live or die by the guidelines: cpt - amazon web services · pdf filelive or die by the...

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Live or Die by the Guidelines:

CPT®

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Common Procedural Terminology (CPT®) codes, descriptions, and material

only are Copyright © 2013 American Medical Association (AMA).

All Rights Reserved. No fee schedules, basic units, relative values, or

related listings are included in CPT. The AMA assumes no liability for the

data contained herein. Applicable FARS/DFARS restrictions apply to

government use.

CPT is a registered trademark of the American Medical Association.

AMA Disclaimer

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Understanding the importance of using

CPT coding guidelines.

Goals

• Listing of Illustrations (pg xvi)

– Anatomic

– Procedure code

• Read the GREEN – EVERY YEAR!

• Transfer your notes

• Review Appendices

CPT® Intimacy

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• Instructions for use of the CPT ® code book

– Unlisted procedure

– CPT ® Surgery vs Medicine • “surgery” or “not surgery”

– APN/PA – same specialty as physician

– Parenthetical notes

– Accuracy and quality of coding • Related guidelines

• Parenthetical instructions

• Other coding resources

Back to the Basics - Introduction

• Format of terminology

– Bubble and highlighting

10060 Incision and drainage of abscess;

simple or single

10061 Complicated or multiple


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• Section guidelines

• Add-on codes

– Same physician

– Modifier 51 exempt

• Place of service and facility reporting

– Home services


Illustrations

Renal Pelvis

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• Starts when anesthesia provider begins to prepare the patient for anesthesia

• Ends when the anesthesia provider is no longer in attendance

• Example:

• Anesthesia time: 5 pm to 8:30 pm Surgery time: 5:30 pm to 8:15 pm – What is the total anesthesia time?

– 3 hours and 30 minutes.

– The surgery times do not matter when reporting the anesthesia service.

Anesthesia – Reporting Time

• Only for anesthesia

• Do not use when the qualifying circumstance is included in

the description of the anesthesia code

Anesthesia – Qualifying Circumstances

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• 00561 Anesthesia for procedures on heart, pericardial sac

and great vessels of chest; with pump oxygenator, younger

than 1 year of age


• 00561 Anesthesia for procedures on heart, pericardial sac

and great vessels of chest; with pump oxygenator, younger

than 1 year of age

• (Do not report 00561 in conjunction with 99100, 99116, and

99135)


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– 00834 Anesthesia for hernia repairs in the lower

abdomen not otherwise specified, younger than 1 year

of age


– 00834 Anesthesia for hernia repairs in the lower

abdomen not otherwise specified, younger than 1 year

of age

– (Do not report 00834 in conjunction with 99100)


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• Services included in global package

– Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia

– One E/M day prior or day of the procedure

– Post op care

– Orders

• Global periods

– Minor surgery – 10 days

– Major surgery – 90 days

Surgery – Global Package

Incl

ud

ed

– n

ot

cod

ed

se

par

ate

ly

• Do not report in addition to the code it is considered

to be a component of

• Report when it is a distinct and separate procedure.

The procedure does not necessarily have to be the

only procedure performed in order to code it.

Surgery – “separate procedure”

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• Before the physician resected the medial rectus muscle of the eye and secured it with sutures, he released extensive scar tissue on that muscle which developed after a previous surgery.


• Before the physician resected the medial rectus muscle of the eye and secured it with sutures, he released extensive scar tissue on that muscle which developed after a previous surgery. – 67311 Strabismus surgery, recession or resection procedure; 1

horizontal muscle

– 67343 Release of extensive scar tissue without detaching extraocular muscle (separate procedure)


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• Before the physician resected the medial rectus muscle of the eye and secured it with sutures, he released extensive scar tissue on that muscle which developed after a previous surgery. – 67311 Strabismus surgery, recession or resection procedure; 1

horizontal muscle

– 67343 Release of extensive scar tissue without detaching extraocular muscle (separate procedure)

(Use 67343 in conjunction with 67311-67340, when such procedures are performed other than on the affected muscle)


