rom cptassistantmay2008

AssistantMay 2008 / Volume 18 Issue 5

Page 3Screening andBriefIntervention(SBI) forAlcohol andSubstance Abuse

Page 5ChromosomeAnalysis

Page 9Manual MuscleTesting, Range ofMotion Testing,and PhysicalPerformance Testor Measurement

3Questions andAnswers

Your practical guide to current coding

CPT® Assistant May 2008 / Volume 18 Issue 5

CPT Assistant Editorial Board* Chair: Peter A. Hollmann, MDVice Chair, CPT Editorial Panel

Secretary: Dan ReyesManaging Editor, CPT AssistantAmerican Medical Association

Claudia J. Bonnell, RN, MLS Blue Cross Blue Shield Association

Albert Bothe, Jr., MDCPT Advisory Committee

Nelly Leon-ChisenAmerican Hospital Association

Helene M. Fearon, PTHealth Care Professionals Advisory Committee

Lee H. Hilborne, MD, MPHCPT Editorial Panel

Charles F. Koopman, Jr., MDAMA Specialty Society RVS Update Committee

Richard A. Molteni, MDCPT Advisory Committee/Former CPT Editorial Panel

Danielle PavloskiAmerican Medical Association

Gerald E. Silverstein, MDAmerica’s Health Insurance Plans

Kenneth B. Simon, MD, MBA Centers for Medicare and Medicaid Services

Lianne StancikAmerican Medical Association

J. Martin Tucker, MDCPT Editorial Panel

Richard W. Whitten, MD, MBAContractor Medical Director

* Established February 2007. Beginning with the May 2007issue, all content has been reviewed by the CPT AssistantEditorial Board.

AMA Acknowledgments Michael D. Maves, MD, MBAExecutive Vice President, Chief Executive OfficerAmerican Medical Association

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CPT® Assistant is designed to provide accurate, up-to-date coding infor-mation. We continue to make every reasonable effort to ensure the accu-racy of the material presented. However, this newsletter does not replacethe CPT codebook; it serves only as a guide.

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Screening and Brief Intervention:What Is It? Screening and brief intervention (SBI) for alcohol andsubstance abuse is a technique used to identify, and inter-vene with, people who use alcohol or drugs in a harmful orhazardous way and are at risk for substance use-relatedproblems or injuries. The goal of SBI is to have sites ofcare, such as trauma centers, hospital emergency depart-ments, ambulatory medical practices, and school clinicsscreen patients at-risk for substance use and, if appropri-ate, provide them with a brief intervention or referral toappropriate treatment. By screening people in these set-tings, it is possible to identify people who have had analcohol-related illness or injury that could provide a moti-vation for behavior change. In addition, screening servesas a form of primary prevention by educating patientsabout the health effects of using alcohol and other drugs.

BackgroundThe impact of hazardous alcohol and substance abuse can exacerbate medical, mental, and social problems,resulting in significant public health cost. (The annualnational economic cost to society is estimated to be $375billion).1 The human suffering and emotional cost of alco-hol and drug abuse are devastating for individuals, fami-lies, and communities.

Historically, the emphasis of substance use-related inter-vention has been placed on universal prevention strategiesaimed at people who have never initiated use2 or specialisttreatment for people who are dependent.3 Little attentionhas been given to the large group of people who use alco-hol and other drugs, are not dependent, and could success-fully reduce their use through early intervention.4,5 Earlyintervention can substantially reduce health and otherproblems associated with hazardous substance use.6

How Does It Work? Screening: Patients are screened for substance use with avalidated questionnaire. These screening questions shouldbe simple enough to be administered by a wide range ofhealth care professionals. The questionnaire should focuson the frequency and the quantity of substance use over aparticular time frame (generally 1 to 3 months).

Brief Intervention: Brief intervention usually happens ina single session immediately following a positive screeningresult. The physician or other qualified health care profes-sional focuses on increasing the patient’s understanding ofthe impact of substance use on his or her health and moti-vating the patient to change risky behaviors. If the patientshows signs of substance dependence or other complica-tions, the provider can refer the patient to specialized sub-stance use assessment and treatment or manage thepatient’s care through specialty consultation.

Coding Correct use of codes 99408 and 99409 requires that thescreening and interventional components of this servicebe documented in the clinical record.

99408 Alcohol and/or substance (other than tobacco)abuse structured screening (eg, AUDIT, DAST),and brief intervention (SBI) services; 15 to 30minutes

99409 greater than 30 minutes

The work effort for codes 99408 or 99409 is separate anddistinct from all other Evaluation & Management (E/M)services performed during the same clinical session (ie,date of service); the work effort of performing code 99408or 99409 is, therefore, not considered in selecting thelevel of any other E/M service on the same date. (Ifreporting E/M that qualifies as a significant, separatelyidentifiable service on the same date as reporting SBI, useModifier 25 with the E/M service).

A physician or other qualified health care professionaluses a validated screening instrument (such as the alcohol use disorder identification test [AUDIT] or thedrug abuse screening test [DAST]). A validated screeninginstrument is an instrument that has been psychometrical-ly tested for reliability (the ability of the instrument toproduce consistent results), validity (the ability of theinstrument to produce true results), sensitivity (the proba-bility of correctly identifying a patient with the condi-tion), and specificity (the probability of correctly identify-ing a patient who does not have the condition). Using aninstrument that has not been validated may increase thechances of misidentification.

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Coding Communication: Screening and BriefIntervention (SBI) for Alcohol and SubstanceAbuse (Other Than Tobacco)


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An intervention is performed when indicated by the scoreon the screening instrument. The instrument used and thenature of the intervention are recorded in the clinicaldocumentation for the encounter.

If an intervention is not required on the basis of the resultof the screening, the work effort of performing the surveyis included in the selection of the appropriate E/M serviceor preventive medicine service. If an intervention isrequired on the basis of the screening result, the interven-tion is conducted. Code 99408 is the most likely screeningservice level for the majority of patients.

The Centers for Medicare & Medicaid Services createdcodes G0396 and G0397 for reporting comparable services for Medicare fee-for-service schedule (FFS)patients because of statutory restrictions on coverage forscreening services.

