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