• Read the body of the note

• Do not code from the pre-operative diagnosis and

procedure lines

– There is important information provided in the

description of the procedure that assists in selecting

the appropriate code

– Documentation to assist in modifier assignment will

typically be found in the body of the operative note

Surgery Reminders – Operative Note

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• Distinguished by Benign and Malignant

• Includes: – Local anesthesia

– Simple repair

• Report each lesion excision separately

• Intermediate and complex closures are reported in addition to the excision code when performed and documented

Surgery – Lesion excision

Review documentation requirements for intermediate vs complex closure

• Intermediate

– Layered closure of deeper layers of subcutaneous tissue and superficial fascia

– Single layer closure of heavily contaminated wounds

• Complex

– More than layered closure required


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PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion of patient's right forehead.

POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion of patient's right forehead.

OPERATION PERFORMED: Wide local excision with intermediate closure of right forehead.

INDICATIONS: The patient is a 78-year-old white male who recently in the last month or so noticed a rapidly enlarging suspicious lesion on the right side of his forehead.

DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on the table, was given no sedation. The area of his right forehead was prepped and draped with Betadine paint in normal sterile fashion. The area to be excised was just located on the right side of the patient's mid forehead. This had a maximum diameter of 1.1 cm. This had a 3 mm margin designed for total resection of 1.7 cm. This was infiltrated with 1% Lidocaine with Epinephrine. After waiting for hemostasis, it was excised, tagged, and sent for permanent pathology. The wound was then irrigated; several bleeders were tied off, and cauterized and closed in multiple layers with inverted dermises of 3-0 Vicryl, a running subcuticular stitch of 4-0 Vicryl and a few 5-0 chromics. The total length of this incision was 3 cm. This was covered with Steri-Strips, gauze, and tape. Patient tolerated this procedure with no complication and was sent home in stable condition.

FINAL DIAGNOSIS: Skin, right forehead, wide local excision: Squamous cell carcinoma, well differentiated, keratoacanthoma type, margins are free of tumor.









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COMMON MISTAKE BY STUDENTS!

• Wound repair

– add lengths together for same anatomical sites or

groups

• Lesion excision

– do not add together

Surgery – Lesion Excision vs. Wound Repair

• Selective catheter placement -

– Enter the vessel or aorta and selectively manipulate it

• Non-selective catheter placement

– Catheter placed directly into the vein or artery

– Not manipulated further

• Appendix L – Vascular Families

– Makes the assumption that the starting point is catheterization of the aorta

Vascular Families

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A patient suffering from frequent TIAs is seen in the vascular cath lab at the local hospital for selective catheterization of the left internal carotid and right internal carotid arteries. The sites are accessed via the brachiocephalic artery.

Vascular families


Vascular families

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Vascular families

• Tunneled – “tunneled” through the skin and subcutaneous tissue to a great

vessel

– Entrance point of the catheter is distant from the entrance to the vascular system

• Non-tunneled – Skin entry site in the great vessel

– More risk for infection

• Review procedure illustrations

• Review Central Venous Access Procedures Table

Surgery – Central Venous Access Procedures

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DX: Lymphoma

OP: Port-a-cath placement via left subclavian vein

Left subclavian vein was cannulated easily with needle provided in the insertion kit. Guidewire was passed with fluoroscopy visualization. Site for placement of the port reservoir was selected and horizontal skin incision made with a 15 blade. Hemostasis was obtained as needed with cautery. Dissection was performed with cautery down to the pectoralis fascia and blunt digital dissection was performed to create a pocket at the fascial level. Catheter was tunneled from the pocket up to the insertion site, where a small incision had been made. Dilator and peel-away sheath were passed over the guidewire. The guidewire was removed, dilator removed, and the catheter passed thru the peel-away sheath, and the sheath was removed. Catheter was pulled back under fluoroscopic visualization until the tip was in the superior vena cava above the right atrium. It aspirated and injected easily. It was cut to appropriate length and tensioned to the reservoir, and then aspirated and injected again with Heparinized saline. The reservoir was sutured down to the fascia with interrupted 0 Ethibond. The pocket was irrigated with antibiotic solution, and the wound was closed with interrupted 3-0 Vicryl in the deep tissues, and running 4-0 Vicryl subcuticular suture in the skin.


