeal stenosis, with graft, with indwelling stent placement, age 12 years or older Replace NOS: CPT 2017 deletes (Laryngoplasty, not otherwise specified [eg, for burns, reconstruction after partial laryngectomy]), but reduces your need for the code by revising and adding codes to provide specific options to report your surgeon s laryngoplasty work. Look at the following revisions: Laryngoplasty; for laryngeal web, 2-stage, with indwelling keel insertion and removal or stent insertion with open reduction and fixation (eg, plating) of fracture, includes tracheostomy, if performed cricoid split, without graft placement For other specific laryngoplasty procedures, you should also prepare to use the following new codes in 2017: Laryngoplasty, medialization, unilateral Cricotracheal resection

5 Now that you no longer have as a code option, if your surgeon performs a laryngoplasty procedure that one of the new or revised codes doesn t describe, you ll need to turn to (Unlisted procedure, larynx). - Published on