ICD-9 & CPT code for feeding difficulty

You should bill (99211-99215, Office or other outpatient visit for the E/M of an established patient, usually the presenting problem[s] are minimal;

Watch out: If your group had not previously treated the infant in any location, you would use the new patient office visit codes (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient …).

Link the office visit code to the infant’s problem(s). Some applicable ICD-9 codes you can report for the baby include:
-------------------------------------------------------------------------------------------------------------------
Pediatric Coding Corner: 4 Tips Ensure Success in Coding Feeding Problems for 2010
Use expanded 779.3x to describe newborn issues.
Brings an expanded 779.3x (Feeding problems in newborn).

• 779.31 (Feeding problems in newborn): Feeding problems can be broadly categorized as underfeeding and overfeeding. Underfeeding results from the infant’s failure to take sufficient amounts of milk. Oftentimes, family physicians spot this problem when there is a failure to gain weight appropriate for their age or when the mother notices that their infant suckles infrequently or for only short periods of time. Overfeeding results from supplemental foods and therefore is not a problem in the perinatal period.

• 779.32 (Bilious vomiting in newborn): Bilious vomiting is vomiting of gastric contents containing bile, often described as greenish vomitus.

• 779.33 (Other vomiting in newborn): Vomiting is the complete emptying of the stomach contents often occurring after feeding.

• 779.34 (Failure to thrive in newborn): This occurs when an infant’s physical growth as measured by his weight and height is significantly below the average for his age group.

Most of these conditions were previously lumped under 779.3. These changes make the coder’s job much easier. “The more specific the codes, the better for all,” says Gwenn S. O’Keeffe, MD, CEO and founder of

Incorporating these new codes into your practice will be a breeze with four easy tips:

1: Use 779.31, 779.34 for Follow-Up Visit Problems
Remember that follow-up visits after a hospital discharge are not necessarily well visits. After a newborn has been discharged from the hospital, “we always do a two- to three-day follow-up visit,” notes Charles Scott, MD, FAAP, a pediatrician at Medford Pediatric and Adolescent Medicine in New Jersey.

Family physicians make use of this visit to evaluate the presence of any problems a newborn may have, and commonly, this will include feeding problems. For example, during a visit, the mother relays to the FP that her infant seems to have difficulty latching onto her nipple. Code 779.31. Likely in this case, the FP will spot low birth weight gains. Therefore, also code 779.34.

2: Distinguish Between Regurgitation, Vomiting

Regurgitation means retuning small amounts of swallowed milk shortly after or while feeding. Compare this to vomiting, which is the complete emptying of stomach contents. Although regurgitation is a natural occurrence during the first months of life, it often makes new parents worry.
Example: During an office visit, a mother tells the FP that she is worried when she notices small amounts of milk coming from her infant’s mouth after feeding. There is no specific code for regurgitation in the ICD-9-CM.
In the ICD-9-CM 2009 index to diseases, the listing for “regurgitation” leads to the code for vomiting alone (787.03). Using the new 2010 codes, here are three possible scenarios:
1.If the FP documents the mother’s observation as newborn vomiting, consider coding it as 779.33 in 2010.
2.Use 779.31 if documentation indicates it’s a feeding problem.
3.If the FP otherwise considers it a normal part of being a newborn, then no code is necessary.
3: Reserve 799.34 for Newborn Period
ICD-9 codes 760-779 are for conditions which have their origins in the perinatal period only, which occurs before birth through the first 28 days after. Look to codes outside this section for similar conditions for older patients.
Example: An FP notes that a 1-month-old (30 days) infant has low weight gain. On evaluation, the FP finds the infant to be below the normal average weight for his age.
The FP diagnoses failure to thrive.
In this case, 783.41 would be the appropriate code. Code 779.34 is for newborns 28 days old or younger.
4: Code for the Specific Disease if Applicable
When the FP specifies obstruction as a diagnosis, there may be no need to use 779.32. Bilious vomiting is inherently a part of intestinal obstruction and is the hallmark sign of the presence of intestinal obstruction.
Example: Three days after delivery, a newborn had vomiting of greenish gastric secretions and was feeding poorly. The FP who evaluates her gives a diagnosis of intestinal obstruction. Code this as:
• 751.1 -- Atresia and stenosis of small intestine
• 779.31 -- feeding problems in newborn.

What CPT code would i use for an excisional biopsy of a duputyren band on the finger?

Watch your surgeon's documentation for clues regarding partial or complete treatment and the number of digits involved, and you'll be on your way to clean Dupuytren contracture release claims every time.

