break time fluid exchanges 1. respiratory system outpatient coding, part ii (cpt) montana hospital...
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Break TimeBreak Time
Fluid Exchanges
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Respiratory System Respiratory System Outpatient Coding, Part IIOutpatient Coding, Part II
(CPT) (CPT) • Montana Hospital Association• June 29, 2011 10 am - Noon• © Irene Mueller, EdD, RHIA
http://media.healthday.com/images/editorial/respiratory.jpg 22
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ObjectivesObjectives
• Review of ICD-9-CM OUTPATIENT coding for common Respiratory system diagnoses (2011 Guidelines) Part I
• Review of CPT OUTPATIENT coding for common Respiratory system procedures Part II
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Respiratory System & CPTRespiratory System & CPT
• Respiratory Subsection
• Headings– Nose
– Accessory Sinuses
– Larynx
– Trachea and Bronchi
– Lungs and Pleura• Lung Transplantation
• Surgical Collapse tx: Thoracoplasty
• Subheadings (1 + each Heading)– Incision
– Excision
– Removal of FB
– Repair
– Destruction
– Endoscopy
– Other Procedures
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NoseNose
• Nose• Nasal septum• Intranasal tissue• Nasal turbinates• Skin of nose
• Codes ranges - simple to complex
• 30901-30906– Control of nasal
hemorrhage
– NOT reported w/other procedure codes
• Considered integral part
55http://www.nlm.nih.gov/medlineplus/nosedisorders.html
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Nose, Excision Nose, Excision
• Turbinates– Type of procedure– Technique
• Endoscopy• Cauterization• Debridement• Laser • Cryotherapy• Radiofrequency
reduction• Ablation
• Can be reported separately with other nose surgical proc– sphenoid, maxillary,
frontal sinus, septoplasty
– NOT w/ ethmoid sinus
• 30130-30140 – unilateral
• -50 if bilateral• -59 if for sep. dx
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Nasal ApproachesNasal Approaches
• Open• Making an incision
into skin or tissues inside the nasal cavity
• Endoscopic• Fiberoptic endoscope
is inserted through the nostrils
77http://www.aed.md/3-Flex-Rhino.html
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Nose ExamplesNose Examples• Total intranasal ethmoidectomy for chronic sinusitis
& complete excision of inferior turbinate for sleep apnea– 31201, 30130-59
• Sinus endoscopy w/ partial ethmoidectomy and septoplasty – 31254, 30520
• Bilateral surgical endoscopic nasal septoplasty w/cartilage scoring– 30520-50, 31254-50-51
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Accessory SinusesAccessory Sinuses
• Heading - unique guidelines for endoscopies
• 31231-31294 unilateral– LT, -RT, or -50
• Dx vs. surgical endoscopy
• Dx endoscopy reported once, even when bilateral
• Surgical endoscopy includes– dx endoscopy
• Surgical sinus endoscopy includes – Sinusotomy AND– Dx endoscopy
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Accessory SinusesAccessory Sinuses
• Middle turbinate is part of ethmoid bone– When removed as part of 31237 OR 31254-31255
• DO NOT report removal
• 30930 (Fx nasal turbinates)– Usually inferior turbinates– Code separately w/ 31255, 30520– When middle turbinates fxed for sinus proc.
