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AdvancedCoding Scenarios:An Expert ReviewAudio Seminar/WebinarDecember 15, 2009Practical Tools for Seminar Learning Copyright 2009 American Health Information Management Association. All rights reserved.
DisclaimerThe American Health Information Management Association makes norepresentation or guarantee with respect to the contents herein andspecifically disclaims any implied guarantee of suitability for any specificpurpose. AHIMA has no liability or responsibility to any person or entitywith respect to any loss or damage caused by the use of this audioseminar, including but not limited to any loss of revenue, interruption ofservice, loss of business, or indirect damages resulting from the use of thisprogram. AHIMA makes no guarantee that the use of this program willprevent differences of opinion or disputes with Medicare or other thirdparty payers as to the amount that will be paid to providers of service.CPT five digit codes, nomenclature, and other data are copyright 2009American Medical Association. All Rights Reserved. No fee schedules,basic units, relative values or related listings are included in CPT . The AMAassumes no liability for the data contained herein.As a provider of continuing education the American Health InformationManagement Association (AHIMA) must assure balance, independence,objectivity and scientific rigor in all of its endeavors. AHIMA is solelyresponsible for control of program objectives and content and the selectionof presenters. All speakers and planning committee members are expectedto disclose to the audience: (1) any significant financial interest or otherrelationships with the manufacturer(s) or provider(s) of any commercialproduct(s) or services(s) discussed in an educational presentation; (2) anysignificant financial interest or other relationship with any companiesproviding commercial support for the activity; and (3) if the presentationwill include discussion of investigational or unlabeled uses of a product.The intent of this requirement is not to prevent a speaker with commercialaffiliations from presenting, but rather to provide the participants withinformation from which they may make their own judgments.Usage RightsThis document is exclusively for use by individuals attending the associated audioseminar or webinar (named on the first page of this document), in conjunction withtheir attendance of the live or recorded version of the presentation. All materialherein is copyright 2009 American Health Information Management Association(AHIMA), except where otherwise noted. It may not be redistributed without priorwritten permission from AHIMA.AHIMA 2009 Audio Seminar Series http://campus.ahima.org/audioAmerican Health Information Management Association 233 N. Michigan Ave., 21st Floor, Chicago, Illinoisi
FacultyLynn Kuehn, MS, RHIA, CCS-P, FAHIMALynn Kuehn is president of Kuehn Consulting in Waukesha, Wisconsin. Ms. Kuehnis a healthcare consultant with over 20 years of experience in operationalassessment, professional fee coding and reimbursement systems, data quality,and management of both independent and hospital-based clinic practices. Shehas authored numerous publications for AHIMA including Procedural Coding andReimbursement for Physician Services, now in its ninth edition; EffectiveManagement of Coding Services; CCS-P Exam Preparation Guide; and A PracticalApproach to Analyzing Healthcare Data.AHIMA 2009 Audio Seminar Seriesii
Table of ContentsDisclaimer . iFaculty . ii, 1Presentation Objectives . 2Sources for Today's Questions . 2-4Who Do We Believe? . 5Diagnostic Coding for Ancillary Tests. 5Q1 (COPD ) . 6Q2 (avascular necrosis ) . 7Q3 (billing out diagnosis of findings ) . 8New to Facility CodingQ4 (rounding HCPCS code amt ) . 8Q5 (surgical global – perineal abscess ), Q6 (casting supplies ) . 9Modifiers .10Q7 (multiple physicians, modifier 27 ).10Q8 (CA modifier, death ) .11Q9 (rotator cuff repairs, modifier 59 ) .12Q10 (discontinued procedure ) .13Q11 (x-rays, modifier 76 ) .14Q12 (OIG workplan, modifier GY ) .15Procedures .17Q13 (foreign body removal ), Q14 (urinalysis collection ) .17Q15 (knee immobilizer ) .18Q16 (disagreement between sources ), Q17 (H1N1 vaccines ) .19Procedures – Injections and Infusions .21Q18 (IV hydration and pushes ) .21Q19 (end times on IV infusions ), Q20 (start time by someone else ).23Additional Questions Answered.24If we didn't get to your question.25Audio Seminar Discussion .26Become an AHIMA Member Today! .26Audio Seminar Information Online .27Upcoming Audio Seminars .27Thank You/Evaluation Form and CE Certificate (Web Address) .28Appendix.29Resource/Reference List .30CE Certificate InstructionsAHIMA 2009 Audio Seminar Series
