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Coding Q&A: Ask the Experts

ADVANCE for Health Information Professionals has assembled a panel of experts to provide health information management (HIM) professionals with a free forum where they can ask a variety of coding questions and get more information about coding a specific condition Click here to submit your coding questions

Q: Many of our physicians state in the H&P that the patient has a history of CAD, CABG and PTCA. I am confused on whether or not to code 414.00. Usually this information has no bearing on the current stay. I know that V45.81 and V45.82 should be coded, but what about 414.00? And if this information would be pertinent to the current stay, what should I code?

A: Your question about when to code CAD when the physician states in the H&P that the patient has a history of CAD with PTCA and CABG comes up all the time with coders in many hospital facilities. Physicians often times refer to "history of COPD," or history of CHF," when in fact the patient still has these conditions, but in an active stable form under current medical management.

History of CAD is different in that a patient may have had CAD in the past, underwent PTCA and/or CABG and is no longer currently experiencing signs and symptoms of CAD presently and is not currently under active medical management for CAD. When I say active medical management, I am referring to a patient being on a drug regimen for residual CAD such as anti-anginal meds, beta blockers, calcium channel blockers, etc. I would also be expecting to see some type of documentation in the H&P that the patient still has signs and symptoms of CAD such as still experiencing chest pain and is on a regular drug regimen for this.

As you know, a patient who has had CAD in the past and has underwent a CABG or PTCA can experience progression of the disease, as we as coders see quite frequently when patients with a previous cardiac intervention return for a "redo" CABG or PTCA. It is important to differentiate between history of CAD and existing CAD, as the patient who is undergoing surgery has increased risk with surgery when CAD is present. Additionally, patients with active but stable CAD who are under a medical drug regimen in actuality have "stable angina" with CAD and the diagnosis of stable angina is a clinically relevant diagnosis to report, appropriately increasing the severity and complexity of the case.

Glenn Krauss, RHIA, CCS, CCS-P

Q: We have an ongoing discussion at our facility regarding the V-code for postmenopausal hormone replacement therapy (HRT) V07.4 vs. V58.69 Long Term Current Use of Other Medications. When is it appropriate to use V07.4? Most of the documentation we received does not state whether the patient is postmenopausal or not just that they are on HRT (estrogen, evista, etc.). Also, some patients are on HRT long term and that is where some coders are using the V58.69 instead. Is there a time limit to using V07.4?

A: In women, treatment with sex hormones is indicated for a number of reasons, including menopause, partial or full hysterectomy or amenorrhea.  When an outpatient medical record lacks the documentation to support that the patient is in a postmenopausal state, you cannot assume she is. If the doctor documents that a patient is on HRT for their postmenopausal state, you would assign two codes: V07.4 for HRT, and V49.81 for the postmenopausal status. Do not assign the V07.4 code if you just happen to have noticed that the patient is on HRT medications; the physician must document the diagnosis. You would not code the V58.69 long-term code because there is a more specific code for the HRT in a postmenopausal patient. It is not uncommon for women in the postmenopausal state to be on hormones for a long period of time, so there is no need to use the V58.69 code. A good resource to view for this logic is in the Fourth Quarter 2000 Coding Clinic pp. 53-54. You can also look up the definition for "hormone replacement therapy" in Stedman's medical dictionary for more information on which diagnoses are treated with HRT. 

Mary Mills, RHIT, CCS

Q: How are hospitals using the G codes for screening for malignant neoplasms of the colon for non Medicare cases? Every hospital I have ever been in as a coder or a consultant, with the exception of my current employment, treat all other insurances as Medicare. They use all the modifiers for OPS and use the G codes for screening colonoscopies and sigmoidoscopies when there is no biopsy or polypectomy removal. Are there any other hospitals out there that do this as well? If so, are they getting paid the full amount or not getting paid at all if they are using the G codes for CPT?

A: This should be referred to a billing person. It is going to depend on what instructions each facility receives from their payers (and there are many nationwide). Also, a coder may be told to do something and the biller/data entry person adjusts the coding based on payer knowledge. Being paid the full or partial amounts is a contract issue, so it is something that is per each system.

