February 2017 Lunch and Learn

Transcription

1 February 2017 Lunch and Learn

2 Housekeeping Items All attendees are muted to eliminate background noise Questions will be addressed at the end of the session via Questions queue Session recording will be provided in the coming day along with a PDF of the slides Attendees will receive an certificate of attendance AHIMA CEUs can be applied for immediately AAPC CEUs will be available in the next several weeks (an notification will be provided when this is finalized)

3 Today s Presenter Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS Ms. Scott is the current director of coding quality and professional development at TrustHCS. She has vast management, education, coding and auditing expertise. She has over 10 years of management experience, a combined 15 years educating, and 26 years of coding and auditing experience. Throughout her management and coding experience she has also performed coding compliance audits and DRG validation reviews. Her engagements with other HIM professionals have focused on guiding coding efforts to increase accuracy and timeliness. She has experience working with a wide range of HIM departments. This experience allows her to combine her knowledge with real-world experience to drive HIM department efforts and programs.

4 Learning Objectives After completing the educational webinar participants will have an understanding of the: Review the anatomy of spine Review the anatomy of cardiovascular Review ICD-10-PCS and CPT coding guidelines for spinal procedures. Review ICD-10-PCS and CPT coding guidelines for cardiac catheterization and interventions Review coding scenarios that apply to ICD-10-PCS and CPT for spinal procedures Review coding scenarios that apply ICD-10-PCS and CPT coding guidelines for cardiac catheterizations and interventions 4

5 Spinal Injections

6 Anatomy of the Spinal Column

7 Injections Questions to Ask When reporting spinal injections keep these keys in mind and it will help you determine which series of codes to use. What is the approach? Epidural/subarachnoid, transforaminal, facet What is being injected? Anesthetic, steroid, contrast, neurolytic agent What regions are treated? Regions: cervical, thoracic, lumbar, sacral How many levels are treated? One or more than one level Is it a unilateral or a bilateral injection?

8 Epidural Injections

9 Epidural Steroid Injection

10 Injection/Infusion Diagnostic/Therapeutic These codes are reported when a catheter is placed to administer one or more epidural or subarachnoid injections Select codes based on level of the spine and the substance injected These procedures are performed to provide and analgesia or local anesthesia to a desired nerve, nerve root or portion of the spinal cord An anesthetic may be injected into the area prior to the epidural injection Injection Procedures are considered unilateral and should be reported one time per level. Reference: AMA CPT Assistant, November 1999 Threading the catheter into the epidural space, injecting substances at one or more levels and then removing the catheter should be treated as a single injection

11 Epidural Injections Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance with imaging guidance (ie, fluoroscopy or CT)

12 Epidural Injections Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance with imaging guidance (ie, fluoroscopy or CT)

13 Epidural Injections Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance with imaging guidance (ie, fluoroscopy or CT)

14 Transforaminal Injections

15 Transforaminal Epidural Injections

16 Transforaminal Epidural Injections Injection, anesthetic agent and/or steroid, transforaminal epidural; with imaging guidance (fluoroscopy or CT); cervical or thoracic, single Level Injection, anesthetic agent and/or steroid, transforaminal epidural; with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedural) Injection, anesthetic agent and/or steroid, transforaminal epidural; with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level Injection, anesthetic agent and/or steroid, transforaminal epidural; with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedural)

17 Transforaminal Epidural Injection Coding Clinic for HCPCS Third Quarter 2012 Page: 7 QUESTION A patient presents to have a transforaminal epidural injection for treatment of lower back and leg pain. The right L3-4, L4-5, L5-S1 neural foramen were marked for needle placement. Under fluoroscopic-guidance utilizing the double-needle technique, a 20- gauge spinal needle was inserted anteriorly into the level of the neural foramen and the corresponding nerve root. A 25-gauge needle was then inserted through the 20-gauge introducer at the midportion of the L3-4, L4-5, and L5-S1 neural foramen. After needle placement was confirmed, and no blood or cerebral spinal fluid (CSF) was aspirated, Isovue contrast was injected. No abnormalities were noted. In the L5-S1 level a cortisone solution was injected. A Depo-Medrol, lidocaine solution was injected at the L3-4 and L4-5 levels. The patient displayed no adverse reactions and was discharged in good condition. What is the correct code(s) for the injections performed at three levels utilizing the double needle technique?

18 Transforaminal Epidural Injection Coding Clinic for HCPCS Third Quarter 2012 Page: 7 ANSWER Transforaminal injections are coded with CPT codes Based on the operative report submitted, assign CPT codes 64483, Injection, anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level, for the injection in the L3-L4 level, and 64484, Injection, anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure), times 2 for injections performed in levels L4-L5 and L5- S1. Although two needles were utilized, this did not alter the actual procedure performed which was an epidural injection involving three levels.

