Clinical Documentation Excellence: CPT Coding Updates for Missy Vance, RHIA, CCS, CPC, AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador

Size: px

Start display at page:

Download "Clinical Documentation Excellence: CPT Coding Updates for Missy Vance, RHIA, CCS, CPC, AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador"

Cathleen Hancock
6 years ago
Views:

Clinical Documentation Excellence: CPT Coding Updates for 2015 Missy Vance, RHIA, CCS, CPC, AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador Kelly Spell, CCS, CPC, CPC-H, CAHIMS, AHIMA Approved

1 Clinical Documentation Excellence: CPT Coding Updates for 2015 Missy Vance, RHIA, CCS, CPC, AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador Kelly Spell, CCS, CPC, CPC-H, CAHIMS, AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador April Rushing, RHIA, CCS-P Today s Speakers Missy Vance, RHIA, CCS, CPC, AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador serves as the University of Mississippi Medical Center s (UMMC s) leader for hospital coding and facility charge capture for emergency services. Kelly Spell, CCS, CPC, CPHIMS, AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador specializes in Health Information Management build for the Epic electronic health record team at UMMC. April Rushing, RHIA, CCS-P is a senior leader for the hospital outpatient coding department at UMMC. 1

2 Disclaimer Speakers and planning committee members have no significant financial interest and this presentation does not have any commercial support. There is no investigational or unlabeled uses of a product in this presentation. The material is designed and provided to communicate information about clinical documentation, coding and compliance in an educational format and manner. The authors are not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding. Every reasonable effort has been taken to ensure that the educational content provided is accurate and useful. Applying best practice solutions, altering work flow, and achieving results will vary with each individual and clinical situation. Learning Objectives 1. Identify new 2015 CPT codes and descriptions 2. Identify revised 2015 CPT codes and descriptions 3. Examine the LCDs for the new and revised 2015 codes 2

3 What is CPT? Current Procedural Terminology (CPT ) codes were developed by the American Medical Association and first published in The purpose of CPT is to provide a uniform language accurately describing medical, surgical and diagnostic services. It serves as an effective means for reliable nationwide communication within the health care industry. Who uses CPT? Physicians for their services, not dependent upon location Hospitals for Outpatient Services Third party payers for reimbursement of Outpatient Services 3

4 What services are represented by CPT? Anesthesia Surgery Radiology Pathology Laboratory Medicine Evaluation and Management What services are represented by CPT? Focusing today only on the codes within the surgical section. 4

5 To Do List Order 2015 CPT codebooks Review 2015 CPT code changes Review and update superbill and chargemaster Update software Train staff on upcoming CPT changes Over 500 CPT Changes Revisions Include: With or without deleted, added including when performed Includes changed to including Single changed multiple (s) such as tumor changed to tumor(s) Listing out every method deleted, changed to any method 5

6 Symbols in CPT Revised code New code Musculoskeletal: Arthrocentesis 20600, 20605, have been revised to read without ultrasound guidance NEW CODES Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow, or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting 6

7 Open Treatment for Rib Fractures Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs ;4-6 ribs ;7 or more ribs DELETED: Closed treatment of rib fracture, uncomplicated, each Treatment of rib fracture requiring external fixation (flail chest) Percutaneous Vertebroplasty Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic ;lumbosacral ;each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure) DELETED: Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body,unilateral or bilateral injection, thoracic lumbar each additional thoracic or lumbar vertebral body 7

8 Percutaneous Vertebral Augmentation Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic ;lumbar ;each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) DELETED: Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation; thoracic lumbar each additional thoracic or lumbar vertebral body Total Disc Arthroplasty has been revised to become the parent code for Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure) 8

9 Arthrodesis of Sacroiliac Joint Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device revised to indicate an open procedure Arthrodesis, sacroiliac joint, open Pacemaker or Implantable Defibrillator Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed Insertion of subcutaneous implantable defibrillator electrode Removal of subcutaneous implantable defibrillator electrode Repositioning of previously implanted subcutaneous implantable defibrillator electrode 9

10 Cardiovascular Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis additional prosthesis(es) during same session (List separately in addition to code for primary procedure) DELETED: Insertion of graft, aorta or great vessels; with shunt bypass Transcatheter Procedures Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection without distal embolic protection Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation 10

11 Endovascular Revascularization Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery each additional artery (List separately in addition to code for primary procedure) Liver Ablation, 1 or more liver tumor(s), percutaneous, cryoablation 11

12 Urinary Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant Custourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure) Esophagoscopy Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker s deverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair when perfomed Esophagoscopy, flexible, transnasal; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery DELETED: Esophagostomy, fistulization of esophagus, external; abdominal approach 12