DX: Lymphoma

OP: Port-a-cath placement via left subclavian vein

Left subclavian vein was cannulated easily with needle provided in the insertion kit. Guidewire was passed with fluoroscopy visualization. Site for placement of the port reservoir was selected and horizontal skin incision made with a 15 blade. Hemostasis was obtained as needed with cautery. Dissection was performed with cautery down to the pectoralis fascia and blunt digital dissection was performed to create a pocket at the fascial level. Catheter was tunneled from the pocket up to the insertion site, where a small incision had been made. Dilator and peel-away sheath were passed over the guidewire. The guidewire was removed, dilator removed, and the catheter passed thru the peel-away sheath, and the sheath was removed. Catheter was pulled back under fluoroscopic visualization until the tip was in the superior vena cava above the right atrium. It aspirated and injected easily. It was cut to appropriate length and tensioned to the reservoir, and then aspirated and injected again with Heparinized saline. The reservoir was sutured down to the fascia with interrupted 0 Ethibond. The pocket was irrigated with antibiotic solution, and the wound was closed with interrupted 3-0 Vicryl in the deep tissues, and running 4-0 Vicryl subcuticular suture in the skin.


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• Hernia repair with mesh

– Incisional hernia repair, mesh is reported separately (49568)

– Parenthetical note following 49568: (Use 49568 in conjunction with 11004-11006, 49560-49566).

– Use of mesh or other prostheses is not separately reported for any other hernia repair

– Laparoscopic hernia repairs (49652-49657) include mesh in the CPT® code description

Surgery – Hernia Repair

Inci

sio

nal

Her

nia

– c

od

e m

esh

sep

arat

ely

PROCEDURE PERFORMED: 1. Repair of left inguinal hernia with placement of mesh on a 45-year-old male.

DESCRIPTION OF PROCEDURE: Under general anesthesia using an LMA, the patient’s left groin was prepped with ChloraPrep and then the appropriate sterile drapes were placed.

A standard skin incision was made and carried down through the dermis and Scarpa’s fascia to the external oblique which was opened in the direction of its fibers through the external ring. The cord structures were identified and were encircled with a Penrose drain. There was no direct hernia component found. There was mild laxity of the floor. The cord structures were skeletonized and a hernia sac was readily identified and cleared from the surrounding tissue down to the internal ring where the preperitoneal space was entered. The hernia sac was inverted into the preperitoneal space and a medium PerFix plug was placed in this area holding the inverted sac in very nicely. The mesh was tacked to the surrounding muscle layers using simple interrupted #0 Vicryl sutures. A sheet of mesh was then placed over the entire floor and held at the pubic tubercle and along the inferior aspect of the shelving edge of the inguinal ligament using a running #2-0 Prolene suture.

The tails of the mesh were then split around the internal ring and the superior tail was tacked down to the shelving edge again recreating the sling. The superior aspect of the mesh was held to the fascia using simple interrupted #0 Vicryl sutures. At the end of this portion of the procedure, the entire floor was covered with mesh and there was absolutely no tension.

The wound was irrigated copiously with normal saline and then injected with 0.25% Marcaine with epinephrine. Closure consisted of reapproximation of the external oblique with a running #3-0 PDS suture followed by reapproximation of Scarpa’s fascia and the dermis with #4-0 Vicryl simple inverted interrupted sutures followed by reapproximation of the skin with a running subcuticular stitch of #5-0 Vicryl followed by Steri-Strips and a sterile dressing.


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PROCEDURE PERFORMED: 1. Repair of left inguinal hernia with placement of mesh on a 45-year-old male.

DESCRIPTION OF PROCEDURE: Under general anesthesia using an LMA, the patient’s left groin was prepped with ChloraPrep and then the appropriate sterile drapes were placed.

