Coding Wars: The Coding and Documentation Weapons to Win the Battle

Transcription

1 Coding Wars: The Coding and Documentation Weapons to Win the Battle Howard W. Rogers M.D., Ph.D. Advanced Dermatology Norwich, CT

2 Conflict of Interest Statement I have no relevant financial conflicts of interest. Except that I am on the AAD RUC team and do insurer chart reviews, and if dermatologists understand coding principles better and code prudently, my job is easier.

3 Do We Still Need to Learn Coding? My EHR does my coding for me

4 Do We Still Need to Learn Coding? Low Complexity Level MDM My EHR does my coding for me

5 EMRs Coding Only As Good As the Programmer

6 Chart Review Observations Triggers that draw chart reviews. (Outliers; High ticket items, Multiple procedures performed in one visit; Recurring procedure on one patient; High percentage use of one procedure code, therapeutic intervention, or diagnosis; Patients who feel their service was not properly coded.) Reviews are becoming more and more common. (Insurer pre and post payment reviews, Modifier and E/M use reviews, Medicare Advantage Care Coordination Reviews ) With EMR, reviews may be done in real time. Remember that your one best chance to be paid for what you do is to bill it right the first time (clean claim)

7 Documentation Basics Remember not good enough anymore just to indicate what you did. You also have to document why it was medically necessary even if it is obvious to you. Documentation must be clear and precise. Insurance reviewers are generally not dermatologists and will not give you the benefit of the doubt.

8 Is it an excision? Patient complains of rapidly growing tender lesion on left arm. Clinical diagnosis SCC (2.2 cm) Shave excision done with 3 mm margins with derma-blade and sent for path Path shows well differentiated squamous cell carcinoma with clear margins; the deep margin extends to the deep dermis Coding11603 Dx C44.622

9 Bill Excisions and Shave Removals Appropriately Problem Excision is defined as removal of a lesion into the subcutis. Tangential or shave excision of benign or malignant lesions are covered by code series. Shave removal may vary in depth in the dermis. The complete histological removal of the lesion is irrelevant to the coding (shave versus excision). If the level of removal does not go through the full thickness of the dermis, it is not an excision. Difference between a shave removal and a biopsy by shave technique is the intent.

10 Excision Documentation ELLIPTICAL EXCISION NAME: DATE OF BIRTH: DATE OF VISIT: OPERATIVE REPORT Margin Lesion Margin Total Excision Size PROCEDURE: EXCISION WITH SIMPLE CLOSURE. SURGEON: HOWARD W. ROGERS, MD PhD PREOPERATIVE DIAGNOSIS: MEDICAL NECESSITY OF EXCISION: MALIGNANT / UNCERTAIN BIOLOGICAL POTENTIAL / SYMPTOMATIC LESION SIZE OF LESION PREOP: CM + MM MARGINS TOTAL EXCISION SIZE = Preop size plus margin times 2: CM LOCATION: PERIOPERATIVE MEDICATIONS: NONE ANESTHESIA: LIDOCAINE WITH EPINIPHRINE: C.C. TYPE OF CLOSURE: SIMPLE LINEAR CLOSURE: EPIDERMAL APPROXIMATION WITH RUNNING PROLENE SUTURES. FINAL SUTURE LENGTH LINE: CM COMMENT: After informed consent was obtained, the patient was positioned on the surgery table in a supine position, the lesional area was prepped with alcohol, and infiltrated with 1% Lidocaine with epinephrine as above. Thereafter, the skin was prepped with Betadine, and draped with sterile towels. Using a surgical marking pen, an elliptical design was created to include above indicated margins. Using a # 15 blade scalpel, an excision was carried out through the full thickness of the skin extending to the subcutis. Undermining was carried out circumferentially. The specimen was placed in formalin and sent for routine histopathological evaluation. The cavity from which the specimen was removed was undermined circumferentially for approximately 1.0 cm and hemostasis was achieved with electrohyfrecation. Standing cones were excised, such that the wound closure lines would fall into relaxed skin tension lines of the body. The epidermis was then approximated with suture and technique as above. Estimated blood loss was minimal. There were no complications. Wound care instructions were provided for the patient in verbal and written form including a 24-hour telephone number in case of emergency. The patient will return in week.

