Coding Q&A

Ask the Experts: July 21, 2014

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Question: We have several patients who have a port and they come in for blood drawn and port flush. We were wondering if there is anybody who has been able to get a 36592 (Port blood draw), 96523 (irrigation) with J1644 (heparin) paid for along with an office call. The patient could be in for a completely different problem and an E&M is charged along with the above codes and we are not able to get payment for these services.
Answer: According to CPT Assistant July 2011, Volume 21, issue 6 pg 16, you cannot bill for 96523 irrigation/flushing of implanted device when drawing a blood specimen for laboratory testing.

HCPCS Coding Clinics 4th Q 2010 pg 10 refers that CPT code 36592 contained a parenthetical note to not report these codes with any to other service. That parenthetical note has been revised to allow the reporting of these codes in conjunction with a laboratory service, HCPCS CC 1st Q 2014 pg 4, Please note that routine flushing of vascular access devices with saline or heparin would not be reported separately with certain services (i.e., injection or infusion procedures). CPT code 96523 may be reported if the patient is seen only for the irrigation/flushing of the vascular access device

As far as the Evaluation and management being reported in addition to the blood draw/port flush it has to be distinct and well documented, refer to CPT Assistant, October 2003, Volume 10, Issue 13, page 10.

1. From a CPT coding perspective, it is appropriate to report either code 36591, Collection of blood specimen from a completely implantable venous access device, or code 36592, Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified, for blood specimen collection from a central venous access port performed for a laboratory service (eg, 85025). The services described by codes 36591 and 36592 include irrigation of the venous access device. Therefore, it is not appropriate to additionally report code 96523, Irrigation of implanted venous access device for drug delivery systems.

To illustrate, the following is a description of service for code 36592: The registered nurse reviews the patient chart for orders and obtains a medical history (eg, chemotherapy-related history). The patient is greeted, gowned, and positioned for a blood draw. The blood draw is completed by the nurse, who (1) draws a 10-cc syringe full to discard, (2) draws a second syringe to collect the blood specimen, and (3) flushes the line. The nurse labels the blood specimen and places it in the appropriate container for transport to the clinical laboratory.
- Tasha Cameron, RHIA, CCS, CDIP 

Question: Can we code radiology findings in the Facility ER Coding?
Answer: No. An incidental finding on a radiology report cannot be coded if there is not supporting documentation by the physician of its importance.  However, if the radiology report further defines a condition documented by the treating physician you can code the more definitive diagnosis.  Although a radiologist is a physician they are not providing direct patient care. The attending physician must review, validate, and interpret the findings in relation to the specific patient being treated. In the inpatient setting, abnormal findings identified in diagnostic reports are not listed as secondary diagnoses unless the physician indicates their clinical significance. If findings are identified and further monitoring and testing is necessary and ordered to evaluate the condition or treatment is ordered, it is appropriate to ask the physician whether a corresponding diagnosis should be added (ICD-9-CM Official Guidelines for Coding and Reporting, effective October 1, 2011, pages 91-92).

Coders are not allowed to assign codes directly from impressions included on diagnostic reports, such as x-rays, MRI, CT scans, electrocardiograms, echocardiograms, and pathology, even if a physician has signed the diagnostic report. The diagnosis must be confirmed by the physician in the body of the medical record (eg, progress notes or discharge summary) before it can be coded. However, if the diagnostic report is adding specificity to an already-confirmed (physician-documented) diagnosis, then the coder may use the more specific code based on the diagnostic report without obtaining physician confirmation (AHA Coding Clinic for ICD-9-CM, 1999, first quarter, page 5).

