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Coding Q&A: Ask the Experts - 12/9/03

Q: A patient comes in for an X-ray of the knee, status post MVA two years ago. The diagnosis is knee pain. Would it be appropriate to code a late effect of an injury? The late effect codes are an ongoing puzzle with our facility.

A: A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. The "late effects" include those specified as such, or as sequelae, which may occur at any time after the acute injury. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to previous injury. Coding of late effects requires two codes: The residual condition or nature of the late effect, and the cause of the late effect.

The residual condition or nature of the late effect is sequenced first, followed by the cause of the late effect, except in those few instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title or the late effect code has been expanded (at the fourth and fifth-digit levels) to include the manifestation(s).

A late effect E-code should be used with any report of a late effect or sequela resulting from a previous injury or poisoning. If the physician does not document that the knee pain is secondary to the previous MVA, then you cannot assume the cause and effect. The above information was taken from the official ICD-9-CM Guidelines for Coding and Reporting 1.7.

Mary Mills, RHIT, CCS

Q: Was there information recently that the E/M Facility Coding Guidelines (hospital) for APCs will not be implemented until June 2004? Have you heard this?

A: According to Nov. 10, 2003 issue of Part B News, the Centers for Medicare and Medicaid Services (CMS) doesn't expect to implement E/M facility coding guidelines before Jan. 1, 2005.  They will give hospitals at least a year's notice before implementing the guidelines.

Currently, hospitals create their own methods for determining facility E/M levels.  These are independent of the physician's professional E/M charges, which are governed by CMS' 1995 and 1997 E/M Documentation Guidelines.

Denis Rodriguez, CPC, CCS

Q: Can you give me some useful information/guidelines to follow on dehydration and gastroenteritis (i.e., viral, infectious, etc) and which can be used as principle diagnosis?

A: Helpful information regarding the selection of dehydration and/or gastroenteritis as the principal diagnosis was published in Coding Clinic articles in July/August 1984 and 2Q 1988 issues.

In both issues the determining factor was which condition necessitated the inpatient admission. Based on these articles, the "guideline" is the circumstances of admission and the medical necessity for inpatient care per the judgment of the attending physician. Many cases of gastroenteritis are treated in outpatient settings such as the Emergency Department and the patients are not in need of further acute care in the inpatient setting.

If the patient was admitted to treat both an infectious gastroenteritis and dehydration, the infectious gastroenteritis is the principal diagnosis (CC 2Q 1988). Take caution here and please do not assume that just because the gastroenteritis is stated as infectious or viral that it is then the principal diagnosis in each and every case. As always, you may need to ask the attending physician to clarify further, if not so stated, which condition or if both conditions medically necessitated the inpatient admission by the type of treatment that was rendered in the acute care setting (intravenous fluids/medications and/or oral medications) if not stated clearly in the medical record.

Kathy Myrick, RHIT, CCS

Q: We code for an ambulatory surgery center that performs many arthroscopic knee procedures. It is my understanding the knee has three compartments: medial, lateral and patellar. Also, it is my understanding if multiple procedures were done in one compartment, you would code the procedure with the highest CPT. But if multiple procedures were performed, each in a different compartment, each procedure could be coded with a possibility of having to append a modifier -59. Having said that, a discussion concerning coding chondroplasties and plica repairs has ensued. There are some times where it is difficult to tell what compartment the plica repair occurred, sometimes it appears it crossed compartments. Is it permissible to code both the chondroplasty and plica repair if the compartments are different?

A: This is going to depend on Medicare vs. private carriers. The American Academy of Orthopedic Surgeons (AAOS) has put out a two-volume publication called "The Global Service Data for Orthopedic Surgeons." In these books they have taken all Orthopedic procedures and stated what is included and what is not included in a given procedure. This correlates pretty much with the CCI edits. If AAOS has listed that a procedure is included, and CCI states with an appropriate modifier it can be reported, that appropriate modifier that CCI is looking for is RT/LT not -59. If AAOS states that you can report a procedure separately and CCI states with an appropriate modifier then that would most likely be a modifier -59.