What happens: Dupuytren contracture release involves excising contracted fibrotic bands of the palmar fascia. Surgeons can either use a standard open incision with fasciectomy (known as the McCash technique) or percutaneous fasciotomy (known as the Luck technique). Here's how to break down these techniques into coding realities.

Fasciotomy Can be Open or Percutaneous
If the surgeon completes fasciotomy to treat Dupuytren's contracture (728.6, Contracture of palmar fascia), check the operative notes for whether he used an open or percutaneous approach. Then, choose between 26040 (Fasciotomy, palmar [e.g., Dupuytren's contracture]; percutaneous) or 26045 (... open, partial) and report the correct code for each finger the surgeon treats.

Extra codes: Your orthopedist can perform percutaneous or minimally invasive treatment of Dupuytren's contracture in an office setting, which means you'll need to report additional codes. Report 26040 for the procedure, along with the appropriate E/M choice. Because of the work involved, your most likely options are 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

The most common type of percutaneous treatment is needle aponeurotomy, or NA. The physician uses the tip of a hypodermic needle as a very small knife to divide the contracting cords of Dupuytren's disease.

Count Digits With Fasciectomy
Your surgeon might opt for fasciectomy to treat more extensive cases of Dupuytren's contracture. Base your codes on whether he completes a palm-only procedure or also accesses the digits:
26121 -- Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft)

26123 -- Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft).

When reporting 26123, append +26125 (... each additional digit [List separately in addition to code for primary procedure]) as needed. Code "26125 is an add-on code required to identify each additional digit," CPT directs you to report +26125 with 26123. Because 26121 applies to palm-only procedures, you don't need codes specifically for digits.

Tip: When coding these cases, you're looking at "otomy" versus "ectomy. "If coders will watch for the wording, they'll know which codes to use.

Use Office Visit Code for Bee Sting Counseling

The mother of a 10-year-old patient who is allergic to bee stings wants to consult with our allergist without the child present. No physician referred her. The consultation will last more than 45 minutes. Which CPT code should I use for the consultation?
Answer: You should report this service as an office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...), not a consultation (99241-99245, Office consultation for a new or established patient ...). To report 99241-99245, CPT requires another physician or other appropriate source, such as a school nurse or social worker, to request your allergist's opinion. And, the allergist must send a written report of her findings to the requesting party.

Although the scenario doesn't meet CPT's consultation criteria, you may report the visit based on time. When counseling accounts for more than 50 percent of a patient and/or family encounter, you should consider time the key factor in selecting the appropriate E/M service level.

In your example, the allergist spends 100 percent of the 45-minute visit counseling the mother about her concerns. Therefore, you should report 99215 (... physicians typically spend 40 minutes face-to-face with the patient and/or family) for an established patient.

How Can You Report Tube Removal?

Question: A physician in another city placed a laparoscopic jejunostomy tube one month ago. A second physician, locally, attempted to remove the feeding tube in his office, but it broke off. Our surgeon then attempted to remove the broken portion in the office, he but failed and had to schedule a trip to the operating room. My surgeon has suggested 43760 for this. Is this correct?

Florida Subscriber

Answer: Code 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance: APC 0121) describes removal and replacement of a gastrostomy tube, which has not occurred in this case. Rather, your surgeon only removed a portion of the feeding tube.

CPT does not contain a specific code to describe removal only of a feeding tube. Generally, the physician would include the tube removal in any E/M service he provides at the same time. In this case, however, you might argue that 43760 with modifier 52 (Reduced service) is appropriate.

Assuming that he removed the broken portion of the feeding tube endoscopically, your best bet in this case is more likely a code for foreign-body removal, such as 43215 (Esophagoscopy, rigid or flexible; with removal of foreign body: APC 0141).

43246 Includes Removal

How should we bill for an EGD with PEG removal?

The correct code for an esophagogastroduodenoscopy (EGD) with removal of a percutaneous endoscopic gastrostomy (PEG) tube is 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube).

The procedure you describe involves your surgeon replacing a feeding tube that runs through the patient's skin straight into the stomach. The removal of the old PEG tube is incidental to its replacement, so you only need the one code.

44238 Captures Lap Intestinal Hernia Repair

If the surgeon performs a laparoscopic release and repair of an incarcerated internal hernia of the small intestine, should I bill an unlisted code such as 49659?

You should use an unlisted code, but the better choice is 44238 (Unlisted laparoscopy procedure, intestine [except rectum]) instead of 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy).

That's because the lap hernia codes (49650- 49659) describe laparoscopic repair of hernias in the abdominal wall. The situation you describe involves an internal hernia in the small intestine, and CPT does not provide a specific code for that service.