19 Facet Joint Injections

20 Cervical Facet Joint Injections Example: Unilateral, single-level injection into the C5-C6 facet joint level. Note: unilateral injections are performed on one side of the joint level, while bilateral injections are performed on the right and left side of the joint level.

21 Lumbar Spine Facet Joints Side View Back View

22 Facet Joint Injections ( ) CPT Codes CPT Code Descriptions Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level and (add-on) second level (list separately in addition to code for primary procedure) third and any additional level(s) (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level and (add-on) second level (list separately in addition to code for primary procedure) third and any additional level(s) (List separately in addition to code for primary procedure)

23 Coding Scenario #1

24 Coding Scenario #1 This 34 year old female presents today with severe chronic low back pain due to displaced lumbar disc with neuritis due to previous trauma. An epidural injection of steroid (anti-inflammatory) for pain is given during this visit. 24

25 Coding Scenario #1 Code #1 Diagnosis: Chronic pain due to trauma Step 1 Go to the alphabetic index and look up the main term and subterm(s) Pain(s); chronic; due to trauma Step 2 Verify code in the tabular list Code G89.21 Chronic pain due to trauma 25

26 Coding Scenario #1 Code #2 Diagnosis: Low back pain Step 1 Go to the alphabetic index and look up the main term and subterm(s) Pain(s); low back Step 2 Verify code in the tabular list Code M54.5 Low back pain 26

27 Coding Scenario #1 Code #3 Diagnosis: Displaced lumbar disc with neuritis Step 1 Go to the alphabetic index and look up the main term and subterm(s) Disorder; disc; radiculopathy; lumbar region. OR Displacement, intervertebral disc, lumbar region, with neuritis, radiculitis, radiculopathy or sciatica Step 2 Verify code in the tabular list Code M51.16 Intervertebral disc disorders with radiculopathy, lumbar region 27

28 Coding Scenario #1 Procedure #1 Procedure: Epidural injection Step 1 Go to the alphabetic index of PCS and look up the main term And subterm(s) Introduction of substance in or on; Epidural Space (3E0S) Step 2 Go to the (3E0S) table and build the code 28

29 Coding Scenario #1 3E0S33Z 29

30 Coding Scenario # Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance

31 Coding Scenario #2

32 Coding Scenario #2 Operative Report PREOPERATIVE DIAGNOSES Right C5-C6 Herniated disc POSTOPERATIVE DIAGNOSES Right C5-C6 Herniated disc OPERATIVE PROCEDURES Right C5-C6 laminotomy, foramintomy and cervical microdiscectomy 32

33 Coding Scenario #2 The patient was brought to the operating room, anesthetized and intubated by the anesthesia team. Preoperative antibiotics were administered. A Foley catheter was placed. The patient s head was then placed in a 3-point Mayfield head fixation device and he was turned prone while keeping his head in the somewhat flexed position onto the operating room table and onto a Wilson frame. After a sterile prep, a single 3-0 nylon suture was employed to secure the laceration and at the conclusion of the procedure, after the Mayfield head holder was removed a second 3-0 Nylon simple suture was employed to completely close the laceration. Bacitracin was applied each time. The arms were taped by his sides and footboard was placed prior to locking the Mayfield head fixation device. All pressure points were then examined and appropriately padded. In addition, bilateral and equal breath sounds were auscultated by the anesthesia team and the peak airway pressures were within normal limits. A lateral fluoroscopic image was employed to confirm the appropriate level of C5-C6. Body Part 33

34 Coding Scenario #2 The lower cervical region was then prepped and draped in the usual sterile fashion. The entire procedure was performed using the aid of an operative microscope. After infiltration with 1% lidocaine with epinephrine, an approximately one-and-a-half inch linear incision was made just right lateral to midline over what was the C5-C6 spinous processes, as determined by a sterile spinal needle placed earlier and visualized fluoroscopically. Dissection down to the dorsal cervical fascia was made. Approach The fascia was them incised just off midline in a curvilinear fashion angled medially, and the fascia was retracted with a suture. The paraspinal musculature was then dissected off the C5 and C6 spinous processes and lamina, and a Williams retractor was then placed. Given the patient s stout neck, and his marked obesity, the positioning and surgical approach took an additional 45 minutes more than a standard posterior cervical microdiscectomy. A Midas Rex drill with a M8 bur was employed to drill down the inferior portion of the lateral C5 lamina and the superior portion of the C6 lamina as well as extension of the bony opening along the nerve root into the medial aspect of the lateral mass. 34