11 Excision of Neoplasm Uncertain Behavior Biopsy done of ill defined pigmented lesion on the calf. Pathologic report reveals junctional melanocytic nevus with severe cytologic atypia and some upward scatter of melanocytes. Can t rule out MMIS. Re-excision recommended. Biopsy site then re-excised with 5 mm margins incorporating an area of ill defined pigment inferior to the biopsy site. Procedure Code Diagnosis D48.5 Or D23.72 with secondary Dx D48.5 Procedure Code Or D03.72

12 Excisional Coding of Neoplasm Uncertain Behavior Issues D48.5 diagnosis will be rejected if billed as malignant excision because it is not a malignant diagnosis (depending on editing software). If pathology report says can t rule out MMIS, MMIS favored, or treat as MMIS, D03.72 diagnosis easily justified. Remember to explain in the procedure note that this neoplasm is excised as melanoma in situ (MMIS). Consider billing with D23.72/D48.5. In you patient you may a patient with a melanoma in situ diagnosis without the pathologic data (life insurance).

13 Types of Linear Closure and definitions Simple Intermediate Complex

14 Simple Linear Closure Simple repair ( ) when the wound is superficial; eg, involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures One layer closure Normal debridement (cleaning the skin tissue until normal tissue is viewed) and single-layered closure are included

15 Intermediate Closure Intermediate repair ( ) includes, in addition to the requirements of a simple repair, layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.

16 Intermediate Closure Documentation EXCISION WITH INTERMEDIATE LAYERED CLOSURE OPERATIVE REPORT NAME: DATE OF BIRTH: DATE OF VISIT: Margin Lesion Margin Total Excision Size PROCEDURE: EXCISION WITH LAYERED CLOSURE. SURGEON: HOWARD W. ROGERS, MD PhD PREOPERATIVE DIAGNOSIS: MEDICAL NECESSITY OF EXCISION: MALIGNANT / UNCERTAIN BIOLOGICAL POTENTIAL / SYMPTOMATIC LESION MEDICAL NECESSITY OF LAYERED CLOSURE: INSUFICIENT SKIN LAXITY TO AVOID DEHISCENCE WITHOUT LAYERED CLOSURE: SIZE OF LESION PREOP: CM + MM MARGINS TOTAL EXCISION SIZE = PREOP SIZE + MARGIN X 2: CM LOCATION: PERIOPERATIVE MEDICATIONS: NONE ANESTHESIA: LIDOCAINE WITH EPINIPHRINE: C.C. TYPE OF CLOSURE: LAYERED CLOSURE WITH PDS BURIED AND DEEP SUTURES. EPIDERMAL APPROXIMATION WITH RUNNING PROLENE SUTURES. FINAL SUTURE LENGTH LINE: CM COMMENT: After informed consent was obtained, the patient was positioned on the surgery table in a supine position, the lesional area was prepped with alcohol, and infiltrated with 1% Lidocaine with epinephrine as above. Thereafter, the skin was prepped with Betadine, and draped with sterile towels. Using a surgical marking pen, an elliptical design was created to include above indicated margins. Using a # 15 blade scalpel, an excision was carried out through the full thickness of the skin extending to the subcutis. The specimen was placed in formalin and sent for routine histopathological evaluation. Standing cones were excised, such that the wound closure lines would fall into relaxed skin tension lines of the body. The cavity from which the specimen was removed was undermined circumferentially for approximately 1.0 cm and hemostasis was achieved with electrohyfrecation. Dead space was closed and the deep wound edges were approximated using interrupted deep buried sutures at the level of the deep subcutis and dermis in a layered fashion using sutures noted above. The epidermis was then approximated with suture and technique as above. Estimated blood loss was minimal. There were no complications. Wound care instructions were provided for the patient in verbal and written form including a 24-hour telephone number in case of emergency. The patient will return in week.

17 Complex Closure Patient with BCC on neck undergoes excision with complex linear closure (4.0 cm). The closure is coded

18 Do Not Bill Complex Closure Just Because Lesion is on Head / Neck Complex closure is a repair that requires more than layered closure such as Scar Revision Debridement (as of traumatic lacerations) Extensive Undermining Stents Retention Sutures REMEMBER MEDICAL NECESSITY!

19 Do Not Bill Complex Closure Just Because You Are Repairing a Mohs Defect Taking standing codes and de-beveling Mohs defect does not constitute debridment

20 Alteration of Standing Cone Placement (Not Complex)

21 Complex Closure Nose with extensive undermining

22 Complex Closure Padded retention suture bridges to prevent suture pull-through due to high wound tension

23 Is it a Flap? A 1 cm BCC is excised from the right forehead and repaired with an M-plasty flap. Flap area 12.0 cm 2. Coding