Option:If your surgeon performed an open release and repair of an incarcerated internal hernia of the small intestine, you would still use a code that involved the "intestines." Your choice for an open procedure would be 44050 (Reduction of volvulus, intussusception, internal hernia, by laparotomy).

238.2: Code Original Excision Dx

If patient comes for the re-excision of a dysplastic nevus. Do I bill the re-excision using a benign or malignant ICD-9?

Follow this to do this properly.

Check pathology report from the original biopsy and make sure it states "dysplastic nevus." If biopsy showed a dysplastic lesion, then the diagnosis is benign, and you should report the diagnosis as 238.2 (Neoplasm of uncertain behavior of skin).

With that diagnosis, you should code the re-excision using a code from the series 11400-11446 (Excision, benign lesion ...) based on lesion's site and size.Important:

If you have a previous malignant lesion diagnosis and the surgeon performs a re-excision because there was a concern about clear margins from the first excision, use the original diagnosis code and the same family of lesion excision codes, even if the pathology subsequently comes back as benign.

Catch Up Your Outpatient Edits to CCI 18.0

Counting on version 17.3 will put you behind.
If you're used to ignoring new CCI edits for the Hospital Outpatient Prospective Payment Systems (OPPS) because the implementation date lags by a quarter -- don't count on it.

Here's why: CMS has announced that the outpatient code editor (OCE) version 18.0 will include the OCE version 17.3 and the new version 18.0, both of which will be implemented at the same time on Jan. 1.

That means you'll need to code according to CCI version 18.0 for inpatient and outpatient billing starting Jan. 1, or face denials.

Describe Abnormal Feces Fluidity With 787.91

A patient says she has had chronic bowel problems for the last 10 years, with diarrhea or loose stool for two to three days in a row, then constipation for another week. Diagnostic tests are being ordered. Because the diagnostic tests are only covered for certain conditions, what diagnosis should be listed? Since this has been her way of functioning for so long, it cannot be considered a change in bowel habits.

Colorado Subscriber Answer: Your ICD-9 report should include: 787.91 (Diarrhea), which describes the patient's abnormal frequency and fluidity of feces. This ICD-9 does not specify chronicity but best describes her symptoms with a code that should justify testing to rule out conditions which can cause similar bowel patterns and that can be treated.

Separate Documentation Keys Modifier 25 Coding

Having trouble with my modifier 25 coding, specifically with documentation to prove a separate E/M service. What documentation should look for to report modifier 25?

- When you are coding an encounter during which the physician provides an E/M service and performs another procedure, you should separate the documentation  and make sure there are two distinct processes. If you follow this documentation advice, your accuracy should improve on claims containing modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

When examining the E/M documentation, make sure you have the history, exam and medical decision-making in the patient's chart. Also, be sure you have documentation to show the E/M service's distinct nature. For the procedure note, make sure it includes notes and diagnosis codes that explain the reason for the procedure.

Diagnosis coding: For modifier 25 claims, you should include a diagnosis code (or codes) to represent accurately the reason for the E/M service and the procedure. Remember, the E/M and the procedure could end up with the same diagnosis code, but this is acceptable.

-The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date,- according to CPT. However, many payers have edits in place that will not allow payment for both services when you cite a single diagnosis, so be sure to report multiple diagnoses when appropriate.

Skin Graft Is More Than Suturing

 Question: The patient sliced the tip of his finger trying to catch a piece of falling metal. Examination revealed a 1.0-cm square avulsion injury to the radial aspect of the index finger down to subcutaneous tissue. There was no bone involvement or exposure, and no nail involvement. The patient wanted the skin replaced as a graft.

The surgeon performed digital block and additional preparation, then sutured the patient's own skin, from the finger, back in place.

The surgeon wants to code this as a full-thickness free graft, while I think this is wound repair. Who's right?

Michigan Subscriber
Answer: From the information you provide, you are correct to want to report wound repair -- probably complex repair, such as 13131 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm) -- for this procedure.

A free skin graft (for example, 15240, Full-thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 20 sq cm or less) includes both suturing the donor skin to the graft location and direct closure of the donor site. In this case, there is no -donor site.- The surgeon is merely re-attaching skin by suture to the area from which it was lost.