• Do NOT report (code)
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Accessory SinusesAccessory Sinuses
• Biopsy of lesion of accessory sinuses– DO NOT REPORT when
• Part of excision, destruction, other type of removal
– Code ONLY once• Multiple
similar/identical lesions• Multiple areas of
respiratory system
1111http://www.nlm.nih.gov/medlineplus/ency/imagepages/1108.htm
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LarynxLarynx• Epiglottis• Larynx• Inside Trachea
• Larynx is a single midline organ– No -50
• Laryngectomy with bilateral radical neck dissection– 31365– 38720-59
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Arytenoid-ectomy/pexyArytenoid-ectomy/pexy
• Arytenold cartilage– Located in bilateral vocal fold
• Arytenoidectomy
• Arytenoidopexy– Can be open 31400– Or closed 31560
• Done to improve breathing
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Larynx EndoscopyLarynx Endoscopy
• Documentation should note– Direct– Indirect– Use of fiberoptic scope
that transmits light– Operating microscope
for magnification
• Direct– Flexible or rigid fiberoptic
scope– Rigid laryngoscope
• Indirect– Small hand mirror in back
of pt’s throat– Dr. headgear w/mirror and
light source
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Laryngoscopy to place Laryngoscopy to place endotracheal tubeendotracheal tube
• DO NOT code laryngoscopy separately– 31500 Laryngoscopy to place endotracheal tube for
air passage in emergency– Laryngoscopy to place endotracheal tube for
nonemergent purposes (anesthesia or bronchoscopy)
– Laryngoscopy for tracheostomy
• DO NOT code tracheostomy separately– 31600– When essential part of laryngeal surgery
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Trachea and BronchiTrachea and Bronchi
• Procedures performed – THROUGH the trachea – On tracheal cartilage (carinii)– Bronchi
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EndoscopyEndoscopy
• Bronchoscopy• Tracheoscopy• Tracheobronchoscopy
– Flexible or Rigid scopes– w/wo brushings– w/wo cell washings
• Brushing– Combing the mucous
lining of trachea/bronchus with bronchial brush to collect cells
• Cell washing– Flushing fluid into an area – Removing fluid via
aspiration to collect cells
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Dx & Surgical EndoscopiesDx & Surgical Endoscopies
• Surgical endoscopies include dx endoscopies
• Dx endoscopy during open procedure – DO NOT CODE endoscopy
• Failed surgical endoscopy converted to open procedure– Code ONLY the open
procedure
1818http://www.nlm.nih.gov/medlineplus/ency/imagepages/1077.htm
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BronchoscopyBronchoscopy
• 31622-31656– May also include bx– Include nasal endoscopy– Laryngoscopy
• 31622-31629 Distinct procedures
• Report each code separately
• Do NOT add -51
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Bronchoscopy BxBronchoscopy Bx
• When endobronchial bx (31625) performed in addition to transbronchial bx (31628)– Edit states 31625 is component of 31628
• When to add -59– IF Bx of bronchus & transbronchial lung bx
are in different lobes, Code 31628, 31625-59.– IF Bronchial bx in same lobe as TBLBx,
cannot charge for bronchial bx, 31628 ONLY
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Bronchoscopy ExampleBronchoscopy Example
• A patient presents with aspiration of a FB. Dx bronchoscopy done to locate FB. Surgical bronchoscopy removes the FB.
• 31635
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Lungs and PleuraLungs and Pleura
• Excision
• Removal
• Endoscopy
• Lung Transplantion
• Thoracoplasty
2222
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Excision, Lungs & PleuraExcision, Lungs & Pleura
• 32400 Biopsy, pleura; percutaneous needle– Long needle inserted
through skin & into other tissues (chest wall, lung, mediastinum)
– NOT fine needle aspiration (10021-10022)
2323http://www.nlm.nih.gov/medlineplus/ency/imagepages/8898.htm
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RemovalRemoval
• 32400 Percutaneous pleural bx– Inserting long needle through skin, etc. to get pleural
TISSUE
• 32420 Pneumocentesis– Puncture of the lung with needle to drain fluid/obtain
dx material
• 32421-32422 Thoracentesis– Surgical puncture of the chest wall with a needle to
obtain fluid from the pleural cavity– Dx evaluation– Drain excess fluid of pleural effusion
2424
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Removal, Lungs & PleuraRemoval, Lungs & Pleura
• Pneumonectomy 32440– Removal of ENTIRE lung
• Lobectomy – 32480– Removal of ONE lobe
• Segmentectomy – 32484– Removal of ONE segment
• Wedge resection – 32500– Removal of lung portion that is less than
segment - lesion
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EndoscopyEndoscopy• Thoracoscopy
– Pleural space between lung and chest wall must be large enough to move instruments around easily and to visualize all important areas of thoracic cavity
– A pneumothorax is created to provide the space to work in
• When open lung/chest procedure follows, code both, open code 1st
• When surgical thoracoscopy converted to open procedure, code open proc. ONLY
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Thoracoscopy ExampleThoracoscopy Example
• Pt has thoracoscopic bx, during which talc was placed via an insufflator. Surgeon used thoracoscope to assist in the placement of talc
• 32602, diagnostic thoracoscopy with bx, AND• 32650, surgical thoracoscopy with pleurodesis
• Sequencing• 32650• 32602-51
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Thoracostomy for PneumothoraxThoracostomy for Pneumothorax
• Surgeon placed a chest tube for patient who presented with pneumothorax. Dr. noted chest tube inserted & placed to negative pressure system.