24 Don t Bill Primary Closures as Flaps Adjacent tissue transfer/rearrangement (ATT) is defined as the transfer of tissue to repair a defect such as traumatic avulsion, or an area where a large defect exists as the result of lesion excision. This procedure involves moving or lifting a normal, healthy section of skin (that remains connected at one or two of its borders) to an adjacent or nearby defect for the repair of the defect. A flap requires the physician to make additional incisions in the skin to develop a flap after excising a lesion. Proper coding in this example would be a linear closure measuring the suture line the closure and each limb of the M-plasty Alterations of standing cone placement do not a flap make! (curvilinear closures, M-plasties)

25 Additional incisions need to be made to create a flap Not a Flap Flap

26 Additional incisions need to be made to create a flap

27 Additional incisions need to be made to create a flap

28 Flap Sizing (1/2 A x B?) A B

29 Understand How to Calculate and Document Flap Size Based on major changes in the 2004 AMA CPT book, adjacent tissue transfer codes (14000 to 14300) are selected based on the size of the primary as well as the secondary defect. CPT states, For the purposes of code selection, the term defect includes the primary and secondary defects. The primary defect resulting from the excision and the secondary defect resulting from flap design to perform the construction are measured together to determine the code. X Y

30 Flap Sizing (A x C) A C

31 Flap Documentation ROTATION FLAP REPAIR OF MOHS SURGICAL DEFECT Reason for procedure: Surgical defect secondary to Mohs micrographic surgery. Medical Necessity: Lack of locally redundant tissue, High risk of wound dehiscence, Presence of local free margin to avoid distortion of the nose, eyelid, lip, ear. Size of primary defect: x cm Perioperative Medications: None. Anesthesia: 1% Lidocaine with epinephrine 1:100,000 infiltrated locally as needed. Sutures: Dermal closure with buried 5-0 PDS sutures. Epidermal approximation with running and simple interrupted 5-0 Surgipro sutures. Estimated blood loss: Minimal. Final Primary and Secondary Defect Dimension: cm x cm. Final Flap Area: square cm. Surgeon: Howard W. Rogers M.D. Ph.D. Comment: After Mohs micrographic surgery, the area of the surgical defect was prepped with betadine and draped with sterile surgical drape. The area was infiltrated with anesthetic as above. The beveled edges of the surgical defect were debrided perpendicular to the skin surface using a #15 scalpel blade. Hemostasis was achieved with electrohyfrecation. Given the lack of locally redundant skin and geometric and cosmetic considerations, a rotation flap from the was selected for repair. The flap design was incised using a #15 scalpel blade and the flap and surrounding area was subsequently undermined. The secondary defect of the flap was first closed using suture technique as above, and the tissue of the flap was subsequently rotated into the primary surgical defect and closed with suture and technique as noted above. There were no complications. Wound care instructions were provided for the patient in written and verbal form including a 24-hour number in case of emergency. The patient will return in one week for suture removal.

32 Billing a Flap and Excision A 1.9 cm BCC is excised from the cheek with 4 mm margins and repaired with rotation flap. Excisional size is 2.3 cm, and flap area is 12.0 cm 2. Procedure codes: and modifier.

33 Flap Code Includes Excision The excisional procedure is included in the description and payment of the flap code. So in this example, only the flap code is billed. Billing and modifier indicates that an excision was performed that was separate from the one that resulted in the flap. Excision is not included in full or split thickness skin graft codes. Mohs micrographic surgical excision codes are not included in flap codes.

34 Even thought you feel it it a lot of work It s still just one flap - Code Flaps One defect Still just one flap

35 2 Flaps 2 Defects This is two flaps x 2 or and

36 Two Flaps One Graft - One Defect 14301, No modifier required

37 Using NCCI Edits to Determine Placement of 59 Modifier NCCI Edits - Physicians CPT Codes Column1/Column2 onalcorrectcodinited/downloads/ccigrp3.zip Column 1 is the payable code Column 2 is the bundled code that will not be payable unless is has an appropriate modifier

38 n

39 Oh what a difference a few words make! Shave biopsy done code Denied!!! Skin biopsy done by shave technique Code Paid!!! Preservice Time: 5 minutes Intraservice Time 12 minutes Post service Time 5 minutes

40 MACs and LCDs for Mohs 6 LCDs for Mohs surgery for the MACs (CGS, WPS, FCSO, Noridian, Novitas, Palmetto). Each LCD has unique wording and requirements. Coverage of Mohs surgery for specific malignant diagnoses, histologic subtypes, locations, and clinical scenarios varies between LCDs. Some LCDs are based directly on the Mohs surgery appropriate use criteria; others have less specific coverage criteria.

41 MACs and LCDs for Mohs To understand the specific documentation requirements of the MAC for a particular state or region, AAD members are encouraged to familiarize themselves with the Mohs surgery LCD of their local MAC.