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsFacultyLynn Kuehn, MS, RHIA, CCS-P, FAHIMAPresidentKuehn Consulting, LLCWaukesha, WisconsinAHIMA Books by Ms. Kuehn Procedural Coding and Reimbursementfor Physician Services Effective Management of Coding Services CCS-P Exam Preparation Guide A Practical Approach to AnalyzingHealthcare DataAvailable at www.ahimastore.orgAHIMA 2009 Audio Seminar Series1
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsPresentation Objectives Answer your outpatient diagnostic orprocedural questions Cite sources from currently publishedcoding advice Additional question and answersession1Sources for Today’s Questions AHA’s Coding Clinic for ICD-9-CMAHA’s Coding Clinic for HCPCSAMA’s CPT AssistantThe Official ICD-9-CM Guidelines forCoding and Reporting, Section IV.Diagnostic Coding and Reporting forOutpatient Services Medicare Frequently Asked Questions,National Coverage Decisions and otherpublished materialAHIMA 2009 Audio Seminar Series22
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsAHA’s Coding Clinic for ICD-9-CM “The official publication for ICD-9-CMcoding guidelines and loffice/html/products.html3AHA’s Coding Clinic for HCPCS “The official publication for Level IHCPCS (CPT-4 codes) for hospitalproviders and specific Level II HCPCScodes for hospitals, physicians andother health professionals.” Same web location4AHIMA 2009 Audio Seminar Series3
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsAMA’s CPT Assistant Official source on CPT for physiciansand professional fee coders AMABookstore.com and search for“CPT Assistant” uct detail.jsp?productId prod1701365CMS Website www.cms.hhs.gov Transmittals athttp://www.cms.hhs.gov/Transmittals/ Frequently Asked Questions at“Questions” on blue menu bar inupper middle, php/enduser/std alp.php?psid yZXrRoNjAHIMA 2009 Audio Seminar Series64
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsWho Do We Believe? The official source for CPT (HCPCSLevel I) codes for the hospitaloutpatient coder is Coding Clinic. The official source for CPT (HCPCSLevel I) codes for the professional feecoder is CPT Assistant. The official source for HCPCS Level IIcodes is Coding Clinic for all coders.7Diagnostic Coding for AncillaryTests “We regularly are questioned regarding the codeswe have selected and have become much moreconservative as a result. This has caused muchdelay in our department and with the physicianson our staff. Are we trying to be over-specific?” The patient comes for a radiologyexam. Their facility method is to code thediagnosis from the order for theservices, not the report.AHIMA 2009 Audio Seminar Series85
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsDiagnostic Coding for AncillaryTesting Q1 – “The diagnosis on the order:COPD, SOB. The exam is a chest x-ray.They are requested to code both theCOPD and the shortness of breath.” Mayo Clinic, athttp://www.mayoclinic.com/health/copd/DS00916 Shortness of breath is the presentingsymptom and COPD is the clinicalhistory.9Diagnostic Coding for AncillaryTesting The Official ICD-9-CM Guidelines, SectionIV, H tells us: List first the ICD-9-CM code for the diagnosis,condition, problem or other reason forencounter/visit shown in the medical record tobe chiefly responsible for the services provided.List additional codes that describe anycoexisting conditions. In some cases the firstlisted diagnosis may be a symptom when adiagnosis has not been established (confirmed)by the physician.10AHIMA 2009 Audio Seminar Series6
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsDiagnostic Coding for AncillaryTesting Q2 – “The diagnosis is avascularnecrosis right hip, hip pain. Therequest is for us to code both thenecrosis and the hip pain.” Merck Manual .html Same guideline but different set ofcircumstances.11Diagnostic Coding for AncillaryTesting Avascular necrosis already diagnosed. Pain was the first symptom listed inthe Merck Manual. Unless they suspect a new diseaseprocess, they are monitoring thedisease of avascular necrosis. Hip pain would not be coded.12AHIMA 2009 Audio Seminar Series7
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsDiagnostic Coding for AncillaryTesting Another facility sent us a similarquestion, asking: Q3 - “CMS has clarified for physicians thatread the reports to bill out the diagnosis offindings (radiologist would use the findingof DJD, a pathologist would use theirfindings). Would the facility also do thesame?” Coding Clinic for ICD-9-CM, 1st Qtr, 200213New to Facility Coding Q4 - The coder says “I coded for a physicianfor 6 years and very recently changed jobs tocode hospital outpatient work. I’m having ahard time knowing when things are the sameand when they’re different in procedurecoding. Do I code drugs the same way I didbefore? I mean using the HCPCS code amountand rounding up to the next whole unit.” This is the same for Pro Fee and Facility. Coding Clinic for HCPCS, 1st Qtr, 2005 and3rd Qtr, 2005 both cover this issue.AHIMA 2009 Audio Seminar Series148