In general, it may be easier to apply the same code set rules to all and Medicare is one of the most published, but what actually happens in the business office can be something different. This is so variable that my answer would be that "it depends" and that you may not need to apply the Medicare rules and requirements to each case that is not Medicare. However, the G codes address what CMS feels reportable lacking in CPT and another payer could feel the same and request them. I just don't feel like I can really give you the answers you are seeking. 

Jean Ryan-Niemackl, LPN, CPC

Q: If a physician documents "trace," "mild" or "trace to mild" heart valve conditions (e.g., mild mitral insufficiency) as a diagnosis in the medical record, would it be appropriate to code these conditions? In the instance where the physician is just restating the echo findings, would it be appropriate for these conditions to be coded? See the examples below for reference.

Example Number 1: Cardiology: 5/2: "echo pending " 5/3: "...echo LVH, NL LV MILD MR TR " Attending: 5/3: "echo - mild MR & TR, EF 57%, LVH" The discharge summary states "Echo finding are left ventricular hypertrophy with normal ejection fraction of 55%, 1+ Mitral regurgitation and tricuspid regurgitation"

Example Number 2: Patient is admitted for CHF. A TEE is ordered. Trace atrial regurgitation and mild mitral regurgitation is found. The attending writes progress notes and discharge summary shows: PN HD # 1: Worsening SOB. Continue IV Lasix. X-ray shows: Large pleural Effusion. Assessment: Decompensated CHF. PN HD # 2: CHF. Plan: TEE, continue IV Lasix PN HD # 3: SOB is gone. Pleural effusion subsiding. TEE showed trace atrial regurgitation and mild mitral regurgitation. Assessment: CHF compensated. Discharge summary: PDX: 1. CHF Hospital Course: Patient admitted via ER in decompensated CHF. IV lasix given until the SOB and pleural effusion subsided. TEE performed showed Trace atrial regurgitation and mild mitral regurgitation. Discharge patient on po lasix.

Example Number 3: Echo indicates "trace mitral regurg" and attending physician documents in PN "trace mitral regurg on Echo." No treatment is provided and there is no further documentation through hospital stay. Discharge summary includes "trace mitral regurg" as a finding on Echo only.

Example Number 4: Physician documents in the progress note and discharge summary patient has 'exceptionally mild aortic stenosis and mitral insufficiency'. No further evaluation, workup, etc. was done for these conditions.

Example Number 5: A Cardiologist Consultant was asked to see the patient to evaluate the patient's heart for any abnormalities. Consultant documented that patient has "aortic and mitral regurgitation, clinically mild" as a diagnosis in the Impression. No further workup, monitoring, etc. is performed during this admission, and there is no conflicting documentation in the medical record regarding these conditions.

Example 6: Echo states mild mitral insufficiency and trace aortic insufficiency. MD also document in the progress notes: The patient is doing well. Echo finding: Trace aortic insufficiency and mild mitral insufficiency. CHF Trace AI and mild MI Dehydration

Example 7: Progress notes: Echo showed "trace to mild mitral regurgitation" Discharge summary final diagnoses: Pneumonia Dehydration Mild Mitral Regurgitation Tachycardia Example 8: Progress note: Patient doing better. Echo showed trace to mild mitral regurgitation and mild aortic insufficiency. Due to echo findings, place patient on antibiotics once a day. CAD Angina Hypertension

A: This is an excellent question as coders are often times at odds on the merits of coding "trace" or "mild" valvular problems. You have supplied several documentation examples to support your question, which is always helpful.

To put your question into proper perspective, consider the pathophysiology of valvular disorders such as mitral regurgitation, insufficiency, etc. Mitral regurgitation may result from many processes, such as rheumatic disease, mitral valve prolapse, myxomatous degeneration, infective endocarditis and subvalvular degeneration (due to papillary muscle dysfunction, or ruptured chordae tendineae). Mitral regurgitation may occur as a congenital anomaly, or also occurs transiently during periods of transient ischemia involving a papillary muscle or the adjacent myocardium and may accompany episodes of angina. MR may be seen in patients with hypertrophic cardiomyopathy and heart failure.

The issue here is that MR and TR can be associated with numerous clinical etiologies. When the terms "trace" or "mild" MR or TR is documented in the record absent a discussion by the physician of the clinical significance of the finding, the question of the legitimacy of assigning an additional code for the condition comes into play. Ask yourself the question of whether the MR or TR contributed to the patient's admission or can be explained by the other conditions the patient was admitted for or be evaluated for. Without the clinical significance of MR/TR stated in the record, I would not be inclined to assign an additional code for the condition, particularly since MR/TR often times serves as the only "CC" in an inpatient case and may be construed to outside reviewers as attempts to be "fishing" for a CC.