G0396 Alcohol and/or substance (other than tobacco)abuse structured assessment (AUDIT, DAST),and brief intervention (SBI) services; 15 to 30minutes

G0397 greater than 30 minutes

Clinical Example (99408)A 21-year-old college student reports to the school infir-mary after injuring his leg when he fell down several steps.

Description of Procedure (99408)A qualified health care professional conducts a detailedscreening interview using the AUDIT and reviews themedical record for all relevant data related to alcoholand/or substance use (ie, blood alcohol level, GGT, drugpanel bioassay, and prescribed medications). The screen-ing reveals that the patient uses alcohol regularly and wasintoxicated at the time the fall occurred. The AUDITscore indicates that the patient requires an intervention.

The intervention seeks to motivate the patient to decreaseor abstain from alcohol consumption and/or drug use. Thecomponents of the intervention include feedback con-cerning the quantity and frequency of alcohol (or drugs)consumed by the patient in comparison with nationalnorms; a discussion of negative physical, emotional, andoccupational consequences; and a discussion of the overallseverity of the problem. Feedback is accompanied by clini-cally appropriate advice for behavior change that fits thepatient’s unique medical and social situation. The quali-

fied health care professional engages the patient in a jointdecision-making process regarding alcohol and/or drug use.Plans for follow-up are discussed and agreed to.

Effective intervention requires specific training and/orexperience in techniques eliciting accurate information,developing a specific treatment plan to which the patientis committed, and motivating the patient to changebehavior. Training in motivational enhancement or moti-vational interviewing is available from a variety of sources.

For More InformationThe National Institute on Alcohol Abuse and Alcoholismprovides a useful resource for developing SBI procedures:“Helping Patients Who Drink Too Much: A Clinician’sGuide.”

http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf

The Substance Abuse and Mental Health ServicesAdministration operates a Web site that provides compre-hensive information about screening and brief interven-tion in medical settings: http://sbirt.samhsa.gov/index.htm.

References1. National Institute on Drug Abuse and the National Institute

on Alcohol Abuse and Alcoholism. The Economic Costs ofAlcohol and Drug Abuse in the United States, 1992. Analysisby the Lewin Group, Harwood, H.; Fountain, D.; andLivermore, G. Bethesda, MD: DHHS, NIH, NIH PublicationNo. 98-4327 September 1998. Summary available online atwww.niaaa.nih.gov/Resources/DatabaseResources/QuickFacts/EconomicData/cost7.htm. Accessed April 4, 2008.

Office of National Drug Control Policy. The Economic Costs ofDrug Abuse in the United States, 1992-1998. September 2001.Available online at www.whitehousedrugpolicy. gov/publica-tions/economic_costs/. Accessed April 4, 2008.

Drug Strategies. Denver on the Horizon: Reducing SubstanceAbuse and Addiction. 2002. Available online atwww.drugstrategies.org/denver/DenvCh_4.html#_edn1.Accessed April 4, 2008. According to Drug Strategies:“NIDA and NIAAA (1998) estimated that alcohol abuse costthe nation $166.543 billion in 1995, and that drug abuse costthe nation $109.832 billion in 1995. Updating NIDA-NIAAA’s 1995 alcohol abuse cost figure for populationgrowth and inflation, Drug Strategies estimates that alcoholabuse cost the nation $212.680 billion in the year 2000.ONDCP (2001) revised and updated NIDA-NIAAA’s drugabuse cost figure, estimating that drug abuse cost the nation$160.664 billion in the year 2000. Combining these revised

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The Pathology and Laboratory section of the CPT code-book includes the Cytogenetic subsection pertaining tochromosome analysis. The October 1999 and July 2005editions of CPT Assistant addressed the specific use ofthese codes, and the CPT Education and InformationServices CPT Network continues to receive specific ques-tions pertaining to the use of these codes (see CommonlyAsked Questions in this article). Although the descriptorsof codes 88245-88291 include terms well known to thecytogeneticists, pathologists, and most others ordering orperforming these studies, a review of the descriptor terms(ie, chromosome, banding, mosaicism, karyotype, andbreakage) and analysis techniques may further understand-ing of these procedural services.

DefinitionCytogenetics is the study of chromosomes by light or fluo-rescent microscopy performed to rule out an inherited(constitutional) or acquired chromosomal abnormality.

Clinical cytogenetics is the branch of cytogenetics con-cerned with relations between chromosomal abnormalitiesand clinical syndromes or conditions. Clinical cytogeneti-cists use knowledge and techniques from the study of cells(cytology) and the science of heredity (genetics) to cate-gorize inherited conditions and predict the risk of futureoffspring inheriting the same condition.

Cytogenetics examines microscopically visible chromoso-mal changes, deletions, or additions. Analysis of chromo-somes is also useful in the further categorization of certainforms of cancer (eg, hematological malignancies) and inguiding therapy as well as identifying a chromosomaldefect associated with congenital disorders (eg, Down syn-drome). Human body cells, exclusive of reproductive cellsfollowing meiosis, have 23 pairs of chromosomes. Anydeviation from this number or deletions or additions to aspecific chromosome is considered abnormal.

HistoryChromosomes were first observed in plant cells by KarlWilhelm von Nägeli in 1842. Chromosomal behavior in salamander cells was described by Walther Flemming,the discoverer of mitosis (cell division), in 1882. Thenumber of human chromosomes remained unknown formore than 70 years. Modern cytogenetics is generally saidto have begun in 1956 with the discovery that normalhuman cells contain 23 chromosome pairs, or 46 totalchromosomes. Previously, humans were thought to have48 chromosomes.

In the late 1960s, techniques were developed that differ-entially stain chromosomes. When stained chromosomesare visualized and enumerated, the resulting pattern istermed the karyotype of that cell.

In the 1980s, advances were made in molecular cytogenet-ics with the use of fluorescently labeled probes. Hybridi-zing probes to chromosome preparations using fluorescentlabels came to be known as fluorescence in situ hybridization(FISH). This change significantly increased the use ofprobing techniques because fluorescently labeled probes aresafer (because conventional staining techniques use somepotentially toxic chemicals), provide more specific diagnos-tic information, and can be used almost indefinitely.

Currently, routine analysis includes that of G-bandedchromosomes, other cytogenetic banding techniques,molecular cytogenetics such as FISH, and comparativegenomic hybridization (CGH).