35 Coding Scenario #2 The level was confirmed by intraoperative fluoroscopy. Two troughs were drilled along the superior and inferior aspects of the C6 nerve root and any of remaining thin bone was elevated using a 1-mm Kerrison punch. A Rhoton 6 microinstrument, as well as a small right-angle nerve hook with a tip of approximately 1-2 mm was employed at the superior aspect of the ligamentum flavum for dissection. The dura was clearly identified, as was the C6 root. A large underlying firm yet soft lateral disc herniation was identified, more accessible at the level of the axilla of the C6 Root. Using a Rhoton 6 dissector, as well as a longer nerve hook, the dissection continued underneath the proximal C6 nerve root. The posterior longitudal ligament was then sharply incised with a #11 blade and a significant amount of disc material was removed from the subannular region along the level of the C5-C6 disc space. Root Operation 35

36 Coding Scenario #2 In addition, the blunt long nerve hook was employed to confirm the adequacy of the foraminotomy, as well as confirm that no medial or superior or inferior residual fragment was present. Thrombin-soaked Gelfoam was employed to assist with hemostasis. Once we were satisfied that the nerve roots were adequately decompressed and the disc herniation was removed, copious amounts of antibiotic irrigation were employed. Thrombin-soaked Gelfoam was placed and irrigated out after 10 minutes. No significant bleeding was identified.

37 Diagnosis Coding Scenario #2 Code #1 Diagnosis: Right C5-C6 Herniated disc Step 1 Go to the alphabetic index and look up the main term and subterm(s) Displacement, displaced; intervertebral disc NEC; cervical, cervicothroacic Step 2 Verify code in the tabular list Code M50.22 Other cervical disc displacement, mid-cervical region 37

38 Root Operation

39 Root Operation - Resection (T) Cutting out or off, without replacement, all of a body part Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS. Coding Guideline B3.8 Excision vs. Resection PCS contains specific body parts or anatomical subdivisions of a body part, such as lobes of the lungs or liver and regions of the intestine. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part. 39

40 Body Part

41 Body Part 41

42 Approach

43 Approach Decision Tree Yes Start Incision Open No Yes Percutaneous Endoscopic Through Scope? No Percutaneous Yes Through Skin? No Through Opening? No Yes Through Scope? No Via Natural or Artificial Opening Endoscopic Yes External Percutaneous Endoscopic Assistance? Yes No Via Natural or Artificial Opening Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance 43

44 Code Assignment

45 Question to ask when building the PCS code(s): What body system is involved? Upper Joints What is the root operations(s)? Resection What is the body part? Cervical Vertebral Disc What is the approach? Open Does the procedure involve a device? No What is the qualifier? No Qualifier 45

46 Coding Resection of Vertebral Disc 0RT30ZZ 46

47 Anterior Cervical Thoracic Fusion with Total Discectomy Coding Clinic, Second Quarter 2014: Page 7 Question: A patient is admitted for surgical treatment of herniated nucleus pulposus C7-T1 with impingement on the nerve root, and radiculopathy. She underwent anterior cervicalthoracic spinal fusion, anterior approach, using interbody cage packed with demineralized bone matrix and autograft, and placement of plate and screw instrumentation with total discectomy. What is the correct ICD-10-PCS code for the spinal fusion? Should the complete discectomy be coded separately?

48 Anterior Cervical Thoracic Fusion with Total Discectomy Coding Clinic, Second Quarter 2014: Page 7 Answer: In this case, the provider documented "total discectomy." Therefore it is coded as a resection. Assign ICD-10-PCS procedure codes as follows: 0RG40A0 Fusion of cervicothoracic vertebral joint with interbody fusion device, anterior approach, anterior column, open approach, for fusion of C7-T1 0RT50ZZ Resection of cervicothoracic vertebral disc, open approach, for the total discectomy Spinal fusion using an interbody cage containing demineralized bone matrix and autograft is coded to the device "Interbody Fusion Device." Additionally, the fixation instrumentation (i.e., rods, plates, screws, etc.) is included in the fusion root operation, and no additional code is assigned.

49 Clarification: Decompressive Laminectomy Coding Clinic, Second Quarter 2015: Page 34 Question: The patient presents for decompressive lumbar laminectomy. The surgeon performed an open complete decompressive laminectomy of L3- L4, as well as superior partial laminectomy of L5, and inferior partial laminectomy of L2. What is the appropriate root operation, "Excision" or "Release"? How is this surgery coded in ICD-10-PCS?

