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Coding Q&A: Ask the Experts

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 Click here to submit your coding questions

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: I am coding an outpatient colonoscopy and need help with the CPT coding. During the colonoscopy, a mucosal lesion was removed from the mid right colon with snare electrocautery; a colon polyp in the left colon was removed with snare electrocautery; an excrescence 35 cm from the anal verge was removed with biopsy forceps; additional colon polyps were removed by snare electrocautery at 30 and 25 cm from the anal verge; and a hyperplastic lesion was removed with piecemeal polypectomy using biopsy forceps. The CPT codes that I come up with are 45380, 45385, 45384 and 45383. Am I heading in the right direction?\

A: Given the information it doesn't look like any "biopsies" were done so using the 45380 would not be correct. In addition the same would be true for your choice of 45383 because I don't see any "ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal....". With the information you gave me it looks like the physician removed four lesions by snare electrocautery and biopsy forceps removed two lesions. The correct codes would be 45385 and 45384. You will note in the definition of the codes it clearly indicates that only one code should be used as these procedures are for multiple lesion(s) or polyp(s) or tumor(s). It also would be incorrect to code using the -51 modifier on the second procedure. These codes are subject to special endoscopy rules for billing. Both of these codes include the value of a diagnostic colonoscopy. With all this in mind you would choose the code 45385 (highest RVU) and place that in the primary position and code 45384 in the secondary. The lesser value code will be paid at full price MINUS the cost of the diagnostic service (in this case subtract the price of code 45378 or the "base" code from the price of 45384). You will need to add modifier -59 to tell the insurance carrier that the lesions were different and were removed from different areas of the colon.

Jean Ryan-Niemackl, LPN, CPC

Q: What is the correct CPT code to use for debridement of necrotizing fasciitis? We have used the debridement codes in the 11040-11044 range in the past, but some of the patients have 2000 to 4000 sq cm of skin area debrided at time of the operation. Is there some other way we should be coding to show for the amount of debridement our doctor is performing?

A: It would depend on the documentation. Without the operative note I hesitate somewhat to answer. The 11040-11044 would be correct unless you are able to pick a specific area because they are also relieving pressure, look at code 27892 for an example. More often than not it is going to be the codes from range 11040-11044. With that large amount of skin area I would add modifier -22 and enclose the operative note with the claim.

Jean Ryan-Niemackl, LPN, CPC

Q: HIV coding can get complicated. How would you code the following diagnosis? Aseptic Meningitis due to AIDS.

A: I agree that HIV coding can often times be complicated, mainly due to incomplete medical record documentation. First of all, aseptic meningitis, which can be defined as a mild from of meningitis, most cases caused by viral organisms. Common causative viruses include coxsackieviruses, mumps virus, and the virus of lymphocytic choriomengitis. Aseptic meningitis is characterized by fever, malaise, headache, nausea, abdominal pain, stiffness of the neck and back, and a short complicated course.

Note that aseptic meningitis is described as mild with a short complicated course. However, when you factor into the equation that the meningitis in your question is caused by AIDS, the "mildness" may not be so mild. Refer to the Coding Clinic 4th quarter 1994 for a discussion on proper sequencing of HIV/AIDs. Here is what the Coding Clinic says on the proper sequencing in the context of your question above.

The sequencing of diagnoses for patients with HIV-related illnesses follows:

Guideline 2 for selection of principal diagnosis. That is, the circumstances of admission govern the selection of principal diagnosis, "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care".

Patients who are admitted for an HIV-related illness should be assigned a minimum of two codes: first assign code 042 to identify the HIV disease and then sequence additional codes to identify the other diagnoses. If a patient is admitted for an HIV-related condition, the principal diagnosis should be 042, followed by additional diagnosis codes for all reported HIV related conditions.

If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (e.g., the nature of injury code) should be the principal diagnosis. Other diagnoses would be code 042 followed by additional diagnosis codes for all reported HIV-related conditions.

Whether the patient is newly diagnosed or has had previous admissions for HIV conditions (or has expired) is irrelevant to the sequencing decision.

In light of the above sequencing discussion in the Coding Clinic, applying to your case, I recommend assigning 042 as the principal diagnosis with 047.9 to report the aseptic meningitis.