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsNew to Facility Coding Q5 - “My other question is about thesurgical global. The GYN did an I&D of aperineal abscess 3 days ago. The patientreturned for repeat I&D of the abscess ofthe perineum. Can I code this? Are theglobals the same for the facility?” Not the same for Pro Fee and Facility Coding Clinic for HCPCS, 4th Qtr,2004 handles a similar issue.15New to Facility Coding Q6 – “Do I code casting supplies like Idid in the physician office? No onehere knows anything about this and Idon’t want to miss the supplies, if I’msupposed to code them.” Not the same for Pro Fee and Facility Coding Clinic for HCPCS, 2nd qtr 200216AHIMA 2009 Audio Seminar Series9
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsNew to Facility Coding Q codes are not to be used by theFacility. Casting supplies are to be billedseparately but with a revenue code027X Physicians code the cast supplies usingQ codes. Ask if supplies are being coded in theED, Orthopedics or a cast lab?17Modifiers Q7- “We have lots of specialty clinics andour patients see multiple physicians on thesame day. Our visits are coded in theclinics and we spend a considerableamount of time checking for this andapplying modifiers before claims aresubmitted. Is modifier 27 reallynecessary?” Medicare FAQ ID #2390, last updated on11-4-0918AHIMA 2009 Audio Seminar Series10
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsModifiers Modifier 27 seems necessary. CPT Assistant, May 2003, pgs 7-16. It tells us that when more than one E/Mservice was delivered on the same day,apply modifier 27 to the 2nd andsubsequent visits of the day. Don’t forget that you need ConditionCode G0 when more than one visitoccurs in the same revenue code.19Modifiers Q8 - “Does the patient have to die toqualify for the use of a CA modifier?” Coding Clinic for HCPCS, 1st qtr, 2003and 4th qtr, 200520AHIMA 2009 Audio Seminar Series11
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsModifiers Q9 – Outpatient coder in acommunity hospital “Our orthopedist does mini-openrotator cuff repairs with arthroscopiclabral debridement and subacromialdecompression. My codes are 29826,23412, and 29822. Which ones getthe modifier 59?”21Modifiers Coding Clinic for HCPCS, FourthQuarter, 2004, page 10. Rotator cuff repair includes the labraldebridement Codes would be 23412, 29826-59 Would not report 29822.22AHIMA 2009 Audio Seminar Series12
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsModifiers Q10 - Discontinued procedure? The physician documents this about apercutaneous repair of a finger fracture with 3bone fragments. “Several attempts were made toreduce the fracture. We placed a wire through thedistal PIP but x-rays showed less than optimalalignment. Several attempts were made to havethe wire align the fracture in all planes, withoutsuccess. Ultimately a simultaneous, bidirectionalwire approach was our only success at properalignment, confirmed on x-ray.” Coding Clinic for HCPCS, 3rd qtr, 200723Modifiers The unsuccessful attempts areconsidered a part of the successfulprocedure. Different from a discontinuedprocedure. Procedure was notattempted or partially attempted and,for some reason, was cancelled or notcompleted.24AHIMA 2009 Audio Seminar Series13
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsModifiers Discontinued after administration ofanesthesia modifier 74 Discontinued after prep but beforeadministration of anesthesia modifier 7325Modifiers Q11 – “Our orthopedic department orderspre- and post-reduction x-rays when theyset certain fractures. Is this anappropriate situation for the use ofmodifier 76? It is listed as a hospitaloutpatient modifier but says it’s a repeatprocedure or service by the samephysician. Is this OK on a facility claim?” Coding Clinic for HCPCS, 2nd Qtr, 200926AHIMA 2009 Audio Seminar Series14
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsModifiers Q12 – “The OIG workplan listsMedicare Billings with Modifier GY asan area being studied. Why wouldthey care about Modifier GY if itmeans that we won’t get payment?Can you explain this? I must bemissing something.”Transmittal B-02-020, March 27, B02020.pdf27Modifiers Modifier GA – Waiver of liabilitystatement on file (Used when service isexpected to be denied and an ABN IS on file) Modifier GZ – Item or serviceexpected to be denied as notreasonable and necessary (Used when anABN is NOT on file) Modifier GY – Item or servicestatutorily excluded or does not meetthe definition of any Medicare benefitAHIMA 2009 Audio Seminar Series2815