What Does One See Under theMicroscope?Cells. The body’s individual cells are so small that a microscope is needed to see the anatomic detail and biochemical activity condensed into just one cell.The chromosomes present with cells contain genes (theunits of heredity, such as for height, sex, and hair color).Each body cell contains 23 pairs of highly condensedchromosomes that contain about 100,000 genes. Genesare constructed of repetitive sequences of DNA (deoxyri-bonucleic acid).

Because the human DNA helix (a spiral ladder form-ation) occupies too much space in the cell, small proteinsare responsible for packing the DNA into units callednucleosomes. To simplify, a chromosomal DNA moleculecontains three specific nucleotide sequences that arerequired for replication: a DNA replication origin, a cen-tromere to attach the DNA to the mitotic spindle, and atelomere located at each end of the linear chromosome.This is important because chromosomes can change theirconformation and degree of compaction throughout thecell cycle.

Identification of where and when a chromosomal alter-ation or abnormality occurs provides vital information forprenatal testing, diagnosing congenital disorders, and diag-nosing and assessing the treatment of certain cancers.Genetic analysis is also being utilized increasingly to pre-dict the best medication or dose for treating a specific dis-ease in an individual patient. Aneuploidy is a change inthe number of chromosomes that can lead to a genetic


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Coding Clarification: Chromosome Analysis


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abnormality. The most common form of aneuploidy isDown syndrome, which is caused by an extra copy of chro-mosome number 21. Aneuploidy is typically detectedthrough karyotyping, a process in which a picture of a per-son’s chromosomes is created and then analyzed.

Of course, not all cells are analyzed (because there areabout 100 trillion cells in the human body, with another 3 billion new cells developed every minute to replacethose that die). Also, changes in chromosome numbermay not necessarily be present in all cells in a person. Achange may be detected in just a specific tissue or withindifferent cells in a tissue. Therefore, specimens for cytoge-netic analysis can be obtained from a variety of tissuescapable of yielding cells that divide in culture (88230-88239), including peripheral blood (lymphocytes), amni-otic fluid (amniocytes), chorionic villi (trophoblasticcells), bone marrow, solid tumors, fluid from cavities (eg,pleural, peritoneal, spinal), and cultured fibroblasts (usual-ly obtained by skin biopsy).

Newer molecular cytogenetic techniques can be used evenin nondividing cells, such as buccal cells obtained nonin-vasively by a cheek swab. Enough cells must be examinedso that the chance of missing a cytogenetically distinctcell line (mosaicism) is statistically minimized. Whenchromosomal abnormalities occur variably (more than onepattern of chromosome is present in the same individualor tissue) within different cells of a person, it is calledchromosomal mosaicism (88263). Examples of mosaicismare found in leukemia cases, specifically, chronic lympho-cytic leukemia and acute myeloid leukemia.

Detection MethodsThe chromosomes in a cell or a single-cell organism arevisible through a microscope during cell division. Eachchromosome is characterized by the length of its arms(short and long arms) and the location of its centromere,which appears as an indentation or a lightly stained region.

KaryotypeA karyotype is the complete set of all chromosomes of a cell of any living organism. In clinical cytogenetics,karyotyping includes the microscopic analysis of thestained chromosomes for abnormalities, arranging them in their proper chronologic order (pair 1 to 23) and thentaking and analyzing a photograph of the chromosomes.This analysis may also be used to determine other visibleaspects of a person’s genotype, such as the number andpattern of their sex (an XX [female] vs XY [male] chromo-somes). The karyotype photograph or image is created by photographing the stained chromosomesthrough a microscope. The chromosomes are thenarranged and displayed in a picture in a standard format,in pairs, ordered by size. The karyotype result describes all

findings, normal and abnormal. Therefore, karyotypes helpcorrelate chromosomal abnormalities with the characteris-tics of specific diseases.

BandingDuring cell division (mitosis), the 23 pairs of human chro-mosomes condense and are visible with a light microscope.A karyotype analysis usually involves stopping cell divi-sion in mitosis and staining the condensed chromosomes.When they are stained, the mitotic chromosomes have a“banded” structure that unambiguously identifies eachchromosome of a karyotype. For example, with the use ofGiemsa stain (G banding), the dye stains regions of chro-mosomes that are rich in the base pairs adenine (A) andthymine (T), producing a dark band. Staining methodsmay result in banding (eg, 88261, 88262, 88263, 88264,and 88283) on the chromosomal arms (chromatids); thechromosomes can then be identified according to theirbanding pattern to allow:

• construction of physical maps of chromosomes;

• analysis of chromosome structure and aberrations; and

• identification of individual chromosomes.

Microscopic analysis of banded chromosomes is performedby a clinical laboratory specialist in cytogenetics.Generally, 20 cells are analyzed, which is sufficient todetect mosaicism, if present, at an acceptable sensitivity.The results are summarized and given to a medical geneti-cist or a pathologist for review and to generate writteninterpretation (88291), taking into account the patient’smedical history and other clinical findings.

There are other techniques in addition to banding thatallow for genetic evaluation of chromosomes. Examplesinclude FISH (88271-88275), quantitative polymerasechain reaction (PCR) of short tandem repeats, quantita-tive fluorescence PCR, quantitative real-time PCR dosageanalysis, quantitative mass spectrometry of single-nucleotide polymorphisms, and CGH. Emerging technolo-gies allow molecular karyotyping to be performed usingmicroarrays (88385 and 88386) via hybridization ofpatient DNA to specific isolated chromosomal regions(array-CGH) or, more generally, with arrays that targetsingle- nucleotide polymorphisms and/or regions of copynumber variation in the human genome.

Chromosomal Breakage SyndromesChromosomal analysis for breakage syndromes (88245,88248, and 88249) refers to studies performed to identify agroup of rare genetic disorders typically transmitted in anautosomal recessive mode of inheritance. In culture, cellsfrom affected individuals exhibit elevated rates of chromo-somal breakage or instability, leading to chromosomalrearrangements. Examples of these disorders include ataxia


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telangiectasia, Bloom syndrome, Fanconi anemia, andxeroderma pigmentosum. They are characterized by adefect in DNA repair mechanisms or genomic instability.