50 Clarification: Decompressive Laminectomy Coding Clinic, Second Quarter 2015: Page 34 Answer: Decompressive laminectomy is done to release pressure and free up the spinal nerve root. Therefore the appropriate root operation is "Release." Assign the following ICD- 10-PCS code: 01NB0ZZ Release lumbar nerve, open approach Coding Clinic, Fourth Quarter 2013, page 116, advised the assignment of the root operation "Excision" for decompressive laminectomy procedures. This advice was based on the ICD-10-PCS' Index entry "Laminectomy," which instructs see Excision. The Editorial Advisory Board for Coding Clinic revisited this advice and determined that the root operation "Release" is more appropriate.

51 Cardiology Procedural

52 Documentation History and medical necessity for procedure Reasons for repeat diagnostic study after prior heart catheterization Vascular access site(s) Vessels catheterized, describing the catheter tip location, and any variant anatomy Pressures and chambers entered, injected and imaged Vessels injected, the areas imaged with interpretation and findings, along with specific documentation of degree stenosis and exact locations of the lesions treated Interventions performed and any complications or additional treatments Specific devices and specialty supplies used during the procedure

53 Anatomy of the Heart 53

54 Valves and Chambers of the Heart

55 Cardiac Catheterization

56 Questions to Ask? What Type of Heart Catheterization? Right Left Right and Left What Injection procedures were preformed? Vessels or chambers injected What Imaging procedures were preformed? Vessels or chambers imaged

57 Cardiac Catheterization Cardiac catheterization codes ( ) include: Contrast injection Imaging supervision, interpretation & report Roadmapping to place catheters For angiography of noncoronary arteries and veins, performed as a distinct service, use appropriate codes form the Radiology and Vascular Injection sections Vascular access approach has NO impact on coding femoral axillary, brachial does not play a role in code selection.

58 Right Heart Catheterization CPT Code and Description Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed Right Heart Catheterization Pulmonary angiography coded separately Ventriculography coded separately Do not additional code Swan Ganz catheter placement (93503) as a right heart catheterization procedure uses this catheter as an integral component to perform the exam No left heart hemodynamics, occurs with aortic valve replacement or when catheter is unable to cross the aortic valve

59 Left Heart Catheterization CPT Code and Description Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Left Heart Catheterization Defined as left heart hemodynamics Systolic and end-diastolic pressures, etc. Pulmonary angiography Included Ventriculography - Included Coronary angiography - Included

60 Combined Right & Left Heart Catheterization CPT Code and Description Combined Right & Left Heart Catheterization including intraprocedural Injection(s) for left ventriculography, imaging supervision and interpretation, when performed Right and left heart catheterization Right and retrograde left Right and transseptal left Right and left via ventricular puncture Right and transseptal left

61 CPT Codes Cardiac Cath CPT code Procedure Description Coronary Angiograms Only Coronary and Bypass angiograms (any and all grafts included) Coronary Angio + Right HC Coronary Angio + Bypass Angios + RHC Coronary Angio + LHC w/wo LV (routine heart cath) Coronary Angio + LHC + Bypass Angios Coronary Angio + R&L HC Coronary Angio + R&L HC + Bypass Angios

62 CPT Codes Cardiac Cath CPT code Procedure Description ADD-ON codes: LHC by transseptal or transapical puncture Pharmacologic agent administration for hemodynamics Physiologic exercise study for hemodynamics Injection RV or RA Injection for supravalvular (aortic root) Injection for pulmonary angiograms Coronary flow reserve measurement, initial vessel Coronary flow reserve measurement, each add vessel

63 ICD-10-PCS Cardiac Cath

64 Coronary Angiography

65 Coronary Interventions

66 Arterial Plaque Deposits 66

67 Coronary Angioplasty

68 CPT Modifiers - Coronary Interventions Major coronary vessels and their modifiers LAD left anterior descending artery - LD Left circumflex artery - LC Right coronary artery - RC Left main coronary artery - LM Ramus intermedius - RI

69 CPT - Coronary Intervention Guidelines Coronary intervention codes are built on the following hierarchy of intensiveness of the service Angioplasty alone least intensive service Stent Atherectomy without stent more intensive service Atherectomy with stent Graft revascularization most intensive service All interventions performed within a defined branch are reported as a single intervention; if two lesions are treated in the circumflex, only one code is reported Bypass grafts of any type are considered separate vessels for interventional coding purposes; each graft is a separate vessel

70 Coronary Intervention Guidelines A maximum of two branches are recognized as separate vessels for the left main left anterior descending, left circumflex and right coronary arteries; the left main and ramus arteries have no recognized branches for interventional reporting purposes; this guidelines applies to reporting codes 92921, 92925, 92929, and These codes include: Vessel access Radiologic supervision and interpretation related to the intervention All imaging performed Closure of the arterial access vessel; verify with individual payers for separate reporting of this service