A standard skin incision was made and carried down through the dermis and Scarpa’s fascia to the external oblique which was opened in the direction of its fibers through the external ring. The cord structures were identified and were encircled with a Penrose drain. There was no direct hernia component found. There was mild laxity of the floor. The cord structures were skeletonized and a hernia sac was readily identified and cleared from the surrounding tissue down to the internal ring where the preperitoneal space was entered. The hernia sac was inverted into the preperitoneal space and a medium PerFix plug was placed in this area holding the inverted sac in very nicely. The mesh was tacked to the surrounding muscle layers using simple interrupted #0 Vicryl sutures. A sheet of mesh was then placed over the entire floor and held at the pubic tubercle and along the inferior aspect of the shelving edge of the inguinal ligament using a running #2-0 Prolene suture.

The tails of the mesh were then split around the internal ring and the superior tail was tacked down to the shelving edge again recreating the sling. The superior aspect of the mesh was held to the fascia using simple interrupted #0 Vicryl sutures. At the end of this portion of the procedure, the entire floor was covered with mesh and there was absolutely no tension.

The wound was irrigated copiously with normal saline and then injected with 0.25% Marcaine with epinephrine. Closure consisted of reapproximation of the external oblique with a running #3-0 PDS suture followed by reapproximation of Scarpa’s fascia and the dermis with #4-0 Vicryl simple inverted interrupted sutures followed by reapproximation of the skin with a running subcuticular stitch of #5-0 Vicryl followed by Steri-Strips and a sterile dressing.


• Both twins vaginal birth

– CPT® Assistant April 1997, 1

– 59400 and 59409-51

• One delivered vaginally, the other cesarean

– CPT® Assistant April 1997, 1

– 59510 and 59409-51

Surgery – Maternity & Delivery - Twins

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• +69990

– Add-on code (do not use modifier 51)

– Do not report for magnifying loupes or corrected vision

– Do not report when included in the description of the

procedure

Surgery – Operating Microscope

• Professional component

• Technical component

• When billed by physicians, should have modifier -26

appended

Radiology – Supervision and Interpretation

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• Specimen - Tissue(s) submitted for:

– Individual

– Separate

– “requiring individual examination and pathological

diagnosis”

– CPT® Assistant, Winter 1991, 18

Lab – Surgical Pathology

• Supplemental tracking codes

• Performance measurement

• Optional

• PQRS

Category II Codes

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• Temporary codes

• “If a Category III code is available, this code must

be reported instead of a Category I unlisted code”

• Allows for data mining for clinical efficacy, utilization

and outcomes.

Category III Codes

• Modifier 22

– Increased procedural service

– “substantially greater than typically required”

– Documentation must reflect additional work and

reason for additional work

• Modifier 52

– Reduced services

– Provider’s discretion

Modifiers – 22 & 52

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• Modifier 50

– Do not use when bilateral is included in CPT® descriptor of the code

– Can be replaced with modifiers LT & RT

• Modifier 51

– Do not use on modifier 51 exempt codes

• Appendix E

• Symbol Ø

– Do not use with add-on codes


• Modifier 58 – Staged or related procedure

– Planned prospectively at the time of the original procedure

– More extensive than the original procedure

– Therapy following a surgical procedure

• Modifier 59 – Procedures not normally reported together

– Different Session or Patient Encounter

– Different Procedure or Surgery

– Different Site or Organ System

– Separate Incision/Excision, Lesion, Injury


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• Modifier 78 – Unplanned return to operating room by same physician following

initial procedure for a related procedure during the post op period

• During the postoperative period

• One or more additional procedures

• Result of complication of the original surgery (not defined by CPT® definition…check with payer)

• Modifier 79 – Unrelated procedure or service by the same physician during the

postoperative period


• Read the question and the entire note/scenario

• Read all coding guidelines in the beginning of each

section and subsection of the CPT® manual

• Read ALL parenthetical notes

Important!

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Thank you!

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