A chromatid is one of two identical copies of DNA mak-ing up a chromosome that are joined at their centromeres,for the process of nuclear division (mitosis or meiosis).Sister chromatid exchange (SCE) (88245) is a sophisticatedcytomolecular technique commonly applied in a search forclastogenicity or genotoxicity. A clastogen is any environ-mental agent, including carcinogens, that causes damageto genetic material. Therefore, SCE is used to help deter-mine whether the chromosomes and, thus, DNA of a par-ticular interest group have undergone genetic damagecompared with a control group.

In the SCE technique, one sister chromatid (half of achromosome) is stained darkly and the other one lightly.In a healthy person, it is not unusual for the sister chro-matids of one chromosome to break and swap pieces witheach other. This is SCE and, provided the number ofSCEs does not go beyond a certain threshold, it is notconsidered harmful. However, any increase in frequency ofSCEs beyond the threshold indicates genetic damage,which can lead to ill health. Many environmental agents(eg, ultraviolet light, X-rays, nicotine, and alcohol) athome or at work can increase the number of SCEs.

Commonly Asked QuestionsQuestion 1: Our chorionic villus biopsy studies include culturing of cells and chromosome study to determine fetalkaryotype, which includes counting and analyzing 20 mitoticcells (two G-banded karyotypes are prepared and analyzed). Is code 88264 appropriate to report for the chromosome analy-sis with this study? Can we additionally report code 88280 forthe second karyotype?

Answer: For the scenario described, code 88264 would not be correct. Code 88235, Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells,should be reported for the cell culture. Code 88267,Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding, should be reportedfor the analysis. (The work involved may vary dependingon whether a laboratory chooses to perform direct chori-onic villus sample preparations in addition to the culturedcells and on whether in situ methods are used or cell cul-ture is performed followed by analysis of dispersed cells.)Twenty cells would be the standard, although some per-forming in situ methods argue that the statistical power ishigher in that setting, so fewer cells can be studied.

Code 88285, Chromosome analysis; additional cells counted,each study, should be reported once for the additional five cells analyzed. Code 88280, Chromosome analysis;additional karyotypes, each study, is reported once for the

additional karyotype analysis. Code 88291, Cytogeneticsand molecular cytogenetics, interpretation and report,should also be reported for the interpretation and report.

Code 88264, Chromosome analysis; analyze 20-25 cells,refers to complete analysis of the chromosomes, as is donein cancer studies because mosaicism for structural abnor-malities is common. In prenatal diagnosis, structural chro-mosome mosaicism is so low relative to numericalmosaicism that it is detected through the simple countingof the chromosomes.

Question 2: Are cell count and karyotyping included in code88264, or is only analysis included? If count and karyotype areincluded, how many cells and karyotypes are built in? If chro-mosome analysis is performed on a specimen by counting andanalyzing 20 cells plus two karyotypes with banding, how isthis reported?

Answer: Yes, code 88264 incorporates both cell count andkaryotyping.The basic distinctions in the 88261-88264series of codes are that code 88262, Chromosome analysis;count 15-20 cells, 2 karyotypes, with banding, is used forcytogenetic studies of inherited (constitutional) chromo-some status, whereas code 88264, Chromosome analysis;analyze 20-25 cells, is used to assess acquired chromosomeabnormalities associated with cancer. Therefore, code88262 is used to describe identification of numerical chro-mosome abnormalities. Counting the number of chromo-somes in 15 to 20 cells and determining two karyotypes tofind abnormal chromosome counts is sufficient becausemosaicism for structural abnormalities is rare.

Regarding code 88264, Chromosome analysis; analyze 20-25 cells, in cytogenetics, the term “analysis” incorpo-rates two tasks: (1) a count of all chromosomes in the cell to determine whether the cell contains a normal orabnormal number of chromosomes and (2) determinationof a karyotype.

Code 88264 describes a procedure that includes both tasksfor each cell reviewed. If 20 cells are reviewed, one per-forms 20 counts and 20 karyotypes, examining each cellfor the possibility of different cell lines (clones and/or sub-clones) because when cancer is present, different clonescan have numerical or structural chromosomal differences.By definition, chromosome counts and karyotypes areinherent in a complete analysis (88264). It would be inap-propriate to use code 88264 with a code (eg, 88262) thatincludes a count and/or karyotype.

The interpretation and report of the cytogenetic servicefor codes 88264 and 88262 is additionally reported withcode 88291, Cytogenetics and molecular cytogenetics, inter-pretation and report.


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Question 3: Is code 88285 appropriately reported for each additional cell counted beyond the number specified in the base code (eg, 88261 or 88262), or does it cover all additionalcells counted for the study (ie, single test result)? For example,assume code 88261 accurately applies as the base code forchromosome analysis for a particular study, but 10 cells arecounted instead of 5 as specified in the descriptor: Do I reportcode 88285 five times to account for the additional cells, oronly once?

Answer: Code 88285, Chromosome analysis; additional cellscounted, each study, covers all additional cells counted and,therefore, should be reported once. The descriptor indi-cates the analysis of additional cells (plural).

Glossary of Termsallele One member of a pair or series of genes that occupya specific position on a specific chromosome.

aneuploidy The gain or loss of individual chromosomesfrom the normal diploid set of 46 chromosomes. As instructural anomalies, the error may be present in all cellsof a person or in a percentage of cells.

banding Techniques that differentially stain chromosomes,allowing chromosomes of otherwise equal size to be differ-entiated and to elucidate the breakpoints. Some typesinclude the following:

• C-banding that stains centromeres;

• R-banding, the reverse of C-banding, that stains non-centromeric regions in preference to centromeres;

• G-banding, obtained with Giemsa stain and yields aseries of lightly and darkly stained bands; and

• Q-banding, a fluorescent pattern obtained usingquinacrine for staining that gives a pattern of bandssimilar to that seen in G-banding.

centromere The constricted part of a chromosome that isresponsible for proper segregation of each chromosomepair during cell division. The chromatids in mitosis andeach pair of homologous chromosomes in meiosis are heldtogether at the centromere until anaphase, when they sep-arate and move to the spindle poles, thus being distributedto the two daughter cells.