CPT code 32551, Tube thoracostomy, includes water seal (eg, for abscess, hemothorax, empyema), when performed (separate procedure)
• CPT code 32421 describes a thoracentesis for aspiration, which denotes more transient procedure
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Lung TransplantationLung Transplantation
• Each distinct component is coded separately– Cadaver donor pneumonectomy 32850– Recipient lung allotransplantation 32851-54– Backbench work 32855-32856
• Unilateral/Bilateral
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Pulmonary ServicesPulmonary Services
• 94002-94799 Tx and Dx
• When provided during E/M encounter
• report w/appropriate E/M code
• Ventilator services
• Laboratory procedures
• Interpretation of test results
3030
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PFTPFT• Dx procedure to allow
physician to measure functional status of lungs– Spirometry 94010, 94375,
94060– Lung Volume 94240,
94260, 94360 – Diffusion Capacity
94720 – Lung compliance 94720 – Pulm. Studies during
exercise testing 94620
3131http://www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_Diagnosis.html
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ExampleExample
• During a Level 3 E/M service to evaluate cystic fibrosis, pt underwent PFT to assess total volume of thoracic gas.
• Physician interpreted the results and adjusted the pt’s meds
• 277.02
• 99213, 94260
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Pulmonary Stress TestingPulmonary Stress Testing
• Done to be sure Pt receiving enough O2 WHILE performing normal tasks
• For reimbursement, need a hallway measuring approx. 100 feet long
• Pt walks 6 minutes, then breathing rate measured • If certain level of SOB, then prescribe oxygen or
other medications• Ask Pt to return in a few days, in order to ensure
that the tx is working properly (repeat PST)
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Pulmonary Stress TestingPulmonary Stress Testing
• Dx code must reflect – some type of chronic breathing condition– acute condition that requires careful monitoring
• VERY careful documentation– Ideally, pt’s weight, height, age, oxygen
saturation, blood pressure, and SOB levels– nurse performing the test should clearly indicate
monitoring activities – Check w/insurance companies
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Pulmonary Stress TestingPulmonary Stress Testing
• For Pulmonary Rehab patients, a 6-minute walk test done to assess progress with therapy is bundled into G0424 code
• even a single study can’t be billed separately
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Pulmonary RehabilitationPulmonary Rehabilitation
• Multidisciplinary team approach for patients with compromised lung function.
• Mainly for pts w/COPD
• Also asthma, cystic fibrosis, or bronchiectasis, pre-lung transplantation
• Includes exercise training, psychosocial support, and education
• Intended to improve pt’s functioning and quality of life
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Typical Rehab ServicesTypical Rehab Services
• Exercise training sessions– Supervised/monitored training in safe exercise techniques
to improve functional independence in ADLs– Bicycle ergometer, treadmill, upper body exercise &
education on energy conservation & compensatory breathing techniques
– Respiratory rate, heart rate, blood pressure, & pulse oximetry monitoring during exercise sessions, as medically indicated
3737
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Typical Rehab ServicesTypical Rehab Services
• Patient education– Breathing training to teach pt methods of relieving & controlling
dyspnea & improving ventilatory function at rest & during activity– Understanding & knowledge of diagnosed pulmonary disease,
home care, – Indicators to help pt know when to seek medical attention– May be in group setting, but individualized to each pt’s specific
needs
• Follow-up– Includes structured home pulmonary rehabilitation program &
may include supervised home exercise conditioning
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Common contraindications to Common contraindications to Rehabilitation Rehabilitation
• Psychiatric disturbance– dementia, organic brain syndrome, etc.