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsModifiers Very hard to tell what is“statutorily d/Choose PFS Relative Value FilesPage down to 2010Download zipped fileUnzip and open PPRRVU10.xlsTranslation file is RVUPUF10.pdf2930AHIMA 2009 Audio Seminar Series16
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsProcedures Q13 – Foreign body removal “We go back and forth with the urgent carephysicians about whether they have to makean incision to code for a subcutaneous foreignbody removal (10120). They constantlycharge it on their pro fee claim and we don’tthink this is right. We don’t code it. What canwe do to make them listen?” Coding Clinic for HCPCS, 3rd Qtr,2002.31Procedures Q14 - “We’ve been told by acompliance reviewer that CPT code51701 cannot be used to code thecollection of urine for urinalysis. Isthis true and if so, how do we codethis service to get paid? It’s timeconsuming and certainly not thesame as regular urine collection.”32AHIMA 2009 Audio Seminar Series17
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsProcedures Coding Clinic for HCPCS, 3rd quarter2007 HCPCS code P9612, Catheterizationfor collection of specimen, singlepatient, all places of service33Procedures Q15 – “I can’t figure out how to codea knee immobilizer. Did you knowthat CPT Assistant and Coding Clinicfor HCPCS don’t agree on this? CPTAssistant says it’s a splint and CodingClinic says it’s a strapping.” Coding Clinic for HCPCS, 2nd Qtr,2001, page 7 CPT Assistant, May 2009, page 8AHIMA 2009 Audio Seminar Series3418
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsProcedures Q16 – “It’s come to our attention thatCPT Assistant and Coding Clinic forHCPCS don’t always agree. We’ve askedfor clarification on this from both butdon’t have an answer yet.” PTA of the left subclavian artery CPT Assistant says 35475 (Sept 2008, p 10) Coding Clinic says 37799 (4th Qtr 2008, p 8)35Procedures Q17 – “I’m really confused about how tocode these new H1N1 vaccines that theyjust started giving. Apparently there arenew codes that aren’t in the CPT book. Ijust heard that there are new HCPCS Gcodes. What am I supposed to do?” Yes, there are new codes Vaccines should be billed at 0.00 or 0.01because they are free from the government36AHIMA 2009 Audio Seminar Series19
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsProcedures 90663 – Influenza virus vaccine,pandemic formulation, H1N1 90470 – H1N1 immunizationadministration (intramuscular,intranasal), including counselingwhen performed37Procedures G9141 – Influenza A (H1N1)immunization administration(includes the physician counselingthe patient/family) G9142 – Influenza A (H1N1) vaccine,any route of administration 2009 payment for G9141 is 24.8938AHIMA 2009 Audio Seminar Series20
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsProcedures CPT ces/cptcodes.shtml CMS ads/R1803CP.pdf- Page 839Procedures - Injections andInfusions Q18 – “We’re the facility administeringthe infusions. How do I code IV hydrationfor 3.5 hours from 8:00 am to 11:30 amand two IV pushes of differentmedications, one at 9:30 am and the otherone at 10:00 am?” CPT Assistant, February 2009, page 17 isthe best source available Coding Clinic for HCPCS, 4th Qtr, 2007 Read every note in the CPT book sectionAHIMA 2009 Audio Seminar Series4021
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsProcedures - Injections andInfusions Hydration cannot be concurrent sosubtract out the time used for thepushes. 3.5 hrs minus .5 hours (15 min x 2) 3 hrs 96374 – 1st IV push – In hierarchy,the initial code 96375 – 2nd IV push – Sequentialpush of a new substance/drug41Procedures - Injections andInfusions 96361 x 3 – Remaining 3 hours ofhydration Note below 96361 says: (Report96361 to identify hydration ifprovided as a secondary orsubsequent services after a differentinitial service (96360, 96374, 96409,96413) is administered through thesame IV access)AHIMA 2009 Audio Seminar Series4222
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsProcedures - Injections andInfusions Q19 – “We still have challengesgetting the end times on IV infusions.Start time doesn’t seem to be asmuch of a problem. Is there anythingwe can do to code this work that wasobviously done?” Coding Clinic for HCPCS, 3rd Qtr, 2007 IV push43Procedures - Injections andInfusions Q20 – “What are we supposed to use for astart time when the patient arrives with anIV that was started by someone else,usually the paramedics?” Medicare Claims Processing Manual(100-04), Chapter 4 - Part B Hospital(Including Inpatient Hospital Part Band OPPS), Section 230.2, D on p c04.pdf44AHIMA 2009 Audio Seminar Series23