71 CPT Codes - Coronary Interventions Service CPT Code CPT Code Additional Vessel Angioplasty only PTCA Atherectomy with PTCA Stent (non DES) with PTCA DES with PTCA C9600 C9601 Atherectomy, Stent (non DES), PTCA Atherectomy, DES, PTCA C9602 C9603 Revascularization Coronary Bypass Graft, any combination intervention, non DES Revascularization Coronary Bypass Graft, any combination intervention, DES C9604 C9605 Revascularization Acute Occlusion, any combination intervention, non DES Use , 92943, 92944

72 CPT Codes - Coronary Interventions Service CPT Code CPT Code Additional Vessel Revascularization Acute Occlusion, any combination intervention, non DES C9606 Use C9600-C9605 Revascularization Chronic Occlusion, any combination intervention, non -DES Revascularization Chronic Occlusion, any combination intervention, non -DES C9607 C9608

73 ICD-10-PCS - Cardiovascular Common cardiovascular procedure root operations: Bypass Destruction Map Dilation Insertion Measurement Replacement Supplement Performance

74 Coding Scenario A 64-year-old man is admitted for a left heart catheterization, coronary angiography of multiple coronary arteries and left ventriculography, using low osmolar contrast. Findings from these procedures resulted in the decision to perform a percutaneous transluminal coronary angioplasty (PTCA) of two separate lesions in the left anterior descending artery. One lesion was treated with a drug-eluting stent and the other lesion treated with PTCA only.

75 ICD-10-PCS - With and Without Stent Z and 02703ZZ

76 ICD-10-PCS Cardiac Cath 4A023N7

77 ICD-10-PCS - Coronary Angiography B2151ZZ and B2111ZZ

78 Pacemakers

79 Pacemaker Insertion

80 Defibrillator

81 Pacemakers and ICD Single lead: a pacemaker or pacing cardioverter-defibrillator with pacing and sensing function in only one chamber of the heart. Dual lead: a pacemaker or pacing cardioverter-defibrillator with pacing and sensing function in only two chambers of the heart. Multiple lead: a pacemaker or pacing cardioverter-defibrillator with pacing and sensing function in three or more chambers of the heart. (Bi-ventricular device)

82 Pacemakers and ICD When coding pacemakers, the following must be documented: Was this an initial insertion, removal and/or reinsertion or repositioning of leads? Was this a pacemaker or pacing cardioverter-defibrillator? Temporary or Permanent? Were electrodes placed? If so, where were they placed and how many? Was the placement transvenous or was a thoracotomy required?

83 Pacemaker and ICD Transvenous Procedures Pacemaker/ICD Insert transvenous single lead only without pulse generator Insert transvenous dual leads without pulse generator Insert transvenous multiple lead without pulse generator Initial pulse generator insertion only with existing single lead Initial pulse generator insertion only with existing dual lead Initial pulse generator insertion only with existing multiple leads 33221

84 Pacemaker and ICD Transvenous Procedures Initial pulse generator insertion or replacement plus reinsertion of transvenous single lead Initial pulse generator insertion or replacement pulse insertion of transvenous dual leads Initial pulse generator insertion or replacement pulse insertion of transvenous multiple leads Upgrade single chamber system to dual chamber system Pacemaker/IC (atrial) or (ventricular) (includes removal of existing pulse generator)

85 Pacemaker and ICD Transvenous Procedures Removal pulse generator with replacement pulse generator only single lead system (transvenous) Removal pulse generator with replacement pulse generator only dual lead system (transvenous) Removal pulse generator with replacement pulse generator only multiple lead system (transvenous) Pacemaker/ICD Removal transvenous electrode only single lead system Removal transvenous electrode only dual lead system 33235

86 Coding Scenario The patient undergoes a placement of a dual chamber pacemaker for treatment of symptomatic sick sinus syndrome. An incision was made and a subcutaneous pocket was created in the chest. The generator was placed in the subcutaneous pocket and the incision was closed. Both the right atrial and right ventricle lead were placed percutaneously.

87 Placement of Battery/Generator 0JH606Z 87

88 Placement Right Atrial Cardiac Lead, Pacemaker 02H63JZ 88

89 Right Ventricle Lead Pacemaker 02HK3JZ 89

90 Thank You For Your Time and Attention!

91 References DeVault, Kathryn. "ICD-10-PCS From the Heart: Cardiovascular Procedures" Journal of AHIMA 86, no.9 (September 2015):