Glenn Krauss, RHIA, CCS, CCS-P

Q: I am coding for a facility. Patient presented with fever, weakness and cellulitis left leg from a cut. Admitting diagnosis is cellulitis left leg. Patient is IDDM, controlled, with peripheral vascular disease and chronic renal failure. On the 2nd hospital day, patient was found to have pneumonia. On discharge the physician documents pneumonia as the principal diagnosis. Per inpatient guidelines, the principal diagnosis is defined as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Is pneumonia appropriate for the principal diagnosis or the cellulitis?

A: Based on the information provided, the principal diagnosis would be the cellulitis of the leg. The patient presented and was admitted to the facility with fever, weakness and cellulitis left leg from a cut. The patient's pneumonia was found on the second day of admission. Treatment for both condititons will be relatively the same. However, Inpatient Coding Guidelines state the condition established after study to be chiefly responsible for admission of the patient to the hospital. The reason for the patient's admission was the cellulits of the left leg...that is the correct principal diagnosis based on the information you provided in your question.

In addition, use caution when coding the cellulitis of the leg, as the cellulitis is not related to the diabetes mellitus and should not be considered a diabetes mellitus related condition.

The patient's presenting symptoms of fever and weakness could also be symptoms of the pneumonia, however the patient also had the cellulitis of the leg as the reason for admission.

The Uniform Hospital Discharge Data Set (UHDDS) has the following guideline;

"Two or more diagnoses that equally meet the definition for principal diagnosis:"  In the unusual situation in which two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of the admission and the diagnostic workup and/or therapy provided, either may be sequenced first when neither the Alphabetic Index no the Tabular List directs otherwise. However, it is not simply the fact that both conditions exist that makes this choice possible. When treatment is totally or primarily directed toward one condition, or when only one condition would have required inpatient care, that condition should be designated as the principal diagnosis.

Lisa Y. Knowles, RHIT, CCS

Q: I am confused about nebulizer breathing treatments. I have been told to use 94664 for the initial breathing treatment and the 95640 for additional breathing treatments. As I read the codes, I understand the 94664 to be for demonstration purposes of how to use the machine and if the patient is using correctly and the 94640 to be the actual treatment that would be given in an office. Please help set me straight if I am thinking in the wrong direction.

A: I refer you to the CPT Assistant April 2000 for an excellent discussion on use of these two codes. Basically, if the patient receives inhalation treatment as described in 94640 more than once on a given day, then you would code the 94640 as many times as the service was provided, using modifier 76 or 77, whichever is appropriate, on the second and other additional procedures. CPT code 94664 does not include the services described by code 94640.

According to the CPT Assistant outlined above, 94664 can be used in the following scenarios:

Codes 94664 has several facets and may be reported to describe:

-  demonstration of a metered-dose inhaler or a nebulizer

-  bronchodilator administration for the purpose of long-term management of bronchospasm

-  bronchodilator administration to mobilize sputum for therapeutic purposes (i.e., movement of thick secretions)

-  bronchodilator administration to mobilize sputum for sputum induction for diagnostic studies (e.g., culture, gram stain)

While the CPT Assistant instructs the coder on the appropriateness of coding both 94640 and 94664 if performed separately, there is a NCCI edit for this code pair set. If the instruction is given in conjunction with services as described in 94640, you only bill the 94664 as this represents the comprehensive procedure, incorporating the services of 94640.

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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Can you please help me with this one::

a 3 year old child came into the outpatient surgery center to have dental caries filled and caps placed on his teeth due to nursing bottle decay syndrome. Anesthesia was provided by an anasthesiologist. Assign the correct CPT code for the anesthesia service. Modifiers should be included.

Traci MierAugust 01, 2016


paulette deese,  billingDecember 16, 2015
red springs, NC

a 3 year old child came into the outpatient surgery center to have dental caries filled and caps placed on his teeth due to nursing bottle decay syndrome. Anesthesia was provided by an anasthesiologist. Assign the correct CPT code for the anesthesia service. Modifiers should be included.

Sandra GoennerNovember 23, 2015

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