chromosome The small bodies in the nucleus of a cellthat carry the chemical “instructions” for reproduction ofthe cell. They consist of strands of DNA wrapped in adouble helix around a core of proteins. Each species ofplant or animal has a characteristic number of chromo-somes. For human beings, for example, it is 46 (23 pairs–22 pairs of autosomal, or nonsex, chromosomes and 1 pairof sex chromosomes).

clastogen Any environmental agent that causes damage to genetic material and may include carcinogens.

diploid Having two sets of chromosomes in each body cell. The diploid number of chromosomes includes a hap-loid set from each parent. Many one-celled organisms arehaploid throughout most of their life cycle. The humandiploid number is 46.

karyotype The chromosomal characteristics of an animal.When stained chromosomes are visualized and enumerat-ed, the resulting pattern is termed the karyotype of thecell. Karyotyping is useful in determining the presence ofchromosomal defects.

meiosis The set of two successive cell divisions that serveto separate homologous chromosome pairs before the for-mation of gametes (sperm and eggs). A critical componentof sexual reproduction, the major purpose of meiosis is theprecise reduction in the number of chromosomes by half,so that a diploid cell can create haploid gametes.

mitosis Cell division.

mosaicism A condition in which an individual has two ormore cell populations that differ in genetic makeup. Thissituation can affect any type of cell, including blood cells,gametes (egg and sperm cells), and skin cells. Mosaicismmay be detected through chromosome evaluation. It isusually described as a percentage of the cells examined.The normal chromosome finding in males is 46 XY, andthat in females is 46 XX.

References

Cohen J. Sorting out chromosome errors. Science. June 21, 2002;296:2164-2166.

Haines JL, Pericak-Vance MA. Approaches to Gene Mappingin Complex Human Diseases. New York, NY: John Wiley &Sons; 1998.

Klug WS, Cummings MR. Concepts of Genetics. Upper SaddleRiver, NJ: Prentice Hall; 1997.

Thompson MW, McInnes RR, Huntington WF. Genetics inMedicine. Philadelphia, PA: WB Saunders Co, 1991.

Verma RS, Babu A. Human Chromosomes: Manual of BasicTechniques. New York, NY: Pergamon Press; 1989.

Vogel F, Motulsky AG. Human Genetics. Berlin, Germany:Springer-Verlag; 1986.

Weaver RF, Hedrick PW. Genetics. Dubuque, IA: WMC BrownPublishers; 1989.

Young ID. Introduction to Risk Calculation in Genetic Counseling.Oxford, England: Oxford University Press; 1999.

Adapted from Jorgenson KF, van de Sande JH, Lin CC. The useof base pair specific DNA binding agents as affinity labels for thestudy of mammalian chromosomes. Chromosoma. 1978;68:287-302.

Nowell PC, Rowley JD, Knudson AD Jr. Cancer genetics, cytoge-netics: defining the enemy within. Nat Med. October, 1998;4:1107-1111.This article incorporates text in the public domain from the USNational Library of Medicine. �


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Manual Muscle Testing (95831-95834)CPT codes 95831, Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk, and 95832, Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side, are intended to report a manual test ofspecific muscles or muscle groups for strength graded bythe physician or other qualified health care professional.Manual muscle test findings can be reported using either anumerical scale (0-5) or equivalent semiquantitative lan-guage, such as zero, trace, fair, good, or normal. Code95831 should be reported once for each extremity and/oronce for the trunk, and code 95832 should be reportedonce for the hand with or without comparison to theother hand. Code 95833, Muscle testing, manual (separateprocedure) with report; total evaluation of body, excludinghands is intended for reporting a total body manual muscletest excluding the hands, and code 95834, Muscle testing,manual (separate procedure) with report; total evaluation ofbody, including hands is for reporting a total body manualmuscle test including the hands. Manual muscle testingrequires the provider to isolate specific muscles and testthem with or without gravity eliminated and with or with-out manual resistance.

Manual muscle testing requires a separate report identify-ing specific muscles and their grades. Manual muscle test-ing that does not meet these criteria should be consideredpart of the evaluation and management (E/M) service orpart of the physical and occupational therapy evaluation/re-evaluation codes 97001-97004. Gross testing of musclestrength (eg, testing plantar flexion without separating thesoleus from the gastrocnemius) is typically included as partof the physical examination, one of the key componentsused to determine the level of E/M service codes. Testingmuscle strength is also a typical component of physicaland occupational therapy evaluations/re-evaluations. Incontrast, manual muscle testing of specific muscles of anextremity, trunk, or hand is indicated when the patient’scondition requires a more thorough review of isolatedmuscle function (eg, lower motor neuron disease).Although it is not typical to see reporting of manual mus-cle testing codes with E/M services or physical therapy andoccupational therapy evaluations/re-evaluations (97001-97004), it is possible that a specific condition will requirecomprehensive testing above and beyond what is consid-ered integral to an examination. The documentation

should support the need for manual muscle testing servicesperformed on the same date of service as an E/M service or a physical therapy evaluation/re-evaluation (97001-97004). Manual muscle testing codes 95831-95833 may be reported on dates subsequent to an E/M service orphysical and occupational therapy evaluations/reevalua-tions as long as the code requirements are met.

The language included in each of the descriptors for use ofthese codes indicates:

• the body area(s) addressed by each code in the series(eg, extremity, trunk, or hand, with or without com-parison to normal side, total evaluation of body);

• manual muscle testing; and

• the preparation of a separate, written report of thefindings as a necessary component of the procedure.

Manual muscle testing that includes standardized scalecomparisons and a separate, written report is separatelyreportable from E/M services performed on the same date.If the key components for a given level of E/M service areperformed, then those services should be reported sepa-rately with modifier 25 appended to identify the E/M serv-ice as a significant, separately identifiable procedure. Asstated in the E/M services guidelines, “Any specificallyidentifiable service (ie, identified with a specific CPTcode) performed on or subsequent to the date of initial orsubsequent E/M services should be reported separately.”

Range of Motion Measurements(95851 and 95852)Range of motion testing measures the degrees of passiveand active movement at a joint, and the provider com-pares the measurements to expected normal ranges ofmovement for that body part or area. Contralateral testingmay be included and indicated. Typically, a goniometer orinclinometer is used for this testing. The physician orother qualified health care professional measures thedegree of movement in multiple planes of motion, assessesthe capsular end feel of the joint, observes muscle substitu-tion patterns due to weakness of surrounding muscles, andnotes pain, tonus, and crepitus at specific places in the arcof motion. This type of testing is not time based and is dif-ferent than endurance, dexterity, and/or strength testing.