Here is a section from that AAOS regarding a medial and lateral meniscectomy procedure 29880:

"AAOS states in their Global Service Data Book under code 29880 that the following are included in that procedure:

"**Articular shaving, debridement, and/or chondroplasty in the SAME compartments (e.g., 29877)
**plica and/or synovial resection (e.g., 29875)
**debridement and/or shaving of meniscus
**debridement and/or shaving of cruciate stump
**meniscal tissue removal
**knee arthroscopy, diagnostic (e.g., 29870)
**additional portal(s) or enlarging portal(s)
**knee lavage and/or drainage (e.g., 29871)"

So in this instance, if you are doing a medial and lateral meniscectomy along with a medial and lateral chondroplasty or articular shaving in those two compartments also, you cannot report 29877, as it would be considered included.

The surgeon must clearly state what compartment they are working in. If it is not clear, the operative note needs to be sent back for further clarification and if needed an addendum to state which compartments they are working in.

For Medicare, they do not recognize the code 29877 and instead you are to report G0289.  Here is what the Dec. 31, 2002 Federal Register said about this code and how it should be reported when done with other procedures:

"We are creating this code to permit appropriate reporting of arthroscopic
procedures performed in different compartments of the same knee during
the same operative session. This is an add-on code and should be added to the
knee arthroscopy code for the major procedure being performed. This code is
only to be reported once per extra compartment, even if both chondroplasty, loose body removal, and foreign body removal are performed. The code may be reported twice (or with a unit of two) if the physician performs these procedures in two compartments in addition to the compartment where the main procedure was performed. This code should only be reported if the physician spends at least 15 minutes in the additional compartment performing the procedure. It should not be reported if the reason for performing the procedure is due to a problem caused by the arthroscopic procedure itself. This code is to be used when a procedure is performed in the lateral, medial, or patellar compartments in
addition to the main procedure.

However, CPT codes 29874, Arthroscopy, knee, surgical; for removal
of loose body or foreign body (e.g., osteochrondritis dissecans
fragmentation, chondral fragmentation) and 29877 Arthroscopy, knee, surgical;
debridement/shaving of articular cartilage (chrondroplasty) may not be
billed with other arthroscopic procedures on the same knee."

I would recommend that you get a copy of the above-mentioned AAOS publication.

Margie S Vaught, CPC, PCE, CCS-P, MCS-P

Q: How is Stretta procedure coded? I see C9701 in the HCPCS book and is still valid but if the patient is not Medicare, would code 42358 be the correct code assignment?

A: Stretta procedure: Use new CPT code 0057T as of January 2004 Stretta procedure defined: this is a minimally invasive endoscopic procedure that's performed on an outpatient basis, used to treat Gastroesophageal Reflux Disease (GERD). The Stretta procedure uses radiofrequency electrosurgery delivered to the lower esophageal sphincter and gastric cardia and represents a minimally invasive, endoscopic treatment alternative to drugs or fundoplication surgery. Radiofrequency energy is delivered to tissue via a specially designed catheter used during outpatient endoscopy.

HCPCS code C9701, the Stretta System, now paid under APC 0980, is used in a procedure that will soon be given a CPT Category Three Tracking Code by the American Medical Association's CPT Editorial Panel. Proposal is use the CPT tracking code to report services using the Stretta System and to delete HCPCS code C9701. They propose to assign the new CPT tracking code in APC 1557.

CMS proposed to delete four HCPCS codes that are currently paid in new technology APCs (C1088 - laser optic treatment system, C9701 - stretta system, C9703 - bard endoscopic suturing system, and C9711 - H.E.L.P. apheresis system) because they represent equipment used to provide a service, rather than an entirely new service. 


Q: I am an instructor, and a test question came up that I wasn't quite sure how to clarify. The question was as follows: Patient has a diagnosis of end-stage renal disease and requires an arteriovenous fistula (shunt) using Gore-Tex graft for hemodialysis. This question is vague but the answer given was 36830, Shunt, Creation, Arteriovenous with Graft. Please help, as this question caused a terrible uproar in the classroom and I'd like clarification.

A: I recently participated in an American Health Information Management Association (AHIMA) teleconference on chronic renal failure and dialysis devices with a close business colleague who is a nephrologists so this question is right up my alley. The CPT code 36830, Creation of arteriovenous fistula by other than direct arteriovenous anastomosis nonautogenous graft, is the correct code to assign for the graft you site your question. The differentiation between 36825 and 36830 is that the latter procedure code represents a synthetic graft such as "Gore-tex" while the former procedure uses the patient's vein to create an anastomosis between an artery and vein for the creation of the fistula.

Glenn Krauss, RHIA, CCS, CCS-P

The consultants, their companies and ADVANCE do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information.

Coding Clinic is published quarterly by the American Hospital Association
CPT is a registered trademark of the American Medical Association.

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