Coding Q&A

Ask the Experts: April 14, 2014

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Q: I have a question about E/M and how you determine that level. I have been told by my auditing teacher in a class I attended it two years ago that if the doctor have an detailed HPI and detailed exam but low medical decision making for established pt, the whole note would be coded to the lowest level which is 99213 is this correct or no because I have hard time to convince the other coders about it, and for me it makes sense but for others no.

A: 99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:  

  • An expanded problem focused history;
  • An expanded problem focused examination;
  • Medical decision making of low complexity.  

Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.    Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
- Bella Logvinov MBA, CCS, CPC

Q: I have, in my opinion, a complicated case. I've come up with CPT codes 44120 and 44015 so far. The rest is giving me difficulty. I really hope you can help me. Thanks so much! Here is the operative report.... PREOPERATIVE DIAGNOSES: 1. Status post remote gastric bypass with gastrostomy tube. 2. Bowel obstruction. 3. Gastrogastric fistula. POSTOPERATIVE DIAGNOSES: 1. Status post remote gastric bypass with gastrostomy tube. 2. Bowel obstruction. 3. Gastrogastric fistula. OPERATION: 1. Exploratory laparotomy with lysis of adhesions. 2. Small bowel resection and anastomosis. 3. Subtotal distal gastrectomy with the antrum left intact. 4. Revision Roux-en-Y gastric bypass with a hand-sewn anastomosis. 5. Common limb distal feeding gastrostomy. FLUIDS IN: Four units of packed cells, five liters of Crystalloid and one liter of Hespan. BLOOD LOSS: 1000. SPECIMENS: None sent. INDICATIONS FOR PROCEDURE: The patient had a remote gastric bypass, this was complex and she had a revision done and at that time we put a distal gastrostomy tube. Most recently she seemed to be doing well and I went to remove the gastrostomy tube and her oral contents came out of that tube. We therefore did an upper GI and diagnosed a gastrogastric fistula. She also appeared to have a small bowel obstruction and I felt we were forced to go to the operating room to take care of the small bowel obstruction and I spoke to her at length about trying to address the gastrogastric fistula but I knew that was going to be difficult. She signed informed consent. I had an extended conversation with her husband also today before the operation. SUMMARY OF OPERATIVE FINDINGS: Distal small bowel obstruction and a completely unrelated diagnosis is inflammation around the gastrogastric fistula which made this extraordinarily difficult. DESCRIPTION OF OPERATION: The patient had prophylactic IV antibiotics, received heparin and sequential compression devices in place. We decided after induction of anesthesia to place a Foley catheter. A surgical safety checklist was accomplished and a clinical surgical safety time out at the time of skin incision. She was prepped with a Chloraprep and draped. She was entered through a midline incision safely, opened her up and there was no fluid in the abdomen. After entry the first thing I did was oversew the distal stomach where the gastrostomy was. I dissected off the anterior abdominal wall and then closed the stomach with interrupted 2-0 silk. At that time Dr. S joined me and we did a lysis of adhesions. One specific area especially, I think because it was a prior staple line was stuck in the pelvis. We liberated that and there was an enterotomy where the adhesion was. After looking at this we decided we needed to do a small bowel resection and this was done with a GIA stapler with blue load and stapled functional end to end anastomosis was made. There was definitely a transition point there. We then endeavored to make our way towards the gastrogastric fistula. There were some light adhesions throughout the abdomen as we made our way towards the actual gastrogastric fistula. There were dense adhesions up there with signs of inflammation. The speculation was the only reason the gastrogastric fistula was there because there was a lot of inflammation that allowed the fistula to form between staple lines. So I very carefully made my way around the pouch and then endeavored to release the gastrogastric fistula. I transected the Roux-en-Y and then ultimately debrided the distal end of the Roux-en-Y and prepared that for subsequent Anastomosis with a GIA stap.er. I endeavored to release the distal stomach to the proximal stomach and there were a lot of dense adhesions especially superior to that. I endeavored to try to take down some short gastrics and that proved to be difficult. At that point Dr. S had to go to another case and Dr. P was kind enough to come in. He and I endeavored to come around the stomach and eventually he was actually able to encircle the stomach and we placed a 90 mm TA stapler across the stomach. This was fired after the pin was deployed and unfortunately those staples did not deploy. Dr. P then, with my assistance, closed the stomach using running 3-0 Vicryl suture and then interrupted 2-0 silk suture. We eventually debrided the proximal essentially upper part of the body of the stomach and completely then released it from the pouch itself. The pouch definitely had a rim of stomach that was relatively large in diameter, I would say about 4 to 5 cm but we certainly did not want to anastomose straight to the esophagus. So very carefully and over the course, I am sure over an hour and a half or two, we did a very tedious hand-sewn anastomosis with I was the primary operator. We did a posterior layer of interrupted silk suture, brought the Roux-en-Y up to the distal pouch, put in that first posterior layer interrupted fashion and then made a enterotomy to continue the anastomosis. The inner layer of the anastomosis was done with running Vicryl and once that was completed we finished the second layer of interrupted silk. I was actually quite pleased with that, it felt like the blood supply was good. My biggest concern is the inflammation of that area is going to make this moderately likely to leak. For that reason I irrigated that right upper quadrant until absolutely clear, made sure that the splenic area was hemostatic and then placed separate 15 mm Blake drain posterior of the anastomosis and anterior to the anastomosis. The right side went anterior and the left side posterior in the splenic bed, superior portion of the pole of the spleen. As I had spoken to the patient and her husband, we decided to put in a feeding jejunostomy tube. At this point Dr. S again operated with me and Dr. P left the room. I did a MIC feeding jejunostomy tube which the inner flange once the jejunostomy tube was tunneled, was sewn to the inside of the abdomen just lateral to the skin incision and then I endeavored to place the Velcro cuff on that just underneath the skin. This was eventually secured to the skin using nylon suture. I performed a Witzel tunnel with the assistance of Dr. S, did a pursestring suture around the jejunostomy tube and put the inner flange of that just inside the bowel and did the Witzel tunnel with interrupted 3-0 silk suture. We made sure that the small bowel was not kinked and were ultimately happy with the placement and its securement to the posterior peritoneum and fascia. We then irrigated the abdomen until completely clear particularly the left upper quadrant and removed all that fluid. We did a running 0 PDS closure of the fascia, irrigated subcutaneous tissues and closed the skin with skin clips. All sponge, needle and instrument counts were reported to be correct.

A: I am coming up with CPT codes 44120, 43633 & 44015.  CPT codes 43634 and 44180 are comprehensive of 43633 and are not allowed even with appropriate modifier.  Staff should apply the NCCI edits when coding.

I hope this is not for outpatient facility; as many of these CPT procedure codes are inpatient only procedures.   What that means is if these procedures were done as an outpatient in an outpatient facility they would be eligible for 0 Medicare reimbursement as they are status "C" procedures.  For Commercial payors it may differ as per their contractuals.
-  Arlene F. Baril, MHA, RHIA, CHC


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