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsProcedures - Injections andInfusions Section title: Infusions StartedOutside the Hospital Assign “HCPCS code(s) that mostaccurately describe the service(s)they provide” Does not state how to determine thetime45Audience QuestionsAHIMA 2009 Audio Seminar Series24
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsOur Apologies Our sincere apology if we did not getto your question today We received a large variety ofquestions and tried to group themtogether by concept Please post your question in theCoding CoP if we did not discuss yourissue during the programAHIMA 2009 Audio Seminar Series25
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsAudio Seminar DiscussionFollowing today’s live seminarAvailable to AHIMA members atwww.AHIMA.orgClick on Communities of Practice (CoP) – icon on top rightAHIMA Member ID number and password required – for members onlyJoin the Coding Community from your Personal Pageunder Community Discussions, choose theAudio Seminar ForumYou will be able to: Discuss seminar topics Network with other AHIMA members Enhance your learning experienceBecome an AHIMA Member Today!To learn more about becoming amember of AHIMA, please visit ourwebsite at ahima.org/membership tojoin now!AHIMA 2009 Audio Seminar Series26
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsAHIMA Audio SeminarsVisit our Web sitehttp://campus.AHIMA.orgfor information on the2010 seminar schedule.While online, you can also registerfor seminars or order CDs,pre-recorded Webcasts, and *MP3s ofpast seminars.*Select audio seminars onlyUpcoming Seminars/WebinarsResequence or Renumber?Facts of Life in CPT DevelopmentJanuary 12, 2010HITECH and Release of InformationJanuary 21, 2010Facility E-D Coding and Charge CaptureJanuary 28, 2010AHIMA 2009 Audio Seminar Series27
Advanced Coding Scenarios: An Expert ReviewNotes/Comments/QuestionsThank you for joining us today!Remember visit theAHIMA Audio Seminars Web siteto complete your evaluation formand receive your CE Certificate online Each person seeking CE credit must complete thesign-in form and evaluation in order toview and print their CE certificateCertificates will be awarded forAHIMA Continuing Education CreditAHIMA 2009 Audio Seminar Series28
AppendixResource/Reference List .30CE Certificate InstructionsAHIMA 2009 Audio Seminar Series29
AppendixResource/Reference ListAmerican Hospital Association (AHA)Coding Clinic for ICD-9-CM: The official publication for ICD-9-CM coding guidelines and adviceCoding Clinic for HCPCS: The official publication for Level I HCPCS (CPT-4 codes) for hospital providersand specific Level II HCPCS codes for hospitals, physicians and other health entraloffice/html/products.htmlAmerican Medical Association (AMA)CPT Assistant: Official source on CPT for physicians and professional fee codershttp://www.AMABookstore.comSearch for “CPT Assistant” or go directly duct detail.jsp?productId ources/cpt-codes.shtmlCenters for Medicare and Medicaid Services (CMS)http://www.cms.hhs.govTransmittals at http://www.cms.hhs.gov/TransmittalsTransmittal B-02-020, March 27, loads/R1803CP.pdf - Page ly Asked Questions at “Questions” on blue menu bar in upper middle, /php/enduser/std alp.php?p sid yZXrRoNjMedicare Claims Processing Manual (100-04), Chapter 4 - Part B Hospital (Including InpatientHospital Part B and OPPS), Section 230.2, D on p c04.pdfCenters for Disease Control and Prevention (CDC)The Official ICD-9-CM Guidelines for Coding and Reporting, Section IV. Diagnostic Coding and Reportingfor Outpatient Serviceshttp://www.cdc.govSearch for “ICD-9-CM Guidelines”Mayo 6Merck Manual .htmlAHIMA 2009 Audio Seminar Series30
To receive yourCE CertificatePlease go to the AHIMA Web lclick on the link to“Sign In and Complete Online Evaluation”listed for this seminar.You will be automatically linked to theCE certificate for this seminar after completingthe evaluation.Each participant expecting to receive continuing education credit must completethe online evaluation and sign-in information after the seminar, in order to viewand print the CE certificate.
Sources for Today's Questions AHA's Coding Clinic for ICD-9-CM AHA's Coding Clinic for HCPCS AMA's CPT Assistant The Official ICD-9-CM Guidelines for Coding and Reporting, Section IV. Diagnostic Coding and Reporting for Outpatient Services Medicare Frequently Asked Questions, National Coverage Decisions and other