• Significant or unstable medical conditions– CHF, acute cor pulmonale, substance abuse,
significant liver dysfunction, metastatic cancer, disabling stroke
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Medical NecessityMedical Necessity
• Team assessment completed w/input by physician, RT, nurse, & psychologist, etc. Includes– Pulmonary function testing w/in past year,
which documents moderate to moderately severe obstructive or restrictive pulmonary disease (FEV 1 or FVC < 80% of predicted) AND
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Medical NecessityMedical Necessity
• Simple pulmonary stress testing, prior to/during admission evaluation,• ID potential for rehabilitation through the assessment
of oxygen status at rest and during exercise • NOTE: appropriate aerobic alternative for pts unable
to perform simple pulmonary stress testing, such as paraplegic patient
– AND
4141
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Medical NecessityMedical Necessity
• Significant respiratory symptoms– Dyspnea at rest or while performing ADLs, etc.– Remains symptomatic after other medical
management has been attempted
• AND
• Medically stable Pt w/ no limitations from other psychological or medical conditions
• Pre-lung transplant meets medical necessity
4242
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2010 Pulmonary Rehab MC2010 Pulmonary Rehab MC
• G0424 (Pulmonary rehabilitation, incl. exercise [includes monitoring], per hour/per session) COPD Dx ONLY (mod – very severe)
• Hospitals & practitioners report up to 2 one-hour sessions/day TOTAL of 36 sessions
• To report one session, treatment must last at least 31 minutes– multiple shorter periods same day– Add minutes, IF at least 31 minutes during day, bill for
one-hour session
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Pulmonary RehabPulmonary Rehab
• Settings– Physician’s office or a hospital (CAH)
outpatient
• Physician– must be immediately available and accessible
for medical consultations and emergencies at all times when services provided
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Pulmonary Rehab Pulmonary Rehab DocumentationDocumentation
• 5 components documented in MR– Physician-prescribed exercise, inc. some aerobic
exercise must be in each session – Education & training related to individual pt’s treatment
and needs, including information on respiratory problem management and smoking cessation counseling, if needed
– Psychosocial assessment– Outcomes assessment– Treatment plan - how components are used for each pt
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Other Pulmonary Rehab CodesOther Pulmonary Rehab Codes
• G0237 and G0238 are timed codes
• G0239 is billable 1/day per patient– Can code 6-minute walk and other services
• BUT walk packaged into G0424
• Pt’s Dx determines which codes are appropriate
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G0237-38G0237-38
• G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minutes (includes monitoring)
• G0238 Therapeutic procedures to improve respiratory function, other than described by g0237, one on one, face to face, per 15 minutes (includes monitoring)
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G0239G0239
• G0239 Therapeutic procedures to improve respiratory function or increase strength or endurance of respiratory muscles, two or more individuals (includes monitoring)
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TB TestingTB Testing• PPD, Mantoux screening
test, Tuberculin Sensitivity Test, Pirquet test, or PPD test for Purified Protein Derivative) - screening test to detect antibodies & presence of a disease
• V74.1 – Special screening examination for bacterial and spirochetal diseases; Pulmonary tuberculosis
• CPT 86580 ONLY – RBRVS does NOT
include reading costs
• IF patient returns– code 99211 for nurse
reading
• IF test positive (795.5), can capture 99212-99214, based on what is discussed + other tests
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Smoking CessationSmoking Cessation
• 99406 3-10 minutes 99407 10 min +• Documentation
– at least 3 minutes discussing smoking issue– providing advice on how to stop– Record time spent on counseling– type and quantity of tobacco used– therapeutic recommendations.
• 99406 Can bill 4xyr, depending on insurance
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MC Smoking CessationMC Smoking Cessation
• Beneficiaries w/ smoking-related disease– heart disease, cerebrovascular disease (stroke),
multiple cancers, lung disease, weak bones, blood clots, and cataracts
• Beneficiaries taking any medication whose effectiveness is complicated by tobacco use– insulin and some medicines for high blood
pressure, blood clots, and depression
• up to 8 FTF visits during 12-month period
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ResourcesResources
• Outpatient Pulmonary Rehabilitation Services. BCBS
Florida. 6/27/11– http://mcgs.bcbsfl.com/?doc=Outpatient Pulmonary Rehabilitatio
n Services
• Correctly code for new cardiac, pulmonary rehab benefits. JustCoding News: Outpatient, 3/10/10– http://www.hcpro.com/HIM-247625-8160/Correctly-code-for-new
-cardiac-pulmonary-rehab-benefits.html
• Mackaman, D. Pulmonary Rehabilitation Services Revisited. 5/10/10.– http://blogs.hcpro.com/medicarefind/2010/05/pulmonary-rehabilit
ation-services-revisited/
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