Glenn Krauss, RHIA, CCS, CCS-P

Q: When a perma-cath is inserted for renal dialysis by interventional radiology, the radiologist is assigning code 86.07 for ICD and code 36533 for CPT. The Coding Clinic advises us to use code 38.95 for the sutured subcutaneous tissue tunneled hemodialysis catheter. Code 36489 is the appropriate assignment in CPT. Do you agree? Are there any CPT Assistants that address this issue? When can 86.07 be used in connection with dialysis patients since it will change the DRG to 315?

A: First, I would like to point out that 36533 is not the correct code to assign for insertion of a hemodialysis catheter, both from a clinical perspective and CPT coding guidelines. For a more accurate code to assign for insertion of a hemodialysis catheter, look at 34689 in the CPT code book. It reads: Placement of central venous catheter (subclavian, jugular, or other vein) (e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy); percutaneous, over age 2. CPT code 36533-Insertion of implantable venous access device, with or without subcutaneous reservoir, entails inserting a catheter with an internal or external (partially implanted reservoir). This latter device is implanted for clinical scenarios requiring IV fluids, blood, hyperalimentation, drug therapy, etc. For a patient needing hemodialysis, a CVL is placed (36533).

An excellent discussion on the differentiation and application of the different catheter insertions can be found in the February 1999, October 1997, and Fall 1995 CPT Assistants.

Now, for the ICD-9 code assignment. The appropriate ICD-9 code is 38.94 for placement of a central venous line for renal dialysis. ICD-9 code 86.07 is not generally used for purposes of hemodialysis; clinical indications for its use are listed above under the CPT discussion above. Refer to Coding Clinic 1st quarter 1996 and 1st Quarter 2001 for a discussion on implantable vascular access device.

I may add that the radiological portion of the insertion of the hemodialysis catheter procedure is separately reportable as I don't see that you have listed a code for this above.

Glenn Krauss, RHIA, CCS, CCS-P

Q: A patient presents with a diagnosis of lupus as the primary and family planning code as secondary. The treatment given was a Depo-Provera shot. Would we still code the family planning code or would another code be used?

A: If the reason for the visit is the Depo-Provera injection given for contraception, assign V25.02, Initiation of other contraceptive measures or V25.49, Repeat prescription, other contraceptive method as the first listed code. For outpatient encounters, list first the ICD-9-CM code for the reason for the encounter or visit to be chiefly responsible for the service provided. You may also add the additional code for the coexisting condition of lupus as it may affect patient care or treatment.

Kathy Myrick, RHIT, CCS

Q: A patient presents as an outpatient for culture of a wound with a diagnosis provided of "drainage." It is verified with the physician that the patient is post-op and they are evaluating for infection. It is also verified that this is not a non-healing surgical wound, there is no dehiscence of the wound, and there is no disruption of the suture line; there is only a small amount of drainage present, which in some circumstances is normal. What would be the appropriate ICD-9 code assignment?

A: I can appreciate your frustration in attempting to properly code the clinical scenario as you describe it. When you mention that it was verified this was "not a non-healing surgical wound" was this verification made after the culture of the wound? I ask this because drainage from a post-op wound site is generally not an "expected" outcome but is a fact of doing any type of surgery. Drainage from a wound implies an infection, something obviously the physician was concerned about given that he or she ordered a culture of the wound. The term "Drainage" is a finding and not a clinical diagnosis. I would venture to say the physician placed the patient on probably some type of antibiotic related to this drainage as a precautionary measure. If this is the case, the culture may not demonstrate anything.

Strictly speaking, either the physician needs to commit to the wound infection or you are stuck with coding a garbage can, nonspecific code such as 782.9, Other symptoms involving skin and integumentary tissue. Now, there probably is an LMRP governing the culture of wound procedure and it is highly unlikely this will be a covered diagnosis. This case really highlights the importance of "educating" the physician on the need to provide specific diagnoses or findings to justify ordering of laboratory work, the relationship and importance of diagnoses to medical necessity and ultimate reimbursement for services provided.

Glenn Krauss, RHIA, CCS, CCS-P

Q: Our interventional radiologist performs chemoembolization for patients with hepatocellular cancinoma. The hepatic arteries are selectively catheterized to view the areas of tumor blush. The vessels are sequentially embolized using doxorubicin, cisplatin, mitomycin C and Lipiodol. What CPT/HCPCS codes would be used for Medicare vs. non-Medicare patients?