The following are examples of findings identified on diagnostic reports and recommendations for follow-up:

  • Elevated blood urea nitrogen, creatinine, and urine-specific gravity or receiving IV fluids is clinically significant and should be brought to the attention of the physician if no diagnosis has been documented.
  • A hematocrit of 28%, even though asymptomatic and not treated, may have been evaluated by the physician with serial hematocrits. Because this is outside the range of normal laboratory values and has been further evaluated, it is significant enough to ask the physician whether an associated diagnosis should be documented.
  • A routine preoperative x-ray on an elderly patient reveals collapse of the vertebral body. The patient was asymptomatic, and no further evaluation or treatment was carried out. This is a common finding in elderly patients and is insignificant for this episode.
  • An echocardiogram showed mitral regurgitation. It was ordered to evaluate a murmur. The patient was referred to a cardiologist for follow-up. It is appropriate to ask if the diagnosis should be added to the final diagnostic statement.

Every record has to stand on its own individual merits. Before a condition can be coded, it must meet two requirements. One, the condition has to be documented by a physician in the body of the medical record, such as history and physical, consultant report, progress notes, or discharge summary. The second requirement is that it must affect patient care in terms of requiring one of these five criteria: clinical evaluation, therapeutic treatment, diagnostic procedure, extended the length of hospital stay, or increased nursing care and/or monitoring.

Laboratory Results
Additional diagnoses should not be arbitrarily added on the basis of an abnormal laboratory finding alone. To make a diagnosis on the basis of a single lab value or abnormal diagnostic finding is risky and carries the possibility of error. The physician must diagnose the patient.

A value reported either lower or higher than the normal range does not necessarily indicate a disorder. Many factors may influence the value of a lab study. These include the method used to obtain the sample (eg, a constricting tourniquet left in place for more than one minute prior to collecting the sample will cause an elevated hematocrit and potassium level), the collection device, the method used to transport the sample to the lab, the calibration of the machine that reads the values, and the condition of the patient. An example is a patient who, because of dehydration, may show an elevated hemoglobin level due to increased blood viscosity.

It is the physician's responsibility to document the patient's diagnoses. In the inpatient setting, a diagnosis based on an abnormal laboratory result or diagnostic test should not be determined by someone other than a physician. The physician must document the diagnosis in the medical record before it can be coded. In addition, it is not adequate for a physician to use only arrows ( or ) to indicate a diagnosis, even if treatment was given for that condition. For example, the physician documents in the progress notes, "Na. Decrease fluid intake. Change IV fluids." In this example, hyponatremia could not be coded without the physician documenting "hyponatremia." Query the physician regarding the patient's specific diagnosis. In other words, it is not acceptable to code a diagnosis based on the physician's up or down arrows or lab values. The physician must document the actual diagnosis (AHA Coding Clinic for ICD-9-CM, 2011, first quarter, pages 17-18).

Pathology Reports
Coding Clinic has clearly stated that in an inpatient setting, coders are not able to assign codes based on the pathology report without physician confirmation of the diagnosis. For example, breast cancer is documented, and the pathology shows mets to lymph nodes. Coders are not allowed to pick up a code for the lymph node mets until confirmed by the physician. In addition, if the physician documents "breast lump" and the pathology confirms it is breast cancer, coders cannot code "breast cancer" until the physician confirms this in the body of the record. In this example, the pathology is not providing specificity to an already confirmed diagnosis-it was providing a separate diagnosis, breast lump vs. breast cancer (AHA Coding Clinic for ICD-9-CM, 2008, third quarter, pages 11-12).

Cancer Staging Form
Coders are allowed to use a completed cancer staging form for coding purposes when it is signed by the attending physician (AHA Coding Clinic for ICD-9-CM, 2010, second quarter, pages 7-8).

Autopsy Reports
Coders can use the autopsy report for code assignment to provide greater detail and specificity. The coder can code diagnoses from the autopsy report as long as the diagnosis does not conflict with the rest of the medical record and as long as the diagnosis is also listed elsewhere in the medical record. If there are conflicting diagnoses or diagnoses listed only in the autopsy report, the attending physician needs to be asked for clarification before assigning a code for the diagnosis (AHA Coding Clinic for ICD-9-CM, 2001, first quarter, pages 5-6).

Coding from diagnostic reports is dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.
- Arlene F. Baril, MHA, RHIA, CHC

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