42 New Mohs Documentation Requirements Note should make clear why the lesion will not be (was not) managed by standard excision or destruction technique. Operative notes and pathology documentation in the patient s medical record should clearly show that MMS was performed using accepted MMS technique, in which the physician acts in two integrated and distinct capacities: surgeon and pathologist (therefore confirming that the procedure meets the definition of the CPT code(s)). Operative documentation should note: location, number, and size of the lesion(s); number of stages performed; number of specimens per stage. Histology documentation must include the following: (a) First stage: if tumor present, depth of invasion; pathological pattern of the tumor; cell morphology; if present, note perineural invasion or scar tissue. (b) Subsequent stages: if the tumor characteristics are the same as in the first stage, note this fact only. If the tumor characteristics are different from the first stage, describe the differences.

43 The Audit Proof Mohs Note

44 The Audit Proof Mohs Note

45 The Audit Proof Mohs Note

46 Excision SubQ Soft Tissue Tumors Symptomatic lipoma excision Code as excision cutaneous lesion 114XX series? My EMR allows

47 Excision Sub Q Soft Tissue Tumors Excision of subcutaneous soft tissue tumors involves simple or marginal resection of tumors that are confined to the subcutaneous tissue below the skin but above the deep fascia (not intra-muscular). These tumors are generally resected without removing a significant amount of surrounding normal tissue.

48 Other Soft Tissue Excision Codes Musculo-skeletal excision codes are used for lesions that occur in the subfascial or fascial tissue, muscles or joints. Radical resection of soft CT tumors involves the resection of the tumor with wide margins of normal tissue. Although these tumors may be confined to a specific layer (Sub Q or sub fascial), radical resection may involve removal of tissue from one or more layers. Typically use this radical resection codes for malignant CT tumors or very aggressive benign CT tumors.

49 Excision Sub Q Soft Tissue Tumors Code selection for excision of ST tumors is based on the location and size of the tumor. Size = clinical tumor size plus margin Excision of soft CT tumors includes simple and intermediate closure (complex closure documented separately) Wide undermining just to remove the tumor doesn t meet criteria for complex closure

50 Excision Soft Tissue Tumors, Sub Q 21011/ Face and Scalp <2 cm/>=2cm 21555/ Neck and Anterior Thorax <3 cm/>=3cm 21930/ Back and Flank <3 cm/>=3cm 23075/ Shoulder area <3 cm/>=3cm 24075/ Upper arm and elbow <3 cm/>=3cm Site and size breakdown not as simple as integumentary excisions

51 Excision Soft Tissue Tumors, Sub Q 25075/ Forearm/wrist <3 cm/>=3cm 26115/ Hand and finger <1.5 cm/>=1.5cm 27047/ Pelvis/hip area <3 cm/>=3cm 27327/ Thigh and knee <3cm/>=3cm 27618/ Leg and ankle <3cm/>=3cm 28043/ Foot and toe <1.5cm/>=1.5cm

52 Excision Soft Tissue Tumors SubQ Documentation Remember to indicate medical necessity of excision and that the lesion removed meets SubQ soft tissue criteria Cysts may push into the subq fatty tissue but are skin lesions and excisions should be coded with the 114XX integumentary lesion excision codes.

53 Biopsy of Eyelid A patient presents with a rapidly growing papule of the lower eyelid. A biopsy is performed and coded Is this correct?

54 Biopsy of Eyelid Eyelid biopsy code has been revised to clarify that eyelid biopsy must include lid margin, tarsal plate or palpebral conjunctiva. Again, typical eyelid skin biopsies would fall under the skin biopsy code.

55 Biopsy of Lip A similar scenario occurs with a biopsy of the cutaneous portion of the lip and the lip biopsy code

56 Biopsy of Lip Cutaneous lip biopsies would be better coded The code is designated for lip biopsies done from the vermillion border to the dry-wet junction of the lip.

57 Remember Your Site Specific Biopsy Codes Biopsy of external ear Biopsy of lip Biopsy of penis and add on Biopsy of vulva Biopsy of vestibule of mouth Biopsy intranasal Nail unit biopsy

58 Do Site Specific Biopsy Codes Make a Difference to Reimbursement?

59 Do Site Specific Biopsy Codes Make a Difference to Reimbursement? $ $ $ $ $ $ % Discount

60 Does It Make a Difference to Reimbursement? Do the math!!! $ $ $ $ $ $ = $ = $184.69

61 Biologic Injection Drug rep came to my office indicating that code was proper injection code for biologics.

62 Biologic Injection Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular J Injection, omalizumab, 5 mg will need 30 units for 150 mg dose

63 Thank you