A: While interventional radiology is not my expertise, I am confident these are the correct codes. For the embolization of the hepatic vessels, I would use 36246 if the embolization was done in the common hepatic or 36247 if the embolization was performed in the left/right hepatic artery. Also, you would need to code the S & I of 75726. Also the HCPCS drugs are additionally assigned as follows- J9000 or J9001 for the doxorubicin (J9001 is sep reimbursable under APC but J9000 is packaged), J9060 or J9062 for the cisplatin (1st has SI of K and the 2nd has SI E meaning there is likely another code to report for Medicare), J9280-J9291 for mitomycin (J9290 & J9291 have SI of E meaning there is likely another code to report for Medicare). As for Lipiodol, there is no entry in the HCPCS book for this drug, and unfortunately I do not have access to my drug reference book as I am on the road in Florida.

Glenn Krauss, RHIA, CCS, CCS-P

Q: Yes...I agree with the selective cath codes but what about the chemo administration? The dispute is between 37204 and the chemo 96400-96549 codes. If the chemo (96400-96549) codes are correct, then we must use the Q code for Medicare but if the 37204 is correct...

A: I did some research on the actual chemoembolization procedure and here is what I found. The hepatic chemoembolization procedure combines peripheral occlusion and local deposition of chemotherapeutic agent or agents. Take a look at code 37204, this is a percutaneous approach so ask yourself the following question: Is the chemoembolization performed percutaneously or is it done through the selective catheterization. Based on what you have described thus far the chemoembolization is performed through selective catheterization. With this in mind, I would suggest coding the 36246 or 36247, whichever is appropriate, and the S& I code. This takes care of the matter used for embolization. For the chemo administered, I suggest coding the Q0084 if the chemo is infused over an extended period of time. However, if the chemo is administered in conjunction with the administration of the embolization under one injection procedure, I would not code the Q0084 but would just code the 36246 or 36247 plus S & I, and of course you would need to bill the HCPCSs injected. If the chemo was infused and the patient happens to be non-Medicare, then you would need the CPT codes 96400-96459 and not the Q0084 code.

Glenn Krauss, RHIA, CCS, CCS-P

Q: What are the correct codes in this documentation situation? Patient has an excision lesion of the breast after localization wire is placed. The physician also documents that "the area was repalpitated and another mass was removed." The path report shows two lesions. Is it appropriate to code 19125 and 19120-59 in this case?

A: Yes, you have used modifier 59 correctly. "Under certain circumstances, the physician may need to indicate that the performance of a procedure or service was distinct or independent from other services performed on the same day." Your example of the two lesions indicates that one was planned for and the other discovered during the procedure. This would be an appropriate use of modifier 59.

Pat Arvantides, RHIA

Q: Just to clarify my question coding 19125 and 19120-59: the physician did not indicate that a separate incision was made to remove the second breast lesion except for the terminology of  "the area was palpitated and another lesion was found and excised." I wanted to make sure there are no guidelines that a "separate incision" has to be documented in that specific terminology. 

A: I see what you are saying. I guess we would like the physician to say that he extended the incision or made another one so that we could justify modifier-59.

Here is what the AMA says:

"Using the modifier correctly"

"Use modifier-59 when billing a combination of codes that would normally not be billed together. This modifier indicates that the ordinarily bundled code represents a service done at a different anatomic site or at a different session on the same date. This may represent:

-different session or patient encounter

-different procedure or service/same day

-different site or organ system (e.g. a skin graft and an allograft in different locations)

-separate incision/excision

-separate lesions(e.g. a biopsy of skin on the neck is performed at the same session as an excision of a 1.0 benign lesion of the face)

-separate injury

If it was a different excision and/or a different type of lesion, then I think that -59 would be OK. However, it sounds like they simply found another lesion while taking the first one and it may have been the same type. Pathology would help here with more information.

I hope I have not confused the issue but as always we wish we had better documentation.

Pat Arvantides, 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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Can you please help me with this one::

a 3 year old child came into the outpatient surgery center to have dental caries filled and caps placed on his teeth due to nursing bottle decay syndrome. Anesthesia was provided by an anasthesiologist. Assign the correct CPT code for the anesthesia service. Modifiers should be included.

Traci MierAugust 01, 2016


paulette deese,  billingDecember 16, 2015
red springs, NC

a 3 year old child came into the outpatient surgery center to have dental caries filled and caps placed on his teeth due to nursing bottle decay syndrome. Anesthesia was provided by an anasthesiologist. Assign the correct CPT code for the anesthesia service. Modifiers should be included.

Sandra GoennerNovember 23, 2015

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