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

Q: The orthopedic surgeon I work for specializes in Total Joint Replacement Surgery. He has asked me if there are any new or existing procedure codes for "minimally invasive Total Hip Arthroplasty." He said it is still a "Total Hip Replacement," but the procedure takes longer because of smaller incision and requires more expertise and may require the use of computer assistance. Due to the case/surgery taking longer and the possibility of learning to use the computer, etc., he feels there may be a different code for this other than the standard 27130 (Total Hip Arthroplasty acetabular & femoral). Do you have any knowledge or advice to offer?

A: In response to your question, please inform your surgeon that there are no variables.

C. C. Moreland, MD

Q: A patient is being seen in the Wound Care Center for an ulcer under her left breast due to radiation treatment in the past. The patient is then placed in a hyperbaric chamber. Would it be appropriate to use the code 990 (Effects of radiation, unspecified) to code the hyperbaric treatment?\

A: Interesting question you present. I have done some research on your question and here is what I have to offer. The Medicare Coverage Issue Manual highlights what conditions meet medical necessity and justify payment under CMS coverage for HBO Therapy. This is in section 35-10 of the Coverage Issues Manual. http://www.cms.hhs.gov/manuals/06_cim/ci35.asp#_35_10

Coverage was updated in December for diabetic wounds and these are covered with certain prequalifications. Here is the link:      http://www.partbnews.com/htm/AB-02-183.htm

The proper way to code your case is with 611.0 or 707.8 with late effect of radiation, ICD-9 code 909.2 as a secondary to explain that the ulcer was a late effect of radiation. However, 909.2 is not a covered diagnosis that qualifies for payment of the HBO therapy. 990, Effects of radiation NOS is a covered diagnosis but this is really not the right code to use because we know what the effect of radiation therapy is, that is the ulcer of the breast. See the excludes notes under 990 and you will see that ICD-9 tells us this code excludes specific effects of radiation. The specific effects of radiation are known in your case so it appears this is not the correct code to assign either.

The long and short of it are that the correct way to code your case is 611.0 or 707.8 with the 909.2 code as a secondary. Unfortunately, Medicare will not likely pay for the HBO therapy using the codes I just mentioned. Perhaps other insurance companies might pay for this procedure using the said mentioned codes 6110 or 707.8 with 909.2 as secondary.

Glenn Krauss, RHIA, CCS, CCS-P

Q: I am a newer coder and my question is: For splint applications, do we code these applications for just Medicare patients or any person who is supplied with a splint? The code being used is CPT 93.54.

A: You would assign the 93.54 code, application of splint, to all cases if performed and documented in the record, regardless of payer. Coding is done on the basis of accuracy, not by payer in general. While payers may have coding nuances that affect payment, a coder's mandate is to follow the coding guidelines regardless of payer.

Glenn Krauss, RHIA, CCS, CCS-P

Q: I am a coder and cancer registrar. When abstracting papillary transitional cell carcinoma of the bladder with no invasion or detrusor muscle present, it is abstracted as insitu in the cancer registry. Our urologists just state bladder cancer in their discharge and operative note and do not indicate whether it is invasive or not. As a coder, should I be coding these cases as insitu cancer or invasive?

A: Coding vs Tumor board conflict of coding

Transitional cell carcinoma is a malignant neoplasm derived from transitional epithelium, occurring chiefly in the bladder, ureters or renal pelvis especially if well differentiated. Frequently noted papillary, the carcinomas are graded 1 to 3 or 4 according to the degree of anaplasia, grade 1 appearing histological benign, but being liable to recur. Grading is done by the pathologist.

1. Tumor registry: Urologist addressing morphology at time of operative report dictation: The surgeon will not be able to document morphology at the time of the operative report dictation, usually they will only address the site and method used to retrieve the specimen, however they will document metastasis, invasion, etc. The pathologist will determine the morphology. 

2. Coder: Traditionally the pathology report will be the deciding factor. The correct code "insitu vs. Primary site" can only be determined by the pathologist. If the pathologist states  "in situ" you assign that as the principal diagnosis. If it does not you would code using the primary malignancy site, as indexed in the ICD-9-CM book.   

3. Conflicting or ambiguous documentation: If there is a conflict, it is recommended to query both the pathologist and the surgeon to clarify. I would suggest enlisting the assistance of the HIM director in relaying your concerns to the attention of medical staff and to encourage providers to document to the highest degree of specificity.

JoAnn Baker CCS, CPC-H, CPC, CHCC

Q: What, if any, are the rules regarding the use of CPT vs. HCPCS codes? Case in question is for GYN wet mounts and KOH preps. According to CPT, these are both represented using CPT code 87210. HCPCS further distinguishes between the two with Q0111 and Q0112. Which is the more appropriate code to use? This same scenario occurs with Rhogam injections; currently there are both CPT and HCPCS codes for the same item. Which is the "correct" code to use?

A: This has always been a puzzling issue. There will be instances where two code types with almost the same definition can be found in both the HCPCS Level II and the AMA's CPT-4 resource.

Most procedures are reported using the CPT. It can be tricky in the instance where the codes are listed both places. These are often carrier specific and providers are encouraged to check with their carriers as to which codes are recognized.

One of the codes in question was code 87210. How is this different from Q0111 and Q0112? If a provider wants to perform a KOH or Wet Mount in the office, code 87210 is approved as CLIA waived tests. Modifier -QW would also need to be appended.

However, to report code Q0111 and Q0112, the physician's office would need to have a (PPMP) Physician Performed Microscopy Procedures certificate. You may also want to review Noridian's Medicare B News Bulletin #144, April, 1996. The new 2003 Clinical Lab Fee Schedule also indicates those tests that are CLIA waived. The reimbursement level for all three of these codes for 2003, is $5.96.

There are also (LMRPs) Local Medical Review Policies, that CMS publishes that will sometimes include required use of certain HCPC Level II codes over CPT codes and visa versa.

For immune globulin's, such as Rhogam that you questioned, please refer to the following reference for CPT's reasoning in creating this section. CPT Assistant: January 1999 Volume 9, Issue 1.

To inquire on the HCPCS process, you may contact:  HCPCS@cms.hhs.gov.

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

Q: A patient presents to the emergency room (ER), is examined by the ER doctor and the ER nurse applies a splint. The ER doctor reviews the splint application and documents to that effect in the ER chart. Can the ER doctor bill the professional fee for the application of the splint, even though it was actually applied by the nurse, but reviewed by the doctor?

A: In order for an ER physician to bill for services, the ER physician must perform the service. Nursing services are not billable by an ER physician, as these are covered on the facility side, under the OPPS and APC grouping. This would be considered double billing and unbundling. I've listed a reference for you to review, which directly outlines various vignettes and scenarios ER physicians encounter along with the appropriate use of reporting casting and strapping codes.
February 1996 Volume 6, Issue 2: Coding ED Physician Procedures
"Casts and Strapping Guidelines Broadened"
Hope this information helps!

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

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