CPT instructions preceding the graft codes expressly state, -These codes are not intended to be reported for simple graft application alone or application stabilized with dressings -- Further, CPT also specifies that complex repair -includes the repair of wounds requiring more than layered closure,- including -retention sutures.-
 

Simplify Your Place-of-Service Coding With This List

Fingertip guide to your most common POS eliminates confusion
Choosing the correct place-of-service (POS) code for your claims is essential to avoiding denials and even investigation for fraud. Keep on your auditor's good side by choosing your code based on these descriptions, straight from CMS:

11 (Office) -- Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis and treatment of illness or injury on an ambulatory basis. Fair market value for the office must be paid for this office to qualify for an office and POS 11.
 21 (Inpatient hospital) -- A facility, other than psychiatric, that primarily provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
 22 (Outpatient hospital) -- A portion of a hospital that provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

23 (Emergency room -- hospital) -- A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

 31 (Skilled nursing facility) -- A facility that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing or rehabilitative services but does not provide the level of  care or treatment available in a hospital.
 32 (Nursing facility) -- A facility that primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.
 33 (Custodial care facility) -- A facility that provides room, board and other personal assistance services, generally on a long-term basis, and does not include a medical component.

ICD-9 Lesion Coding: Why Patience Pays

The info you need is in the pathology report, not necessarily encounter notes
When assigning a diagnosis for lesion removal, remember that you should wait and rely on the pathology report to choose the correct ICD-9, rather than refer to the surgeon's own note.

Consider this example of why this is important:

The procedure: Your surgeon documents, -I removed one approximately 9-mm lesion from the patient's wrist using surgical curettage. Lesion had a red outer crust and an irregular border, but it looked dissimilar from the patient's actinic keratosis spots on her face, so I am uncertain of the lesion's status. Sent lesion to the lab, and will await results.-

What not to do: In this case, based on the documentation, you might be tempted to assign a diagnosis of 238.2 (Neoplasm of uncertain behavior of other and unspecified sites and tissues; skin) to this claim. But this is a mistake.

Here's why: -You can report 238.2 only if the pathologist who examines the sample states that the lesion exhibits uncertain behavior, not when the physician thinks it might be,- says Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC, medical coding instructor for Orion Medical Services in Eugene, Ore. -It has to come from the histopathology. So unless the physician is looking at it under the microscope, that code has to be assigned from the pathologist.-

In fact, according to ICD-9, -uncertain behavior- means something totally different from what people think, Felthauser says.
Example: -Sometimes a physician will review a patient's lesion that is growing in size, or changing color or irritating a patient, and from looking at the lesion it is -uncertain- to the physician whether this lesion is benign or malignant, so he elects to remove it and send it to pathology for review,- Felthauser says. -But if the lesion has not yet been histologically assessed, you should not report 238.2.-

If you code this report, you should either wait for the pathology report to determine the correct ICD-9 code, report a diagnosis code based on the symptoms, or select an -unspecified- code such as 239.2 (Neoplasms of unspecified nature; bone, soft tissue, and skin).

Tip: -If the lesion was irritated, bleeding or had other such features, make sure you have that information documented as well because most carriers do not cover -cosmetic- removals of benign skin neoplasms,- Felthauser says. -So you need to make sure there is documentation as to why he chose to remove it, and remember to code for those services.-

CPT for ultrasound biopsy of the axillary tail lymph node with biopsy clip placement?

If the radiologist performs a breast biopsy with clip placement, don’t forget to report +19295 (Image-guided placement, metallic localization clip, percutaneous, during breast biopsy).

Tip: If the radiologist performs the breast biopsy using stereotactic guidance, payers include a follow-up mammogram in the guidance codes. So if the radiologist performs a follow-up mammogram to confirm clip placement, you should not report the mammo-gram separately.

When your radiologist performs a stereotactic breast biopsy, you first need to determine which biopsy code to report. You’ll have to decide between 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance) and 19103 (… percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance) based on the documentation your radiologist provides.

How to choose: "The difference between 19102 and 19103 is that 19102 is only the needle core biopsy using imaging," explains Karen Caputo, CCS-P, certified coder for the University of Toledo Physicians in Ohio. You’ll see the radiologist use a different device (also with imaging) for 19103.

19102: You’ll use 19102 when your physician documents that he simply inserts the device and then pulls out a core of tissue, says Laura Singleton, billing specialist at the Center for Surgery & Breast Health in Joliet, Ill. Keep in mind that your physician may make several "passes" in order to ensure that he has obtained a sufficient sample for pathology, Singleton adds.

Key: For both 19102 and 19103, report one unit per lesion -- not per sample -- unless your payer tells you otherwise in writing.

19103: Code 19103, like 19102, reflects a percutaneous procedure, but for 19103 the physician uses a "more sophisticated device that has suction or a rotating action to obtain the sample," Singleton explains.

For example, the radiologist may use a Mammotome device, which vacuums, cuts, and removes tissue samples.

"Generally 19103 is the code to use for stereotactic biopsies because of the automated vacuum assisted or rotating device that is used