Coding Communication: Manual MuscleTesting, Range of Motion Testing, andPhysical Test or Measurement


Code 95851, Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine), may be reported for eachextremity (excluding hand) measured or for each trunksection measured (eg, cervical, thoracic, or lumbar). Code 95852, Range of motion measurements and report (separate procedure); hand, with or without comparison withnormal side, is intended to report range of motion measure-ments of the hand.

Interpretation of the results with preparation of a separate,distinctly identifiable, signed written report is requiredwhen reporting codes 95851 and 95852. In instanceswhen separately reporting these codes is appropriate, writ-ten documentation of medical necessity in the medicalrecord should reflect the need for each individual service.

How to CodeCodes 95831-95834 and 95851-95852 are designated as “separate procedures.” Some of the procedures or services listed in the CPT codebook are commonly per-formed as an integral component of a total service or pro-cedure. These procedures are identified by including theterm separate procedure in the code descriptor. An integralcomponent would be considered necessary to complete thetotal procedure or service. From a CPT coding perspec-tive, codes designated as separate procedures should not bereported in addition to the code for the total procedure orservice for which they are considered integral compo-nents. It is incumbent upon the provider to support theneed for range of motion or manual muscle testing servicesin the documentation.

Physical Performance Test orMeasurement (97750)Code 97750, Physical performance test or measurement (eg,musculoskeletal, functional capacity), with written report, each15 minutes, describes tests and measurements performed bya physician or other qualified health care professional.Testing may be manual and/or performed using equipment.Examples include isokinetic testing, functional capacitytesting, timed up and go test, dynamic gait index, andcomputerized muscle testing. Standardized testing batteriesmay be incorporated into a physical performance test.Elements involved in physical performance tests or meas-urements, as reported by code 97750, include the test ormeasurement procedure itself, as well as time required toanalyze and interpret the resulting data while the patientis present. Code 97750 is time based. Documentation ofthe following time elements will assist in supporting thenumber of units billed for this procedure:

• Total time spent with the patient in providing the testand measurement, including the time spent preparingthe patient for the test and measurement procedure

• The time spent performing the selected protocol

• The time spent with the patient in providing anyposttesting instructions

The descriptor for code 97750 does include the terminolo-gy “by report.” Documentation to support the reporting ofthis code should include a description of the test andmeasure protocol, the data collected, and the impact ofthe outcome of the test and measure on the patient’s planfor care (ie, need for continuing treatment, discharge fromtreatment, or referral to other provider[s]).

Although it is atypical, code 97750 may be reported onthe same date of service as an E/M service or a physicaltherapy and occupational therapy evaluation/re-evalua-tion. Documentation should support the need for thephysical performance test or measurement to be done onthe same date of service as physical or occupational thera-py evaluation/re-evaluation, as well as a separate writtenreport stating the findings, as described above.

Clinical Example (97750)A patient who is a data entry operator requires physicalperformance testing to determine if job duties exacerbateclinical findings of carpal tunnel syndrome. Nerve con-duction studies were negative; however, the patient com-plains of a numbness in the median nerve distribution and pain in the proximal palm while on the job and oftenat night.

Description of Procedure (97750)The patient’s level of pain is measured through theuse of the Magill Pain Questionnaire. Sensation test-ing is performed specifically to assess light touch anddeep pressure with testing of contralateral side forcomparison. Pinch and grip strength are measured,also bilaterally, through the use of both a pinch andhand grip dynamometer. Specific functional abilitiesrelated to her identified work activities are measuredand documented. The provider develops a program toaddress the instruction or practice of accommodatedwork-related activities.

Commonly Asked QuestionsQuestion: When is it appropriate to report code 97750, Physical performance test or measurement, manual muscletesting (95831-95834), and/or range of motion testing(95851-95852)?

10


Answer: If the intent of the physician or qualified healthcare provider is to perform a range of motion and/or man-ual muscle test (eg, to compare the right and left sides) asa separate procedure, it would be appropriate for theprovider to choose the appropriate codes from the 95831-95852 series. For example, a patient with a lower motorneuron disease (eg, post-polio syndrome or Guillian-Barresyndrome) presents with weakness of isolated musclegroups. The provider will want to identify any restrictionsin passive and active range of motion as well as specificmuscles that are weak. The provider will use this informa-tion to establish a treatment plan that will positivelyimpact identified impairments. If the provider insteaddetermines that it is appropriate to measure and test thepatient’s physical performance during specific activities,then code 97750 is the appropriate service to report.

Question: What are the appropriate components of documenta-tion that will support the use of code 97750?

Answer: When reporting code 97750, the physician orother qualified health care professional is required to havea separate written report noting the findings. The providershould include the reason for performing the test or meas-urement, identification of any protocol or standardized testthat was used, data that were collected, direct contacttime spent with the patient, and analysis of the findings.

Question: Can manual muscle testing (95831-95834), rangeof motion testing (95851-95852), and physical performancetest and measurement (97750) be performed on the same dateof service?

Answer: No. Codes 95851, Range of motion measurementsand report (separate procedure); each extremity (excludinghand) or each trunk section (spine), and 95831, Muscle test-ing, manual (separate procedure) with report; extremity(excluding hand) or trunk, are designated in the codedescriptors as separate procedures. Codes designated asseparate procedures should not be reported in addition tothe code for the total procedure or service for which theyare considered an integral component. In this case,because range of motion testing (95851) and manual mus-cle testing (95831) may be performed as part of a physicalperformance test or measurement (eg, musculoskeletal orfunctional capacity), only code 97750 should be reported.Codes 95851 and 95831 should not be reported separatelybecause both services are designated as separate proceduresand, as such, would be considered integral components ofa physical performance test (97750).

Question: How is computerized muscle testing reported?

Answer: Computerized muscle testing should be reportedusing code 97750. A separate written report is required.Only direct patient contact time is reported. �

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and updated estimates yields $373.344 billion in economiccosts to the United States due to alcohol and drug abuse inthe year 2000.”