13 Intestines: Endoscopy, Stomal Ileoscopy, through stoma; diagnostic, with or without including collection of specimen(s) by brushing or washing, when performed (separate procedure) ;with transendoscopic balloon dilation ;with placement of endoscopic stent (includes pre- and postdilation and guide wire passage, when performed) Endoscopic evaluation of small intestine pouch (abdominal eg, Kock pouch, ileal reservoir [ S or pelvic J]) pouch; diagnostic, with or without including collection of specimen(s) by brushing or washing, when performed (separate procedure) with biopsy, single or multiple Intestines: Endoscopy, Stomal Colonoscopy through stoma; diagnostic, with or without including collection of specimen(s) by brushing or washing, when performed (separate procedure) ;with ablation of tumor(s), polyp(s), or other lesion(s) includes pre- and post-dilation and guide wire passage, when performed) ;with endoscopic stent placement (including pre-and postdilation and guide wire passage, when performed) ;with endoscopic mucosal resection ;with directed submucosal injection(s), any substance 13

14 Intestines: Endoscopy, Stomal ;with transendoscopic balloon dilation ;with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures ;with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures ;with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed Endoscopy, Sigmoid Sigmoidoscopy, flexible; diagnostic, with or without including collection of specimen(s) by brushing or washing, when performed (separate procedure) ;with decompression (for pathologic distention) of volvulus (eg, volvulus, megacolon), including placement decompression tube, any method when performed ;with dilation by transendoscopic balloon, 1 or more strictures dilation ;with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) ;with placement of endoscopic stent (includes pre- and postdilation and guide wire passage, when performed) 14

15 Endoscopy; Sigmoid, continued ;with endoscopic mucosal resection ;with band ligation(s) (eg, hemorrhoids) Colonscopy Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without including collection of specimen(s) by brushing or washing, with or without colon decompression when performed (separate procedure) ;with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) ;with dilation by transendoscopic balloon, 1 or more strictures dilation 15

16 Colonoscopy, continued ;with endoscopic stent placement (includes pre- and postdilation and guide wire passage, when performed) ;with endoscopic mucosal resection ;with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed ;with band ligation(s) (eg, hemorrhoids) Take Away Get a new CPT book and become very familiar with the codes for your service. 16

17 What is an LCD? LOCAL COVERAGE DETERMINATIONS What is an LCD? Local coverage determinations (LCDS) are defined in Section 1869(f)(2)(B) of the Social Security Act (the Act). This section states: For purposes of this section, the term local coverage determination' means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A). For LCD searches visit: ippi&cpthcpcscode=45380&bc=gaaaaaaaaaaaaa%3d%3d&=& 17

18 CMS WEBSITE LCD L30304 Colonoscopy and Sigmoidoscopy-Diagnostic Juridsiction: Mississippi LCD L30304 Colonoscopy and Sigmoidoscopy-Diagnostic Definitions: 1. Sigmoidoscopy (CPT , , 45345) is the examination of the entire rectum and sigmoid colon, and includes examination of a portion of the descending colon. 2. Colonoscopy (CPT , 45355, , 45391, 45392) is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. 18

19 LCD L30304 Colonoscopy and Sigmoidoscopy-Diagnostic 013x Hospital Outpatient 014x Hospital - Laboratory Services Provided to Non-patients 071x Clinic - Rural Health 085x Critical Access Hospital 19

20 20

21 INPATIENT ONLY? On list for 2014: Treatment of rib fracture New codes may be on list for 2015 * Open Treatment of rib fracture(s) INPATIENT ONLY? On list for 2014: Fusion of sacroiliac joint Revised code on list for Arthorodesis, sacroiliac joint, open 21

22 INPATIENT ONLY? On list for 2014: Stent carotid artery Revised/new codes on list for Stent cervical carotid, intrathoracic carotid or innominate INPATIENT ONLY? *No data on Transcatheter mitral valve repair, but strongly suspect it will be INPT only. 22

23 Questions & Answers Join us in 2015 January 21 st at noon Clinical Documentation Excellence Program Overview This session will define the importance of Clinical Documentation Excellence at UMMC. The Clinical Documentation Excellence team will provide an overview of the program and academic department composition. Key objectives and initiatives addressed in collaboration with each academic department team at UMMC will be reviewed. Learning Objectives: 1. Define Clinical Documentation Excellence program at UMMC. 2. Identify academic department team composition. 3. Review Initiatives and objectives of Clinical Documentation Excellence teams. 23

BC ADVANTAGE AUDIO SERIES:

BC ADVANTAGE AUDIO SERIES: UPDATES FOR 2015 SURGICAL CPT CODES 1 Presented by: Darlene Boschert, RHIA, CPC, CPC-H, CPC-I Providing LOW-COST educational resources for Medical office Professionals OBJECTIVES