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Coding Q&A: Ask the Experts - 7/22/03

Q: Because it's not realistic to query every case, how would you code restenosis of a coronary stent if it's documented as in-stent stenosis? Would this be a continuation of the disease or a complication of the stent?

A: If a patient has native coronary artery disease with previous percutaneous transluminal coronary angioplasty (PTCA) and stent placement that has now developed intraluminal stenosis, and this is documented by the physician as coronary artery stent stenosis due to stent placement, assign code 996.72. Restenosis is one of the most common problems of coronary angioplasty stents and tissue growth or scar tissue between the struts causes significant compromise of the lumen and results in restenosis. Code 996.72 is indexed under complications, cardiac, device, implant, graft NEC 996.72. This is outlined in Coding Clinic 2001 3rd Q. It is important to remember that if you have a question or the documentation is unclear or ambiguous, it is always recommended that you query the physician before making a code assignment.


Q: Our GI physicians are performing EUS with celiac plexus blocks. They inject the celiac plexus through an echoendoscope in conjunction with color flow doppler to identify vascular structures surrounding the nerve plexus before injecting it. The GI department wants to use codes 93976, 43259 and 34530. Our coders want to use 64999 citing the "scopy" coding guidelines. What is the correct way to code this procedure?

A: Following the Endoscopy/Laparoscopy Guidelines published in the March 2000 CPT Assistant you have reached the conclusion that 64999, Unlisted procedure, nervous system is the code to report for this service at this point in time with the codes currently available in the CPT listing. Because you will need to provide a copy of the operative report when filing the claim with an unlisted procedure code to the insurance company, you may also want to take this opportunity to contact the Carrier and/or Fiscal Intermediary and discuss the guidelines that you referenced and the other reporting option with 43259 and 64530 (color flow Doppler, 93976 is included in the service reported 43259 according to NCCI edits). Once an agreement is reached, obtain documentation from the Carrier/FI for your records to support the decision. Your proactive effort will assist not only your staff in the correct coding of this procedure, but the GI physicians as well and solve what appears to be a difference of coding opinions as they believe it is appropriate to be reimbursed for the place of service and technique of the EUS and the celiac plexus block.

Kathy Myrick, RHIT, CCS

Q: I have researched newborn guidelines and Coding Clinic, and I cannot find an answer to my question. If a baby 22 days old is admitted to the inpatient setting and the diagnosis is pneumonia, would you use 486 or 770.89 (with or without a 486 for further explanation). Or if a 22-day-old is admitted with GERD, would you code 777.8 (with or without the 530.81) or would you code 530.81. Basically if it is a newborn and the specific code cannot be found in the newborn section what is the guideline?

A: You raise an interesting question in the coding of a condition that exists in a newborn less than 28 days old. First of all, a newborn is defined as 28 days old or less, which in your question, the 22-day-old baby who presents with GERD or pneumonia qualifies as a newborn. If you examine the issue at hand here, whether a code from the 760-779 ICD-9 series -- Certain Conditions Originating In The Perinatal Period, or a code from the "regular" ICD-series of codes describing a condition.

Take a look at the exclusion note under 770.0- Congenital Pneumonia-"Excludes: Pneumonia from infection acquired after birth (480.0-486). Applying the rationale associated with this exclusion note, if a newborn was admitted to the hospital and determined to have GERD, and this was the initial diagnosis of GERD, then the appropriate code to assign is 530.81. If a baby is discharged after birth with a given condition, then the condition is considered be in the "perinatal period."  If the condition develops after birth, such as pneumonia, then the condition should be coded from the ICD-9 codes outside of the newborn category.

Glenn Krauss, RHIA, CCS, CCS-P

Q: We have physicians that as part of an ERPC, they "sweep" the bile ducts with a balloon catheter to try and remove and stones or sludge if present. Sometimes, nothing is retrieved. How would this "sweeping" of the bile duct be coded if nothing is retrieved?

A: The ICD-9 Code would be 51.19 and the CPT Code would be 43260, Diagnostic Procedure on Biliary Tract.

C.C. Moreland, MD

Q: This issue is always resurfacing. Please confirm the fact that because a patient has poor control of their diabetes, it does not quantify the use of uncontrolled diabetes, unless it is stated in the documentation in the record.

A: Your absolutely correct in your statement. Diabetes category 250.XX is specific not only for specifying insulin dependency (IDDM) and non-insulin dependent (NIDDM), but whether or not it is in a controlled state. Unless the documentation for a given specific date of service states that the patient's diabetes is uncontrolled, we cannot assume. We can also not interpret lab values; that's the provider's call. Unfortunately, if the patient does have uncontrolled diabetes and the provider doesn't document this, his/her potential level of decision-making could be affected. The patient is at a definitive higher risk then a diabetic in a controlled state. Likewise, just because a patient is on insulin to get the diabetes under control, does not necessarily mean the patient is "insulin dependent." As always, the provider must be specific in his/her documentation.

Robin Linker, CPC, CPC-H, CCS-P, MCS-P, CCP

Q: The physician performed an I&D of hematoma on the external ear. He repaired the ear with simple suture closure. Does the complicated code 69005 include closure or should I bill simple I&D 69000 with simple closure 12001?

A: You raise an interesting question, as there is always the issue of what constitutes a complicated drainage of an external ear abscess or hematoma. Generally speaking, the physician will not dictate specifically that he performed a "complicated" I&D of a hematoma. This is also the case when a physician performs an excision of a pilonidal cyst. There are three choices when it comes to assigning a CPT code for this procedure, 11770 for simple, 11771 for extensive and 11772 for complicated. I have infrequently seen a physician actually document that he/she performed an extensive or complicated or simple pilonidal cyst excision procedure.

It is up to the coder to read the operative report, have a sound clinical understanding of the actual procedure performed and then assign the most accurate CPT code. In the case that you describe of an I&D of an external ear hematoma with sutured closure, I suggest assigning the complicated code, 69005, representing that the I&D required a sutured closure. The fact that the physician had to suture the ear after the I&D was performed signifies that the procedure performed was fairly deep in nature, requiring more physician time and skill to perform. This very point is reflected in the reimbursement assigned to the simple (69000) vs. complicated (69005) code. The former code is reimbursed under APC 6, approximate reimbursement of $93.49 excluding patient copay, vs. the latter code, which reimburses under APC 7, approximate reimbursement of $522.51 excluding patient copay.

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.

ICD Q & A Archives


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