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Coding Q&A: Oct. 9, 2007

Q: A patient was admitted with a recurrent pleural effusion for thorascopic evaluation to include biopsy and talc pleurodesis. The patient has a history of CHF and the only drug he is taking for it is Toprol XL, which is also treating his HTN. The history and physical and operative note states that the pleural effusion is of unknown etiology and the bx. is being done to rule out malignancy or specific inflammatory cause. The discharge summary lists the final diagnoses as: #1 recurrent bloody right pleural effusion and #5 as history of CHF. Please help with the principal diagnosis in this case, would pleural effusion (511.9 ) be principal or because it is present with history of CHF would CHF (428.0) be principal. Any help you could provide in this case would be appreciated.

A: The principle diagnosis in this case would be the pleural effusion because it was the condition for which the patient was admitted. The CHF would be secondary as it was a commorbid condition but was not related to the pleural effusion.

Christina Benjamin, RHIA, CCS, CCS-P

Q: Our doctor has been performing a cystoscopy (52000) along with a Botox injection. We should be using CPT code 53899 for the injection, correct? She is doing this procedure at the hospital, so she therefore cannot bill for the actual medication, correct? She can only bill for doing the injection?

A: Per CPT Assistant the use of code 53899 for the Botox injection is correct. Because code 52000 is a separate procedure code I would not code 52000 and 53899 together; instead I would utilize code 53899 to indicate both the cystoscopy and the Botox injection. You are correct in that the physician can only bill for the injection procedure. The hospital will bill for the medication because they incurred the expense of providing it. 

Here is what CPT Assistant states regarding the Botox injection coding.

CPT® Assistant, February 2006, Volume 16, Issue 2, page 14

Surgery: Urinary System


What is the appropriate code to report for a Botox injection into the detrusor muscle of the bladder?

AMA Comment:

From a CPT coding perspective, the CPT code set does not contain a code that specifically identifies injection of Botox into the detrusor muscle of the bladder. It would be most appropriate, therefore, to report code 53899, Unlisted procedure, urinary system, for this specific procedure. When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (e.g., the procedure report) with the claim to provide an adequate description of the nature, extent, need for the procedure, and the time, effort, and equipment necessary to provide the service.

Reimbursement of supplies and materials provided by the physician is a carrier-specific reimbursement issue that may vary from carrier to carrier. It is best to check with the third-party payers regarding their specific reporting guidelines.

Lisa L. Withers, RHIT, CCS

Q: The patient, gravida II, para 1, was admitted at 37 weeks gestation with spontaneous rupture of membranes and contractions every 2 to 3 minutes. She has a history of congenital heart block with pacemaker. Because there was no descent, even though she was pushing adequately, three attempts at forceps delivery were made with no success due to cephalopelvic disproportion. Because of failure of forceps due to bony pelvic obstruction, a primary low transverse cesarean section was performed. A live single male was delivered. The postoperative course was uneventful. Physician D/C Dx: Cesarean delivery of term, live infant complicated by bony pelvis and cephalopelvic disproportion and failed forceps. What are the codes?

A: The appropriate diagnosis codes for this case are 660.11, obstruction by bony pelvis during labor, delivered; 648.51, congenital cardiovascular disorder in mother complicating pregnancy, delivered; 746.86, congenital heart block; 653.41, fetopelvic disproportion, delivered; v27.0, mother with single liveborn; v45.01, status post cardiac pacemaker in situ; 660.71, Failed forceps, delivered. For the procedure codes, you should use 74.1, low cervical cesarean section and 73.3 for the failed forceps.
Angie Comfort, RHIT, CCS

Q: When coding for an Inpatient Rehab Facility (IRF) and utilizing the IRF-PAI Coding Guidelines, which Impairment Group Code (IGC) would be used with the diagnosis for sun stroke?

A: I am not an expert in IRF coding, but I did review the allowable ICD-9-CM codes and 992.0 (sunstroke) isn't found as a qualifying diagnosis for any of the IGC codes.   Most strokes fall under IGC 01.9, but that code is not listed in the IRF-PAI manual that went into effect on 4/1/04. Sorry I couldn't be or more help. Refer to Appendix B of the manual.

Arlene F. Baril, MS, RHIA

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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