2. Muñoz, RF, Mrazek, PJ, Haggerty, RJ. Institute of MedicineReport on Prevention of Mental Disorders: Summary andCommentary, Psychology in the Public Forum. 1996; Volume51(11): p 1116-1122.

3. Gerstein D and Harwood H (eds). 1990. Treating DrugProblems, Vol. I. Washington DC: National Academy Press: p58-104.

4. Klitzner M, Fisher D, Stewart K, and Gilbert S. 1992. EarlyIntervention for Adolescents. Princeton NJ: Robert WoodJohnson Foundation.

5. Fleming MF. 2002. Screening, assessment, and interventionfor substance use disorders in settings. In: Strategic Plan forInterdisciplinary Faculty Development: Arming the Nation’sHealth Professional Workforce for a New Approach to SubstanceUse Disorders. Providence RI: Association for MedicalEducation and Research in Substance Abuse (AMERSA).

6. Babor TF and Higgins-Biddle JF. 2001. Brief Intervention forHazardous and Harmful Drinking: A Manual for Use in PrimaryCare. Geneva: World Health Organization. WHO/MSD/MSB/01.6b. �

Screening continued from page 4

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Evaluation and Management: Officeor Other Outpatient ServicesQuestion: What is the appropriate code to report the servicewhen a physician uses a fluorescein dye and Wood’s lamp tocheck the eye for a corneal abrasion or foreign body?

Answer: The examination and fluorescein dye test areincluded in the evaluation and management (E/M) serviceand are not reported separately. However, the workinvolving the detailed eye examination and history mayallow the reporting of a higher-level E/M code. It is rec-ommended that the 1997 CMS documentation guidelinesat the following Web site, http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf, which containthe reporting criteria for single specialty examinations, beconsulted in selecting the appropriate level of E/M service.

Medicine: Physical Medicine andRehabilitationQuestion: What services do the work hardening/conditioningcodes 97545 and 97546 include? Do they require one-on-onepatient-therapist contact?

Answer: Although these codes appear under the 97110-97546 heading of Therapeutic Procedures, these servicesdo not require one-on-one physician or therapist contact.These codes represent a program developed to address theperson’s strength, endurance, flexibility, motor control,and cardiopulmonary capacity related to performance ofthe work tasks that are identified through a job descrip-tion or through communication with others involved inthe person’s health care and return to work management.

Work hardening and work conditioning are typically per-formed with people who have experienced an injury atwork or are disabled from an injury or disease process andhave the goal to return to work. These services could beguided by return-to-work protocols developed by providersand other external sources. Work hardening and workconditioning are provided in a program format that typi-cally include certain components, as follows.

Work hardening (1) is a highly structured, goal-oriented,individually designed intervention program with the goalof return to work; (2) is multidisciplinary, using real orsimulated work activities designed to restore physical,behavioral, and vocational functions; (3) addresses theissues of productivity, safety, physical tolerances, andworker behaviors specific to a category of work or a specif-

ic job task;(4) is typically provided for a duration of 4 to 8 weekswith a typical frequency of 4 or 5 days; and (5) requirespatient attendance for multiple hours at each scheduledvisit depending on the type or category of work for whichthe work hardening goals are developed.

The person typically participates 4 to 8 hours at eachtreatment session. The therapist’s content of the serviceincludes patient education, work simulation, and specifictherapeutic exercises geared toward improving identifiedwork functions and may be spread over the visits. Time ofwork hardening and not the therapist’s personal time ofdirect supervision is reported.

Work conditioning is an intensive, work-related, goal-ori-ented conditioning program designed specifically torestore systemic neuromusculoskeletal functions (eg, jointintegrity and mobility; muscle performance, includingstrength, power, and endurance; motor function [motorcontrol and motor learning]; range of motion, includingmuscle length; and cardiovascular and pulmonary func-tions [eg, aerobic capacity and endurance, circulation,ventilation, respiration, and gas exchange]). The objectiveof the work conditioning program is to restore physicalcapacity and function to enable the person to begin thereturn-to-work process, but it does not have goals relatedto a specific job task or category of work.

Work conditioning can be from 1 to 6 hours per day and is typically for a shorter duration than work hardening (4-6 weeks). Work conditioning programs can either allowa person to return to work or can lead to a more specificwork hardening program and more specific work-relateddischarge criteria.

If a provider reports code 97545 or 97546 on the samedate of service as the codes that describe other therapeuticprocedures that also address parameters of strength, flexi-bility, endurance, range of motion, motor control, orreturn of function (97110, 97112, and 97530), the docu-mentation must support these as direct contact, separatelyidentifiable services and must clearly differentiate theseservices from services provided in a work hardening orwork conditioning program.

Source: American Physical Therapy Association. Guidelines:Occupational Health Physical Therapy: Work Conditioning andWork Hardening Programs. BOD G03-01-17-58 (Program 32)[Retitled: Occupational Health Guidelines: Work Conditioningand Work Hardening Programs, Amended BOD 03-00-25-62;BOD 03-99-16-49; BOD 11-94-33-109; Initial BOD 11-92-29-134] [Guideline])

AMA CPT Assistant, Q/A Winter 1992

Coding Consultation: Questions and Answers

Pathology and Laboratory: SurgicalPathologyQuestion: What is the correct way to report a microarray ofmore than 500 probes? If the array has 1500 probes, for exam-ple, do I report code 88386, Array-based evaluation of mul-tiple molecular probes; 251 through 500 probes, threetimes? Or should I report the unlisted procedure code, 88399,Unlisted surgical pathology procedure?

Answer: The array-based evaluation of more than 500probes is an unlisted service and should be reported withCPT code 88399. When reporting an unlisted code todescribe a procedure or service, it is necessary to submitsupporting documentation (eg, procedure report) alongwith the claim to provide an adequate description of thenature, extent, and need for the procedure and the time,effort, and equipment necessary to provide the service

Radiology: Diagnostic Radiology(Diagnostic Imaging)Question: During the insertion of a dual-chamber implant-able cardioverter-defibrillator, the physician indicated a left subclavian venogram was obtained to facilitate entry. Is itappropriate to report code 75820, Venography, extremity, unilateral, radiological supervision and interpretation, sep-arately in addition to codes 33249, Insertion or repositioningof electrode lead(s) for single or dual chamber pacing car-dioverter-defibrillator and insertion of pulse generator andcode 71090, Insertion pacemaker, fluoroscopy and radiog-raphy, radiological supervision and interpretation?

Answer: No. The service described is not a diagnosticvenogram, but is rather used for guidance of the leads“obtained to facilitate entry.” Therefore, it would not beappropriate to separately report code 75820.

Question: When a gastrointestinal procedure, such as an endo-scopic retrograde cholangiopancreatography, is performed andincludes radiological supervision and interpretation, who canreport the radiology services? For example, if the images aresent to a radiologist for review after the case has ended, wouldit be appropriate for the radiologist to report the supervision andinterpretation service? By definition, it seems that for supervi-sion and interpretation, the provider must be in attendance forthe intraoperative session in order to report the service. TheCPT codes in question are code 43260, Endoscopic retro-grade cholangiopancreatography (ERCP); diagnostic, withor without collection of specimen(s) by brushing or wash-ing (separate procedure) and code 74328, Endoscopiccatheterization of the biliary ductal system, radiologicalsupervision and interpretation.

Answer: Radiologic supervision and interpretation codesare used to describe the personal supervision of the per-formance of the radiologic portion of a procedure by oneor more physician(s) and the interpretation of the find-ings. To report the supervision aspect of the procedure,the physician must be present during its performance. Thiskind of personal supervision of the performance of theprocedure is a service to an individual patient and differsfrom the type of general supervision of the radiologic pro-cedures performed in a hospital for oversight of thedepartment, such as for safety and quality control process-es. The interpretation of the procedure may be performedlater by another physician. In situations in which a cardi-ologist, for example, bills for the supervision (the “S”) ofthe S&I code, and a radiologist bills for the interpretation(the “I”) of the code, both physicians should use modifier52 indicating a reduced service, eg, the interpretationonly, in the case of the radiologist.

Surgery: Digestive SystemQuestion: Which CPT code should be reported for a tonsillecto-my and adenoidectomy when the physician excises the tonsilsusing electrocautery and then destroys, ablates, or vaporizesthe adenoid tissue using suction diathermy?

Answer: Code 42820, Tonsillectomy and adenoidectomy;younger than age 12, should be reported if the patient isyounger than age12. Code 42821 is reported for patients12 and older. Suction diathermy is a term generallyapplied to electrosurgery/electrocautery. Medicaldiathermy generally indicates that no tissue harm ordestruction is done. Ablation implies removal or destruc-tion of tissue. The same is true for removal of tonsils,whether with electrosurgical dissection, tonsillotome, coldknife dissection, laser, microdebrider, harmonic scalpel, orthermal welding technique. Removal of tonsils is a tonsil-lectomy, and removal of adenoids is an adenoidectomy, nomatter what the technique.

Surgery: Nervous SystemQuestion: The procedure was right frontal Ommaya reservoirplacement with Stealth guidance and neuroendoscopy place-ment of the ventricular catheter with intraventricularchemotherapy infusion. Stealth was used for correct placementof the catheter because of small ventricles, and the burr holewas placed. The dura was opened, and the ventricular catheterwas placed. An endoscope was used to verify the correct place-ment of catheter tip because chemotherapy will be infused. Theendoscope was removed, and a catheter was attached andsecured to the reservoir. Gelfoam was placed in the burr hole,and the site was irrigated and closed. Chemotherapy wasadministered into the reservoir. Should code 0169T,Stereotactic placement of infusion catheter(s) in the brain for

14

15

delivery of therapeutic agent(s), including computerized stereo-tactic planning and burr hole(s) be reported for this procedure?Is placement of the ventricular catheter reported separately?

Answer: Code 0169T is to be used only for placingcatheters into the brain for convection-enhanced deliveryof chemotherapy into the brain parenchyma surrounding a tumor resection cavity. It is not appropriate to use thiscode for Ommaya reservoir placement.

Code 61210, Burr hole(s); for implanting ventricular catheter,reservoir, EEG electrode(s), pressure recording device, or othercerebral monitoring device (separate procedure) should bereported for this procedure. Codes 61795, Stereotactic com-puter-assisted volumetric(navigational) procedure, intracranial,extracranial, or spinal (List separately in addition to code forprimary procedure) and 62160, Neuroendoscopy, intracranial,for placement or replacement of ventricular catheter andattachment to shunt system or external drainage (List separate-ly in addition to code for primary procedure) could also bereported in this obviously difficult case.

Surgery: Digestive SystemQuestion: What is the appropriate code to report the Maloneprocedure (appendicocolostomy) that is performed for fecalincontinence after repair of an imperforate anus?

Answer: Code 44799, Unlisted procedure, intestine, should bereported for this procedure. The Malone procedure is usedfor children with constipation secondary to congenitalproblems and is not commonly performed. When report-ing an unlisted code to describe a procedure or service, itis necessary to submit supporting documentation (eg, pro-cedure report) along with the claim to provide an ade-quate description of the nature, extent, need for the pro-cedure and the time, effort, and equipment necessary toprovide the service.

Surgery: Cardiovascular SystemQuestion: What is the appropriate code to report for a second-ary mechanical arterial thrombectomy?

Answer: Code 37186, Secondary percutaneous transluminalthrombectomy (eg, nonprimary mechanical, snare basket, suc-tion technique), noncoronary, arterial or arterial bypass graftincluding fluoroscopic guidance and intraprocedural pharmaco-logical thrombolytic injections, provided in conjunction withanother percutaneous intervention other than primary mechani-cal thrombectomy (List separately in addition to code for pri-mary procedure) should be reported for this procedure.However, it should be noted that secondary mechanicalthrombectomy is not reported when performed in additionto primary thrombectomy, nor is the fluoroscopic guidanceor intraprocedural injection of thrombolytic agents report-ed separately in that instance.

Surgery: Respiratory SystemQuestion: If multiple, distinct procedures are performed during a single bronchoscopy, is it appropriate to report each separately?

Answer: It is appropriate to report multiple proceduresSperformed during a single bronchoscopy. For example,bronchoscopy in a patient with lobar pneumonia toSidentify the infectious cause might include a bronchialalveolar lavage (31624), a protected brush sampling(31623), and a transbronchial lung biopsy (31628), allduring the same session. �

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